What are the diagnostic and treatment approaches for a patient presenting with epigastric pain?

Diagnostic and Treatment Approach for Epigastric Pain

Immediate Life-Threatening Exclusions

First, immediately obtain an ECG to exclude myocardial infarction, particularly in women, diabetics, and elderly patients who may present atypically with epigastric pain rather than classic chest pain. 1

• Check vital signs urgently for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1
• Consider acute aortic syndromes if pain is sudden, severe, or radiates to the back 1, 2
• Cardiac causes carry a 10-20% mortality rate if missed 1

Critical Clinical Assessment

Evaluate for alarm symptoms that mandate urgent endoscopy: 1, 2

• Persistent vomiting (excludes functional dyspepsia and suggests serious organic pathology) 1
• Weight loss, anemia, dysphagia, hematemesis 1, 2
• Age-dependent risk factors for gastric cancer 1

Characterize the pain pattern to narrow the differential: 1, 3

• Sudden onset suggests perforation, vascular catastrophe, or pancreatitis 4
• Pain with heartburn/regurgitation indicates GERD (affects 7% of Americans daily) 1, 2
• Pain 2-3 hours after eating or at night, relieved by food, suggests duodenal ulcer 3
• Pain immediately after eating, worsened by food, suggests gastric ulcer 3
• Pain radiating to the back suggests pancreatitis or aortic pathology 2, 3

Initial Laboratory Workup

Order the following tests immediately: 1

• Complete blood count, C-reactive protein, serum lactate
• Liver and renal function tests
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis (80-90% sensitivity/specificity) 1
• H. pylori testing if peptic ulcer disease suspected 2

Imaging Strategy

For most presentations with nonspecific symptoms, CT abdomen and pelvis with IV contrast is the most appropriate initial imaging study, as it evaluates multiple potential causes simultaneously. 2, 5

CT Abdomen/Pelvis with IV Contrast Detects: 6, 1

• Perforation: extraluminal gas (97% sensitivity), fluid/fat stranding (89%), focal wall defect (84%) 1
• Gastric cancer: nodular wall thickening, soft tissue attenuation, lymphadenopathy, metastases 6
• Pancreatitis, vascular emergencies, and other serious pathology 2, 5

Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate the intraluminal space. 6

Alternative Imaging Modalities:

• Bedside ultrasound is rapid, noninvasive, and should be performed by the emergency physician as first-line imaging to reduce time to diagnosis 7
• Upper endoscopy is the gold standard for GERD, esophagitis, gastritis, and peptic ulcer disease 2, 5
• Fluoroscopy with upper GI series evaluates structural and functional abnormalities when endoscopy is unavailable 6, 2

Immediate Treatment Approach

Start high-dose proton pump inhibitor therapy immediately while awaiting diagnostic workup: omeprazole 20-40 mg once daily before meals. 1

• PPI therapy achieves 80-90% healing rate for duodenal ulcers and 70-80% for gastric ulcers 1
• This is first-line for ulcer-like dyspepsia 1

Critical Pitfalls to Avoid

Never assume all epigastric pain is acid-related; missing cardiac causes can be fatal. 1, 2, 5

• Persistent vomiting excludes functional dyspepsia and mandates investigation for structural disease 1
• Delaying endoscopy in patients with alarm features leads to poor outcomes 1
• CT has limited sensitivity for GERD and uncomplicated peptic ulcer disease; do not rely on it solely for these diagnoses 2, 5
• In women of reproductive age, consider gynecological causes including ectopic pregnancy 5
• Peptic ulcer perforation carries up to 30% mortality and requires immediate surgical intervention 1

Special Population Considerations

In pregnant patients with epigastric pain, consider: 1

• Preeclampsia (with headaches, visual changes, swelling)
• HELLP syndrome (with nausea, vomiting, malaise)
• Acute fatty liver of pregnancy (with jaundice)
• Use ultrasound as initial imaging to avoid radiation exposure 5

Follow-Up Algorithm

Patients without alarm symptoms: Treat empirically with PPI therapy and reassess 5

Patients with alarm symptoms or persistent symptoms despite treatment: Proceed to urgent upper endoscopy 1, 2, 5

Positive findings on imaging: Tailor management to specific diagnosis (surgical consultation for perforation, oncology for malignancy, etc.) 6, 1