What are the common causes of acute onset epigastric pain in adolescents that can be fatal?

Life-Threatening Causes of Acute Epigastric Pain in Adolescents

In adolescents presenting with acute onset epigastric pain, the most critical potentially fatal causes to immediately rule out are perforated peptic ulcer (mortality up to 30%), acute myocardial infarction, acute aortic dissection, acute pancreatitis, and mesenteric ischemia. 1, 2, 3

Immediately Life-Threatening Causes

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, tachycardia, and absent bowel sounds 1, 2
• Mortality reaches 30% if treatment is delayed, making this the most lethal gastrointestinal cause 2, 3
• CT with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 2
• Requires emergent surgical consultation for laparoscopic or open repair with omental patch 1

Acute Myocardial Infarction

• Adolescents, particularly females and diabetics, can present atypically with epigastric pain as the primary manifestation of cardiac ischemia 2, 3
• Obtain ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours 3
• Mortality rate of 10-20% if missed 2
• Never dismiss cardiac causes based on age alone—atypical presentations are common 3

Acute Aortic Dissection

• Presents with sudden, severe epigastric pain that may radiate to the back or shoulders 3
• Requires emergent CT angiography for diagnosis 1, 3
• Rapidly fatal without immediate intervention 3

Acute Pancreatitis

• Characterized by epigastric pain radiating to the back with elevated serum amylase (≥4x normal) or lipase (≥2x normal) 2, 3
• Sensitivity and specificity of 80-90% for enzyme elevation 2
• Can progress to necrotizing pancreatitis with multiorgan failure 2

Mesenteric Ischemia

• Presents with severe, sudden-onset epigastric pain that becomes generalized, often with pain out of proportion to examination findings 1
• Requires CT angiography for diagnosis 1
• May necessitate open or endovascular mesenteric vessel reconstruction 1
• High mortality if bowel infarction occurs 1

Other Serious Causes Requiring Urgent Evaluation

Gastric Cancer

• Although less common in adolescents, gastric cancer can present with epigastric pain, and is now the most common cause of gastric outlet obstruction in adults 1, 2
• Alarm features include weight loss, dysphagia, hematemesis, and persistent vomiting 2, 4
• CT shows nodular or irregular wall thickening, soft tissue attenuation, and lymphadenopathy 1
• Requires upper endoscopy with biopsy for definitive diagnosis 1, 2

Complicated Peptic Ulcer Disease

• Bleeding is the most common complication, presenting as hematemesis or melena with occult blood in stool 2, 4
• PUD complications occur in 2-10% of cases 2, 3
• In children aged 10 years and older, primary PUD becomes more common with high recurrence rates 4
• Gastritis frequently coexists with PUD and was found in 75% of adolescents with epigastric tenderness in one study 5

Critical Clinical Algorithm

Immediate Assessment (First 10 Minutes)

1. Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, hypotension, or respiratory distress—these predict perforation, anastomotic leak, or sepsis 1, 2
2. Obtain ECG within 10 minutes to exclude myocardial ischemia 3
3. Examine for peritoneal signs (rigidity, rebound, guarding)—if present, obtain immediate surgical consultation 1, 2
4. Assess for epigastric tenderness, which has 93.2% positive predictive value for endoscopic findings in adolescents 5

Laboratory Workup

• Complete blood count, C-reactive protein, serum lactate 2
• Cardiac troponins at 0 and 6 hours (never rely on single measurement) 3
• Serum amylase or lipase to exclude pancreatitis 2
• Liver and renal function tests 2
• Check stool for occult blood—presence indicates GI bleeding requiring urgent endoscopy 4

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, showing perforation, pancreatitis, and vascular emergencies 1, 3
• Use neutral oral contrast (water or dilute barium) to delineate intraluminal space when gastric pathology suspected 1
• CT angiography if mesenteric ischemia or aortic dissection suspected 1, 3
• Upper endoscopy is definitive for PUD, gastritis, and esophagitis once patient is stable 2, 3

Common Pitfalls to Avoid

• Do not attribute persistent vomiting with epigastric pain to functional dyspepsia—this is a red flag for serious organic pathology 2
• Previous negative workup should not dissuade systematic re-evaluation in adolescents with recurrent symptoms 6
• Do not delay imaging in patients with peritoneal signs—perforation mortality increases significantly with delayed diagnosis 3
• Epigastric tenderness must trigger gastrointestinal evaluation, not just cardiac workup 5
• In adolescents with fever, tachycardia, and epigastric pain, assume perforation or sepsis until proven otherwise 1, 2

Empiric Management While Awaiting Diagnosis

• Maintain NPO status until surgical emergency excluded 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 3
• Start high-dose PPI therapy (omeprazole 20-40 mg) for suspected acid-related pathology 2, 3
• Avoid NSAIDs as they worsen PUD and bleeding risk 3
• If septic shock develops, initiate broad-spectrum antibiotics (meropenem 1g q6h by extended infusion or eravacycline 1 mg/kg q12h) 1