What is the differential diagnosis of epigastric pain radiating to the back?

Differential Diagnosis of Epigastric Pain Radiating to Back

The most critical diagnoses to rule out immediately are acute pancreatitis, perforated peptic ulcer, myocardial infarction, and acute aortic dissection, as these carry significant mortality risk if missed. 1, 2, 3

Life-Threatening Causes (Rule Out First)

Cardiovascular Emergencies

• Myocardial infarction presents atypically with epigastric pain as the primary manifestation, particularly in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 1, 2
• Obtain ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours to exclude acute coronary syndrome 2, 3
• Acute aortic dissection causes sudden, severe epigastric pain radiating to the back or shoulders and requires emergent CT angiography 1, 2
• Never dismiss cardiac causes based on age alone or "atypical" presentation patterns 2

Gastrointestinal Catastrophes

• Perforated peptic ulcer presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed 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% 1, 3
• Requires emergent surgical consultation for laparoscopic or open repair 3

Pancreatic and Vascular Emergencies

• Acute pancreatitis characteristically presents with epigastric pain radiating to the back, diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 1, 4
• Can progress to necrotizing pancreatitis with multiorgan failure 3
• Mesenteric ischemia causes severe epigastric pain with pain out of proportion to examination findings, requiring CT angiography for diagnosis 3
• Spontaneous celiac artery dissection is a rare cause presenting with epigastric pain radiating to the back, detected on contrast-enhanced CT 5

Common Gastrointestinal Causes

Peptic Ulcer Disease

• Duodenal ulcers cause epigastric pain several hours after eating, often at night, with hunger provoking pain that decreases after meals 4
• Gastric ulcers cause pain immediately after eating that worsens with food, localized to epigastrium and radiating to the back 4
• PUD has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 2
• Bleeding is the most common complication, presenting as hematemesis 1

Acid-Related Disorders

• GERD affects 42% of Americans monthly and 7% daily, presenting with heartburn, regurgitation, and epigastric pain 1, 2
• Esophagitis manifests as fine nodularity or granularity of mucosa, erosions, ulcers, and thickened longitudinal folds 1
• Biphasic esophagram has 88% sensitivity for detecting esophagitis when using combined technique 6
• Gastritis appears as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 1

Malignancy

• Gastric cancer may present with ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 6, 1
• Now the most common cause of gastric outlet obstruction in adults with 5-year survival rate of 32% 6, 2
• Alarm features include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia 1, 3

Chronic Pancreatitis

• Typical symptom is pain radiating to the back, distinguishing it from other causes 4

Diagnostic Algorithm

Immediate Assessment (Within 10 Minutes)

• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis 1, 3
• Obtain ECG within 10 minutes to exclude myocardial ischemia 2, 3
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation 3

Laboratory Workup

• Complete blood count, C-reactive protein, serum lactate levels 1, 3
• Cardiac troponins at 0 and 6 hours (never rely on single measurement) 2, 3
• Serum amylase or lipase to exclude acute pancreatitis 1, 3
• Liver and renal function tests 1, 3

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 2, 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 6
• CT angiography if mesenteric ischemia or aortic dissection suspected 3
• Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable 2
• Fluoroscopic upper GI series evaluates structural and functional abnormalities of esophagus, stomach, and duodenum 6

Empiric Management While Awaiting Diagnosis

Immediate Interventions

• Maintain NPO status until surgical emergency is excluded 2, 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2, 3
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• Avoid NSAIDs as they worsen PUD and bleeding risk 2
• Initiate broad-spectrum antibiotics if septic shock develops 3

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age 2, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 3
• Never rely on single troponin measurement; serial measurements at least 6 hours apart are required to exclude NSTEMI 2, 3
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 2
• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer or acute coronary syndrome 1
• Do not delay endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia), as this leads to poor outcomes 1