What is the appropriate management for a patient with new onset epigastric pain since waking up?

Management of New Onset Epigastric Pain Since Waking Up

Immediately obtain an ECG within 10 minutes of presentation and check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict life-threatening conditions including myocardial infarction, perforated peptic ulcer, or sepsis that require emergent intervention. 1, 2, 3

Immediate Life-Threatening Causes to Rule Out First

The sudden onset of epigastric pain upon waking demands urgent exclusion of cardiac and surgical emergencies before considering benign gastrointestinal causes:

Cardiac Evaluation (First Priority)

• Obtain ECG within 10 minutes and serial troponins at 0 and 6 hours—never rely on a single troponin measurement, as myocardial infarction presents atypically with epigastric pain as the primary manifestation in 10-20% of cases, particularly in women, diabetics, and elderly patients 1, 2, 3
• Mortality reaches 10-20% when cardiac causes are missed, and the American College of Cardiology advises against dismissing cardiac causes based on age alone 1, 2

Surgical Emergencies (Second Priority)

• Examine for peritoneal signs including abdominal rigidity, rebound tenderness, and absent bowel sounds, which indicate perforated peptic ulcer with mortality reaching 30% if treatment is delayed 1, 3
• Check for tachycardia ≥110 bpm, fever ≥38°C, or hypotension within the first 10 minutes, as these vital sign abnormalities predict perforation, anastomotic leak, or sepsis with high specificity 1, 2, 3

Additional Life-Threatening Conditions

• Acute aortic dissection presents with sudden, severe epigastric pain that may radiate to the back or shoulders, requiring emergent CT angiography for diagnosis 1, 3
• 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, 3
• Mesenteric ischemia causes severe epigastric pain with pain out of proportion to examination findings, requiring CT angiography 1, 3

Immediate Laboratory Workup

Order the following tests simultaneously while awaiting imaging:

• Complete blood count and C-reactive protein to assess for infection or inflammation 1, 2, 3
• Cardiac troponins at 0 and 6 hours (serial measurements mandatory—never rely on single measurement) 1, 3
• Serum amylase or lipase to exclude acute pancreatitis 1, 2, 3
• Serum lactate levels to assess for mesenteric ischemia or sepsis 2, 3
• Liver and renal function tests for comprehensive evaluation 2, 3

Imaging Strategy

CT Abdomen/Pelvis with IV Contrast (Gold Standard)

• CT with IV contrast is the gold standard when diagnosis is unclear, showing extraluminal gas in 97% of perforations, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 1, 2, 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 3
• CT angiography if mesenteric ischemia or aortic dissection suspected based on clinical presentation 1, 3

Bedside Ultrasound

• Emergency ultrasound is rapid, noninvasive, and can identify biliary pathology, free fluid, or abdominal aortic aneurysm while awaiting CT 4

Empiric Management While Awaiting Diagnosis

Immediate Interventions

• Maintain NPO status until surgical emergency is excluded 1, 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 3
• Start high-dose PPI therapy with omeprazole 20-40 mg once daily before meals for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2, 3, 5
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1, 3
• Initiate broad-spectrum antibiotics if septic shock develops (consider meropenem or eravacycline) 1

Common Gastrointestinal Causes (After Excluding Emergencies)

Once life-threatening causes are ruled out, consider:

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 2, 3
• GERD affects 42% of Americans monthly and 7% daily, presenting with heartburn, regurgitation, and epigastric pain 2, 3
• Gastritis appears as enlarged areae gastricae, disrupted polygonal pattern, or erosions 2, 3
• Gastric cancer may present with ulcer associated with nodularity of adjacent mucosa, now the most common cause of gastric outlet obstruction in adults with 5-year survival rate of 32% 3

Critical Pitfalls to Avoid

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

Disposition and Follow-Up

• Emergent surgical consultation is required for perforated peptic ulcer, requiring laparoscopic or open repair with omental patch 1
• Immediate cardiology consultation if ECG or troponins suggest acute coronary syndrome 6, 1
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when patient is stable and life-threatening causes excluded 3
• Continue omeprazole 20 mg once daily for 4 weeks for duodenal ulcer treatment, or 4-8 weeks for gastric ulcer or erosive esophagitis 5