What is the differential diagnosis for epigastric pain and nausea that feels like contractions?

Differential Diagnosis for Epigastric Pain with Nausea That Feels Like Contractions

In a patient presenting with epigastric pain and nausea that feels like contractions, you must immediately rule out life-threatening causes—particularly myocardial infarction, perforated peptic ulcer, acute pancreatitis, and in pregnant patients, HELLP syndrome—before considering more benign gastrointestinal etiologies. 1, 2, 3

Immediate Life-Threatening Causes (Rule Out First)

Cardiac Causes

• Myocardial infarction can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 1, 2, 3
• Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours—never rely on a single troponin measurement 1, 2, 3
• Never dismiss cardiac causes based on age alone or "atypical" presentation patterns 2, 3

Acute Aortic Dissection

• Presents with sudden, severe epigastric pain radiating to the back or shoulders 1, 2
• Requires emergent CT angiography for diagnosis 2

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 1, 2, 3
• Mortality reaches 30% if treatment is delayed 1, 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, 2
• Requires emergent surgical consultation for laparoscopic or open repair 2, 3

Acute Pancreatitis

• Characteristically presents with epigastric pain radiating to the back, which may feel like waves or contractions 1, 2, 3
• Diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 1, 2
• Can progress to necrotizing pancreatitis with multiorgan failure 2, 3

Mesenteric Ischemia

• Causes severe epigastric pain with pain out of proportion to examination findings 2, 3
• Requires CT angiography for diagnosis 2, 3

Pregnancy-Specific Emergencies (If Applicable)

HELLP Syndrome

• Presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients 4, 1
• Clinical signs include epigastric pain, upper abdominal tenderness, proteinuria, hypertension, jaundice, and nausea and vomiting 4
• Maternal mortality is 3.4% 4
• Requires immediate delivery after stabilization 4

Preeclampsia

• Can present with epigastric or right upper quadrant pain, headaches, visual changes, or swelling 1

Acute Fatty Liver of Pregnancy

• May present with malaise, headache, nausea, vomiting, jaundice, and epigastric pain 1

Common Gastrointestinal Causes

Peptic Ulcer Disease (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, 2
• Can present with epigastric pain not relieved by antacids 1

Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily 1, 2
• Presents with epigastric pain often accompanied by heartburn and regurgitation 1, 2

Gastritis

• Appears as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 1, 2

Gastric Cancer

• May present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 4, 1, 2
• Now the most common cause of gastric outlet obstruction in adults 4, 2
• Alarm features include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia 1, 2

Critical Clinical Algorithm

Immediate Assessment (First 10 Minutes)

• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis 1, 2, 3
• Obtain ECG within 10 minutes to exclude myocardial ischemia 1, 2, 3
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation 2, 3
• Assess severity on a scale of 1-10 and evaluate timing and onset of pain (sudden vs. gradual) 1

Laboratory Workup

• Complete blood count, C-reactive protein, serum lactate levels 1, 2, 3
• Cardiac troponins at 0 and 6 hours—never rely on single measurement 1, 2, 3
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis 1, 2, 3
• Liver and renal function tests 1, 2, 3

Imaging Strategy

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2, 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 4, 2
• CT angiography if mesenteric ischemia or aortic dissection suspected 2, 3
• Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable 2

Empiric Management While Awaiting Diagnosis

• 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, 3
• Initiate broad-spectrum antibiotics if septic shock develops 2, 3

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age 1, 2, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 3
• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer or acute coronary syndrome 1, 2
• Do not delay endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia), as this leads to poor outcomes 1, 2
• In pregnant patients, do not miss HELLP syndrome or preeclampsia, as maternal mortality is significant 4, 1