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

Epigastric Pain: Diagnostic and Treatment Approach

Immediate Life-Threatening Causes Must Be Ruled Out First

Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours to exclude myocardial infarction, which presents atypically with epigastric pain in 10-20% of cases, particularly in women, diabetics, and elderly patients. 1, 2

Critical Initial Assessment

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis 2, 3
• 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, 2
• Never rely on a single troponin measurement—serial measurements at least 6 hours apart are required to exclude NSTEMI 2

Life-Threatening Differential Diagnosis

• Perforated peptic ulcer presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever and abdominal rigidity 1, 2
• 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, 2
• Acute aortic dissection causes sudden, severe epigastric pain radiating to the back or shoulders and requires emergent CT angiography 2
• Mesenteric ischemia causes severe epigastric pain with pain out of proportion to examination findings 2

Pregnancy-Specific Emergencies

• HELLP syndrome presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients, with clinical signs including upper abdominal tenderness, proteinuria, hypertension, and jaundice, requiring immediate delivery after stabilization 1, 3
• Preeclampsia can present with epigastric or right upper quadrant pain, headaches, visual changes, or swelling 3

Common Gastrointestinal Causes

Peptic Ulcer Disease and Gastritis

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases, and presents with epigastric pain not relieved by antacids 1, 3
• Duodenal ulcers cause epigastric pain that commences several hours after eating, often at night, with hunger provoking pain that decreases after meals 4
• Gastric ulcers cause pain immediately after eating, with food consumption increasing pain, localized in the epigastrium and radiating to the back 4
• Gastritis appears on imaging as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 5, 3

GERD and Esophagitis

• Gastroesophageal reflux disease affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation 1, 3
• Esophagitis manifests as fine nodularity or granularity of the mucosa, erosions, ulcers, thickened longitudinal folds, and inflammatory esophagogastric polyps 5, 3

Gastric Cancer

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

Diagnostic Algorithm

Laboratory Testing

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

Imaging Studies

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies. 1, 2, 3

• CT with IV contrast shows extraluminal gas in 97% of perforations, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 5, 1, 2
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space and assess mucosal enhancement 5
• CT angiography if mesenteric ischemia or aortic dissection suspected 2
• Bedside ultrasound is rapid, noninvasive, and can be used as first-line imaging in the emergency department to reduce time to diagnosis 6

Fluoroscopic Studies

• Biphasic esophagram has 88% sensitivity for detecting esophagitis when using combined technique with double-contrast and single-contrast phases 5
• Double-contrast upper GI series evaluates structural and functional abnormalities of the esophagus, stomach, and duodenum 5
• Barium esophagram provides anatomic and functional information on esophageal length, hiatal hernia, diverticulum, esophageal stricture, and gastroesophageal reflux events 5

Endoscopy

• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is stable 1, 2
• Do not delay endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia), as this leads to poor outcomes 2, 3

Empiric Management While Awaiting Diagnosis

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. 1, 2, 3

Specific Treatment Protocols

• For active duodenal ulcer: omeprazole 20 mg once daily for 4 weeks, with most patients healing within this timeframe 7
• For active benign gastric ulcer: omeprazole 40 mg once daily for 4 to 8 weeks 7
• For erosive esophagitis: omeprazole 20 mg once daily for 4 to 8 weeks 7
• Maintain NPO status until surgical emergency is excluded 2
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2

H. pylori Eradication

• Triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all taken twice daily for 10 days 7
• In patients with an ulcer present at initiation, continue omeprazole 20 mg once daily for an additional 18 days for ulcer healing and symptom relief 7

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age, as mortality rates reach 10-20% if missed 1, 2
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 2
• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer or acute coronary syndrome 2, 3
• Never assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 2
• Do not perform single-phase CT when peptic ulcer disease is suspected—IV contrast significantly improves conspicuity of interrupted mucosal enhancement and bowel wall hyperenhancement 5