What is the differential diagnosis (Ddx) for epigastric pain?

Differential Diagnosis for Epigastric Pain

The differential diagnosis for epigastric pain must prioritize life-threatening causes first—myocardial infarction, perforated peptic ulcer, acute pancreatitis, and aortic dissection—before considering common gastrointestinal pathology like GERD, peptic ulcer disease, and gastritis. 1, 2, 3

Life-Threatening Causes (Rule Out First)

Cardiovascular

• Myocardial infarction presents 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
• Acute aortic dissection causes sudden, severe epigastric pain that may radiate to the back or shoulders, requiring emergent CT angiography 3
• Obtain ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours to exclude cardiac ischemia 1, 2, 3

Gastrointestinal Emergencies

• 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 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
• 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, 4
• Mesenteric ischemia presents with severe, sudden-onset epigastric pain that becomes generalized, often with pain out of proportion to examination findings 3

Pregnancy-Specific Emergencies

• HELLP syndrome presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients, requiring immediate delivery after stabilization 1, 2
• 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

Acid-Related Disorders

• Gastroesophageal reflux disease (GERD) affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation 5, 1, 2
• Distal esophageal wall thickening (≥5 mm) on CT has moderate association with reflux esophagitis (sensitivity 56%, specificity 88%) 5
• Esophagitis manifests as fine nodularity or granularity of the mucosa, erosions or ulcers, thickened longitudinal folds, inflammatory esophagogastric polyps, and scarring with strictures 5, 1

Peptic Ulcer Disease

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 5, 1, 2
• 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
• CT findings include gastric or duodenal wall thickening, mucosal hyperenhancement, fat stranding, focal outpouching from ulcerations, or focal interruption of mucosal enhancement 5

Other Gastrointestinal Pathology

• Gastritis appears as enlarged areae gastricae, disruption of normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions 1
• Hiatal hernia can be detected on imaging studies and may contribute to reflux symptoms 5, 1
• Gastric cancer may present with an ulcer associated with nodularity of adjacent mucosa, and is now the most common cause of gastric outlet obstruction in adults 1, 2
• Gangrenous gallbladder can present with epigastric pain in older adults with atypical signs and symptoms, requiring early diagnosis to prevent complications 6

Functional Disorders

• Epigastric pain syndrome is characterized by epigastric pain and/or burning that does not necessarily occur after meal ingestion, may occur during fasting, and can be improved by meal ingestion 4
• Irritable bowel syndrome presents with abdominal pain related to defecation 4
• Functional disorders should only be considered after organic pathology has been confidently excluded 7

Critical Diagnostic 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, 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 1, 3

Laboratory Workup

• Complete blood count, C-reactive protein, serum lactate levels, liver and renal function tests 1
• Cardiac troponins at 0 and 6 hours to rule out myocardial infarction 2, 3
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis 1, 2

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
• Fluoroscopy biphasic esophagram or upper GI series is usually appropriate for suspected GERD, esophagitis, or hiatal hernia, providing anatomic and functional information 5, 1
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when patient is stable 2
• Bedside ultrasound is rapid, noninvasive, and can identify biliary, pancreatic, and hepatic pathology as first-line imaging 8

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on age alone or "atypical" presentation, as myocardial infarction can present with isolated epigastric pain 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
• Delaying endoscopy in patients with alarm features (weight loss, anemia, dysphagia, persistent vomiting, age-dependent risk for gastric cancer) can lead to poor outcomes 1
• Older adults may present with covert signs and symptoms of serious pathology like gangrenous gallbladder, requiring high clinical suspicion 6