What is the workup for an adult female presenting with epigastric pain and nausea for 3 days?

Workup for Epigastric Pain and Nausea in an Adult Female

Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours to rule out myocardial infarction, as women frequently present with atypical symptoms including epigastric pain rather than classic chest pain, with mortality rates of 10-20% if missed. 1, 2

Immediate Life-Threatening Exclusions

The first priority is ruling out cardiac causes, as the American College of Cardiology emphasizes that women with myocardial infarction often present with epigastric pain, nausea, back pain, dizziness, and palpitations rather than typical chest pain. 2 This atypical presentation is particularly common in women, diabetics, and elderly patients. 1, 2

Critical initial workup includes:

• ECG within 10 minutes of presentation 1, 2
• Serial troponins at 0 and 6 hours 1
• Continuous cardiac monitoring with defibrillation capability available 2
• Assessment of cardiac risk factors: smoking, hyperlipidemia, hypertension, diabetes, family history 2

Essential Laboratory Testing

Order the following labs immediately: 3

• Complete blood count (to assess for anemia, leukocytosis suggesting infection/inflammation) 3
• Serum electrolytes and glucose 4
• Liver function tests 4, 3
• Serum lipase (≥2x normal has 80-90% sensitivity/specificity for acute pancreatitis) 1, 3
• Serum amylase (≥4x normal suggests pancreatitis) 1, 3
• C-reactive protein and serum lactate (elevated in perforation, sepsis) 3
• Urinalysis 4

The presence of persistent vomiting with epigastric pain is a red flag that excludes functional dyspepsia and mandates investigation for structural disease. 3

Imaging Strategy

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, as recommended by the American College of Radiology, identifying pancreatitis, perforation, and vascular emergencies. 1, 3

CT findings that confirm specific diagnoses:

• Perforated peptic ulcer: Extraluminal gas (97%), fluid or fat stranding (89%), ascites (89%), focal wall defect (84%) 1, 3
• Acute pancreatitis: Pancreatic inflammation, peripancreatic fluid collections 1

Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is hemodynamically stable. 1

Pregnancy Considerations for Women of Childbearing Age

Check a pregnancy test immediately in all women of childbearing age, as pregnancy-specific emergencies can present with epigastric pain and nausea: 3

• HELLP syndrome: Epigastric pain, nausea, vomiting, malaise, with signs of hemolysis, elevated liver enzymes, low platelets—requires immediate delivery after stabilization 1, 3
• Preeclampsia: Epigastric or right upper quadrant pain with headaches, visual changes, hypertension 3
• Acute fatty liver of pregnancy: Malaise, nausea, vomiting, jaundice, epigastric pain 3

Empiric Management While Awaiting Results

Start high-dose proton pump inhibitor therapy immediately (omeprazole 20-40 mg once daily before meals) for suspected acid-related pathology, as recommended by the American College of Gastroenterology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1, 3

For symptomatic relief of nausea: 4

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 4
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours (avoid peripheral IV due to tissue injury risk) 4
• Prochlorperazine 5-10 mg every 6-8 hours 4

Differential Diagnosis Algorithm

Life-threatening causes to exclude first:

1. Myocardial infarction (10-20% mortality if missed) 1
2. Perforated peptic ulcer (30% mortality if delayed) 1, 3
3. Acute pancreatitis (diagnosed by lipase ≥2x normal) 1
4. Acute aortic syndrome (sudden, severe pain) 3

Common gastrointestinal causes after exclusion of emergencies:

• Peptic ulcer disease (incidence 0.1-0.3%, complications in 2-10%) 1, 3
• Gastroesophageal reflux disease (affects 42% monthly, 7% daily) 1, 3
• Gastritis/esophagitis 3
• Gastric cancer (may present with ulcer and nodular mucosa) 1, 3
• Gastroparesis (nearly 90% report epigastric pain) 5

Critical Pitfalls to Avoid

Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age, as emphasized by the American Heart Association—this is the most common fatal error. 1, 2 Women are less likely to receive timely and appropriate care for heart attacks. 2

Do not delay imaging in patients with peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds), as perforated ulcer mortality increases significantly with delayed diagnosis. 1

Do not attribute persistent vomiting to functional disease—Rome IV criteria state this likely suggests serious organic pathology requiring urgent investigation. 3

Do not use relief with nitroglycerin as a diagnostic criterion to exclude cardiac causes, as this is unreliable. 2

Obtain baseline ECG before administering ondansetron due to QTc prolongation risk. 4