What is the differential diagnosis for an individual presenting with severe epigastric pain and vomiting for 10 hours?

Differential Diagnosis for Severe Epigastric Pain with Vomiting (10 hours duration)

The differential diagnosis must prioritize life-threatening conditions first: acute pancreatitis, perforated peptic ulcer, and myocardial infarction, followed by common gastrointestinal causes including peptic ulcer disease, gastritis, and GERD. 1, 2

Immediate Life-Threatening Causes (Rule Out First)

Acute Pancreatitis

• Most likely diagnosis given the classic presentation of severe epigastric pain with vomiting. 3, 4
• Pain typically radiates to the back and may feel like waves or contractions, worsening with eating. 3, 4
• Diagnosis requires serum amylase ≥4x normal or lipase ≥2x normal (80-90% sensitivity and specificity). 1, 2
• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis. 5
• Critical pitfall: Persistent vomiting with severe pain mandates checking lipase/amylase immediately—do not delay this test. 1

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds. 1, 2
• Mortality reaches 30% if treatment is delayed. 1, 2
• 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
• Critical pitfall: Do not delay imaging in patients with peritoneal signs—mortality increases significantly with delayed diagnosis. 2

Myocardial Infarction

• Can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients. 1, 2
• Mortality rates of 10-20% if missed. 1, 2
• Obtain ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours. 2
• Critical pitfall: Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age. 2

Acute Aortic Syndromes

• Can cause sudden, severe epigastric pain. 1
• Consider in patients with risk factors for vascular disease. 1

Common Gastrointestinal Causes

Peptic Ulcer Disease (Non-Perforated)

• Incidence of 0.1-0.3%, with complications occurring in 2-10% of cases. 1, 2
• Presents with epigastric pain not relieved by antacids. 1, 2
• Bleeding is the most common complication of duodenal ulcers and can present as hematemesis. 1, 6
• Pain typically relieved by food intake or antacids, may cause awakening at night or occur between meals. 6

Gastritis

• Appears as enlarged areae gastricae, disruption of normal polygonal pattern, thickened gastric folds, or erosions. 1
• Often associated with NSAID use or H. pylori infection. 6

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
• Less likely with severe pain and persistent vomiting—these symptoms suggest another disorder. 1

Gastric Cancer

• May present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds. 1, 2
• Now the most common cause of gastric outlet obstruction in adults. 2
• Consider in patients with alarm features: weight loss, anemia, dysphagia, persistent vomiting. 1

Pregnancy-Specific Emergencies (If Applicable)

HELLP Syndrome

• Presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients. 2
• Clinical signs include upper abdominal tenderness, proteinuria, hypertension, jaundice. 2
• Requires immediate delivery after stabilization. 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

Other Considerations

Mesenteric Ischemia

• Life-threatening condition that must be excluded. 5
• Consider in elderly patients with vascular risk factors and pain out of proportion to examination. 5

Leaking Abdominal Aortic Aneurysm

• Life-threatening condition that must be excluded. 5
• Consider in patients >50 years with vascular risk factors. 5

Diagnostic Algorithm

Immediate Actions (Within 10 Minutes)

• Obtain ECG to exclude myocardial ischemia. 2
• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension—these predict anastomotic leak, perforation, or sepsis. 1

Laboratory Testing (Immediate)

• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis. 1, 2
• Complete blood count, C-reactive protein, serum lactate levels. 1
• Liver and renal function tests. 1
• Serum electrolytes and glucose. 1
• Serial troponins at 0 and 6 hours. 2

Imaging Studies

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies. 2
• Chest and abdominal plain x-rays to exclude perforated viscus and intestinal obstruction. 5
• Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable. 2

Empiric Management While Awaiting Results

• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology. 1, 2
• For symptomatic relief of nausea: ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk), promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours. 1