What is the recommended course of action for a patient experiencing epigastric pain, nausea, and vomiting for 6 days?

Epigastric Pain with Nausea and Vomiting for 6 Days: Recommended Management

A patient with 6 days of epigastric pain, nausea, and vomiting requires urgent evaluation to exclude life-threatening conditions, followed by immediate empiric high-dose PPI therapy while pursuing diagnostic workup, as persistent vomiting is a red flag that excludes functional disease and mandates investigation for structural pathology.

Immediate Life-Threatening Exclusions

Cardiac Assessment

• Obtain an ECG within 10 minutes of presentation to rule out myocardial infarction, which 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
• Order serial troponins at 0 and 6 hours 2, 3
• Never dismiss cardiac causes regardless of age, as this is a critical pitfall 2, 3

Perforation Assessment

• Check immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1, 3
• Examine for peritoneal signs including abdominal rigidity, absent bowel sounds, and guarding, which suggest perforated peptic ulcer with 30% mortality if treatment is delayed 2, 3

Urgent Laboratory Workup

Order the following tests immediately:

• Complete blood count and C-reactive protein 1
• Serum lactate levels 1, 3
• Liver and renal function tests 1, 3
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, with 80-90% sensitivity and specificity 1, 2, 3
• Serum electrolytes and glucose 1

Imaging Strategy

If peritoneal signs are present or diagnosis is unclear:

• CT abdomen and pelvis with IV contrast is the gold standard for diagnosing perforated peptic ulcer and other emergencies 2, 3
• CT findings for perforation include: extraluminal gas (97%), fluid or fat stranding along gastroduodenal region (89%), ascites (89%), and focal wall defect/ulcer (84%) 2, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 3

Immediate Empiric Treatment

Acid Suppression

Start high-dose PPI therapy immediately while awaiting diagnostic workup:

• Omeprazole 20-40 mg once daily before meals 1, 2, 3, 4
• This achieves healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2, 3
• Most patients with active duodenal ulcer heal within 4 weeks; some may require an additional 4 weeks 4

Antiemetic Therapy

For symptomatic relief of nausea and vomiting, use:

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 1
• Prochlorperazine 5-10 mg every 6-8 hours 1
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Metoclopramide or haloperidol as dopamine receptor antagonists 5

If nausea persists despite as-needed regimen:

• Administer antiemetics around the clock for 1 week 5
• Add therapies targeting different mechanisms (e.g., serotonin receptor antagonists like granisetron or ondansetron) for synergistic effect 5
• Consider olanzapine, which may be especially helpful for patients with bowel obstruction 5

Definitive Diagnostic Workup

Endoscopy Indications

Upper endoscopy is definitive when patient is stable for diagnosing peptic ulcer disease, gastritis, and esophagitis 2

Do not delay endoscopy if alarm features present:

• Persistent vomiting (red flag that excludes functional dyspepsia) 1, 3
• Weight loss 1
• Anemia 1
• Dysphagia 1
• Age-dependent risk factors for gastric cancer 1

Helicobacter pylori Testing

• Offer non-invasive testing for H. pylori in patients without alarm features 3
• Provide eradication therapy if infected 3

Surgical Consultation Criteria

Immediate surgical consultation required for:

• Signs of perforation 3
• Hemodynamic instability 3
• CT evidence of perforation or free air 3

Critical Clinical Context

Why Persistent Vomiting Matters

• Persistent vomiting is a red flag that excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease or acute coronary syndrome 1, 3
• According to Rome IV criteria, vomiting suggests another disorder beyond functional disease, with high risk of missing serious pathology 1

Common Differential Diagnoses

• Peptic ulcer disease (incidence 0.1-0.3%, complications in 2-10% of cases) 2
• Acute pancreatitis (mortality <10% overall, but 30-40% in necrotizing pancreatitis) 1
• Gastroesophageal reflux disease (affects 42% of Americans monthly) 2
• Gastric cancer (now most common cause of gastric outlet obstruction in adults) 2

Critical Pitfalls to Avoid

• Avoid assuming all epigastric pain is GERD-related without excluding other serious causes 3
• Never dismiss cardiac causes in patients with "atypical" epigastric pain 2
• Missing cardiac causes can be fatal, with mortality rate of 10-20% 2
• Delaying endoscopy in patients with alarm features can lead to poor outcomes 1