What is the differential diagnosis and initial management approach for a patient presenting with epigastric pain?

Differential Diagnosis for Epigastric Pain

Immediate Life-Threatening Causes (Rule Out First)

Myocardial infarction must be excluded immediately in any patient with epigastric pain, as it 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

• Obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours to rule out acute coronary syndrome 2, 1
• Atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea, particularly in elderly patients, women, and those with diabetes, chronic renal disease, or dementia 2
• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation 1, 3

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, 4

• CT abdomen/pelvis 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, 4
• Do not delay imaging in patients with peritoneal signs, as mortality increases significantly with delayed diagnosis 1, 3

Acute pancreatitis characteristically presents with epigastric pain radiating to the back and is diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity. 1, 4

• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 4
• Pain may feel like waves or contractions radiating posteriorly 1, 5

Acute aortic dissection and leaking abdominal aortic aneurysm must be excluded, especially in patients over 50 years with vascular risk factors. 4, 3

Common Gastrointestinal Causes

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, 4

• Duodenal ulcers cause pain several hours after eating, often at night, with hunger provoking pain that decreases after meals 5
• Gastric ulcer pain occurs immediately after eating, with food consumption increasing pain and radiation to the back 5
• Bleeding is the most common complication and can present as hematemesis 4

Gastroesophageal reflux disease affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation. 1, 4

• Esophagitis manifests as fine nodularity or granularity of mucosa, erosions or ulcers, thickened longitudinal folds, and scarring with strictures 4
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 3

Gastritis appears as enlarged areae gastricae, disruption of normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions. 4

• Often associated with NSAID use, alcohol, or H. pylori infection 3

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. 1, 4

• Consider in patients with alarm symptoms: weight loss, anemia, dysphagia, persistent vomiting 4, 3

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, 4

• Preeclampsia can present with epigastric or right upper quadrant pain, headaches, visual changes, or swelling 4
• Acute fatty liver of pregnancy may present with malaise, headache, nausea, vomiting, jaundice, and epigastric pain 4

Other Important Causes

Mesenteric ischemia must be excluded, particularly in elderly patients with vascular risk factors and pain out of proportion to examination. 4

Irritable bowel syndrome presents with abdominal pain related to defecation. 5

Chronic pancreatitis causes pain that radiates to the back. 5

Initial Diagnostic Approach

Immediate Assessment

• Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict anastomotic leak, perforation, or sepsis with high specificity 4
• Perform physical examination looking for peritoneal signs, cardiac murmurs, irregular pulse, jugular vein distension, friction rub, and pain reproduced by palpation 2
• Assess timing and onset (sudden vs. gradual), severity (1-10 scale), and associated symptoms (nausea, vomiting, hematemesis, heartburn, regurgitation) 4

Laboratory Testing

• Order complete blood count, C-reactive protein, serum lactate, liver and renal function tests, and serum amylase or lipase 4
• Obtain serum electrolytes and glucose testing 4
• Measure cardiac troponins at 0 and 6 hours (do not rely on single measurement) 1, 3

Imaging Strategy

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

• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when patient is stable 1, 3
• Chest and abdominal plain x-rays can help exclude perforated viscus and intestinal obstruction 4

Initial Management

Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1, 4

• Maintain NPO status until surgical emergency is excluded 3
• Provide IV access and fluid resuscitation if hemodynamically unstable 3
• Avoid NSAIDs as they can worsen peptic ulcer disease and bleeding risk 3

For symptomatic relief of nausea, use ondansetron 8 mg sublingual every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours, with baseline ECG obtained before administering ondansetron due to QTc prolongation risk. 4

Critical Pitfalls to Avoid

• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease or acute coronary syndrome 4
• Delaying endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia, age-dependent risk factors) can lead to poor outcomes 4
• Serial troponin measurements at least 6 hours apart are required to exclude NSTEMI 3