What is the appropriate management for a patient presenting with sharp epigastric pain and tenderness?

Management of Sharp Epigastric Pain and Tenderness

Immediately obtain an ECG to exclude myocardial ischemia, as acute coronary syndrome can present with epigastric pain and carries a 10-20% mortality rate if missed, especially in women, diabetics, and elderly patients. 1, 2

Immediate Life-Threatening Conditions to Exclude

The first priority is ruling out conditions that require emergent intervention:

• Perforated peptic ulcer: Presents with sudden, severe epigastric pain that may generalize, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality up to 30% if treatment is delayed 3, 1
• Acute pancreatitis: Characterized by epigastric pain radiating to the back; check serum lipase or amylase (≥3 times upper limit of normal for diagnosis), with overall mortality <10% but reaching 30-40% in necrotizing pancreatitis 3, 1, 4
• Mesenteric ischemia: Must be excluded in elderly patients with vascular risk factors, particularly when pain is out of proportion to examination 1
• Leaking abdominal aortic aneurysm: Consider in patients over 50 years with vascular risk factors 1

Initial Assessment and Diagnostic Workup

Vital Signs and Clinical Evaluation

• Check for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis with high specificity 1, 4
• Assess for abdominal rigidity, masked liver dullness, and absent bowel sounds—signs of perforation 3
• Evaluate for persistent vomiting, which is a red flag excluding functional disease and mandating investigation for structural pathology 1

Laboratory Testing

Order immediately:

• Complete blood count, C-reactive protein, serum lactate 3
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis 3, 1
• Liver and renal function tests 3
• Serum electrolytes and glucose 1
• Serial troponins at 0 and 6 hours 4

Imaging Studies

• CT abdomen with IV contrast is the gold standard, showing:
  • Extraluminal gas (97% sensitivity for perforation) 3, 1, 4
  • Fluid or fat stranding along gastroduodenal region (89%) 1
  • Focal wall defect and/or ulcer (84%) 1
  • Wall thickening (72%) 1
• Chest and abdominal plain x-rays to exclude perforated viscus and intestinal obstruction 3, 1

Treatment Algorithm Based on Diagnosis

If Perforated Peptic Ulcer Confirmed

• Immediate surgical consultation for laparoscopic or open repair with omental patch (standard procedure for small perforations) 3, 4
• Distal gastrectomy for large perforations near the pylorus or suspicion of malignancy 3
• Conservative management only in patients not eligible for surgery due to severe comorbidities 3, 5

Antibiotic regimen:

• Non-critically ill, immunocompetent patients: Amoxicillin/clavulanate 2 g/0.2 g q8h for 4 days if source control is adequate 3
• Critically ill or immunocompromised patients: Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 3
• Beta-lactam allergy: Eravacycline 1 mg/kg q12h or Tigecycline 100 mg loading dose then 50 mg q12h 3
• Septic shock: Meropenem 1 g q6h by extended infusion or continuous infusion 3

If Acute Pancreatitis Confirmed

• Non-aggressive intravenous fluid resuscitation (less than 10 ml/kg/hour), as aggressive fluid protocols increase mortality threefold in non-severe cases 4
• Ondansetron 8 mg sublingual every 4-6 hours for nausea (obtain baseline ECG due to QTc prolongation risk) 4, 2
• Patients with sharp pain require closer monitoring, as this is associated with higher odds for severe disease and mortality 6

If No Perforation or Pancreatitis

• Start high-dose PPI therapy immediately: Omeprazole 20-40 mg once daily before meals or pantoprazole 40 mg IV 1, 2, 7
• Test for Helicobacter pylori in all patients without alarm features, as eradication eliminates peptic ulcer mortality risk 2, 8, 9
• Discontinue NSAIDs if currently in use 9

Indications for Urgent Endoscopy

Refer immediately if any alarm features present:

• Age ≥40 years in high-risk populations or ≥55 years in average-risk populations 2
• Persistent vomiting 1, 2
• Unintentional weight loss 2, 9
• Dysphagia 2, 9
• Family history of gastric or esophageal cancer 2
• Symptoms refractory to 8 weeks of optimized PPI therapy 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on age alone or "atypical" presentation—obtain ECG within 10 minutes for all patients 4, 2
• Do not delay endoscopy in patients with alarm features, as this can lead to poor outcomes 1
• Avoid aggressive fluid resuscitation in acute pancreatitis unless severe disease with persistent organ failure is present 4
• Do not attribute persistent vomiting to functional disease—this is a red flag for serious organic pathology 1