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

Differential Diagnosis of Epigastric Pain in Females

In a female presenting with epigastric pain, immediately exclude myocardial infarction with an ECG within 10 minutes and serial troponins at 0 and 6 hours, as cardiac ischemia frequently presents atypically with epigastric pain in women and carries a 10-20% mortality if missed. 1, 2

Life-Threatening Causes (Exclude First)

Cardiovascular

• Acute coronary syndrome/myocardial infarction: Women, diabetics, and elderly patients commonly present with atypical symptoms including epigastric pain, indigestion, and isolated dyspnea rather than classic chest pain 1, 2
• Obtain ECG within 10 minutes of arrival and measure cardiac troponins at 0 and 6 hours (never rely on single measurement) 2
• Never dismiss cardiac causes based on "atypical" presentation regardless of age 2

Vascular Emergencies

• Acute aortic dissection: Presents with sudden, severe epigastric pain radiating to back or shoulders; requires emergent CT angiography 3, 2
• Leaking abdominal aortic aneurysm: Consider especially in patients over 50 years with vascular risk factors 3, 2
• Mesenteric ischemia: Severe sudden-onset pain that becomes generalized, often with pain out of proportion to examination findings; requires CT angiography 3, 2

Gastrointestinal Catastrophes

• Perforated peptic ulcer: Sudden, severe epigastric pain becoming generalized, accompanied by fever, abdominal rigidity, absent bowel sounds; mortality reaches 30% if treatment delayed 3, 2, 4
  • CT abdomen/pelvis with IV contrast shows extraluminal gas (97%), fluid/fat stranding (89%), ascites (89%), focal wall defect (84%) 3, 2
  • Requires emergent surgical consultation for laparoscopic or open repair 4
• Acute pancreatitis: Epigastric pain radiating to back; diagnosed by serum amylase ≥4x normal or lipase ≥2x normal (80-90% sensitivity/specificity) 3, 2
  • Overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 3, 2

Pregnancy-Specific (Critical in Females)

• Preeclampsia: Epigastric or right upper quadrant pain with headaches, visual changes, or swelling 3
• HELLP syndrome: Epigastric pain with nausea, vomiting, and malaise 3
• Acute fatty liver of pregnancy: Malaise, headache, nausea, vomiting, jaundice, and epigastric pain 3

Common Non-Life-Threatening Causes

Gastrointestinal

• Gastroesophageal reflux disease (GERD): Affects 42% of Americans monthly and 7% daily; epigastric pain with heartburn and regurgitation 3, 2, 5
• Peptic ulcer disease: Incidence 0.1-0.3%; epigastric pain not relieved by antacids; complications occur in 2-10% of cases 3, 2
  • Duodenal ulcers: Pain several hours after eating, often at night, relieved by food 5
  • Gastric ulcers: Pain immediately after eating, worsened by food 5
• Gastritis: Enlarged areae gastricae, thickened folds, erosions; associated with NSAIDs, alcohol, H. pylori 2
• Esophagitis: Fine nodularity, erosions/ulcers, thickened folds, strictures 3, 2
• Gastric cancer: Ulcer with nodular adjacent mucosa; now most common cause of gastric outlet obstruction in adults 2
• Pancreatitis: Pain radiating to back 3, 5
• Biliary disease: Consider cholecystitis, choledocholithiasis 1

Other Causes

• Pulmonary: Pneumonia, pleuritis, pneumothorax 1
• Musculoskeletal: Costochondritis, cervical radiculopathy 1
• Psychiatric: Somatoform disorders, panic attack, anxiety disorders 1

Initial Diagnostic Algorithm

Immediate Assessment (First 10 Minutes)

1. Check vital signs: Tachycardia ≥110 bpm, fever ≥38°C, hypotension predict perforation, leak, or sepsis with high specificity 3, 2, 4
2. Obtain 12-lead ECG within 10 minutes to assess for cardiac ischemia 1, 2
3. Physical examination: Look for peritoneal signs (rigidity, rebound), cardiac murmurs, irregular pulse, jugular vein distension, friction rub, unequal pulses, blood pressure differential between arms 1, 2

History Details to Elicit

• Timing and onset: Sudden versus gradual 3, 2
• Severity: Rate 1-10 scale 3, 2
• Associated symptoms: Nausea, vomiting, hematemesis, heartburn, regurgitation, dyspnea, diaphoresis 1, 3
• Alarm features: Weight loss, anemia, dysphagia, persistent vomiting (excludes functional dyspepsia and mandates investigation) 3, 2
• Pregnancy status: Essential in all females of reproductive age 3
• Risk factors: Age, diabetes, vascular disease, prior MI, family history of CAD 1

Laboratory Testing

• Cardiac troponins at 0 and 6 hours (do not rely on single measurement) 2
• Complete blood count, C-reactive protein, serum lactate 3, 2
• Liver and renal function tests 3, 2
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis 3, 2
• Serum electrolytes and glucose 3, 2

Imaging Strategy

• CT abdomen/pelvis with IV contrast: Gold standard when diagnosis unclear; identifies pancreatitis, perforation, vascular emergencies 3, 2
• CT angiography: If mesenteric ischemia or aortic dissection suspected 2, 4
• Chest x-ray: Useful to identify pulmonary causes and widened mediastinum in aortic dissection 1
• Transthoracic echocardiography: Identifies pericardial effusion, tamponade, regional wall motion abnormalities 1

Initial Management

Immediate Interventions

• Maintain NPO status until surgical emergency excluded 2, 4
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2, 4
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology while awaiting workup; healing rates 80-90% for duodenal ulcers, 70-80% for gastric ulcers 3, 2
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2

Symptomatic Relief

• For nausea: Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG 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 3, 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in females with epigastric pain, even without classic chest pain presentation; atypical presentations are common and carry 10-20% mortality if missed 1, 2
• Persistent vomiting excludes functional dyspepsia and mandates investigation for structural disease per Rome IV criteria 3
• Delaying endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia) can lead to poor outcomes 3
• Do not rely on single troponin measurement; serial measurements at 0 and 6 hours are required 2
• Missing perforated peptic ulcer leads to 30% mortality; maintain high suspicion with sudden severe pain and peritoneal signs 3, 2, 4