What is the initial workup for an elderly patient presenting with constant epigastric (region of the abdomen) pain and nausea without vomiting, no family history of Gastrointestinal (GI) carcinomas, and no palpable masses?

Upper GI Endoscopy (EGD) is the Appropriate Initial Workup

For an elderly patient presenting with constant epigastric pain and nausea, upper GI endoscopy (EGD) should be performed as the initial diagnostic test, not CT abdomen. This recommendation is based on the patient's age being a critical risk factor for upper gastrointestinal malignancy, which becomes significantly more common after age 55 years 1.

Why Endoscopy Takes Priority Over CT

Age-Based Risk Stratification

• The American Gastroenterological Association explicitly recommends endoscopy for patients older than 55 years presenting with new-onset dyspepsia, regardless of alarm symptoms 1
• Upper gastrointestinal malignancy incidence increases substantially after age 55, making direct visualization and tissue sampling essential 1
• Even without classic alarm features (weight loss, dysphagia, vomiting, GI bleeding, family history), age alone qualifies this patient for endoscopy 1

Diagnostic Superiority of Endoscopy

• Endoscopy should be preferred over upper gastrointestinal radiography (and by extension, CT) because it has greater diagnostic accuracy and allows biopsy specimens to be obtained for H. pylori testing 1
• Direct visualization enables detection of mucosal abnormalities, erosions, ulcers, and early malignancies that may be missed on cross-sectional imaging 1
• Biopsy capability allows simultaneous H. pylori testing, which is critical since eradication reduces risk of subsequent peptic ulcer disease and gastric malignancy 1

When CT Abdomen Would Be Appropriate

Limited Role in This Clinical Scenario

• CT abdomen is "usually appropriate" when there is specific clinical suspicion for gastric cancer with concerning features, but serves as an alternative to endoscopy rather than a replacement 1
• The ACR Appropriateness Criteria note that CT may miss gastric masses due to gastric underdistension, and endoscopy remains the reference standard for diagnosing gastric cancer 1
• CT is most valuable when evaluating for complications (perforation, obstruction) or staging known malignancy, not as the initial diagnostic test for dyspepsia 1

CT's Primary Indications in Epigastric Pain

• Ruling out life-threatening emergencies: perforated peptic ulcer (shows extraluminal gas in 97% of cases), acute pancreatitis, or vascular catastrophes 2, 3
• When peritoneal signs are present on examination suggesting perforation 2, 3
• When the clinical presentation suggests pancreatitis (pain radiating to back) or other non-gastric pathology 2, 3

Critical Pitfalls to Avoid

Don't Let Absence of Alarm Symptoms Delay Endoscopy

• A systematic review shows alarm symptoms are not very useful in diagnosing upper gastrointestinal malignancy, particularly in younger patients 1
• In one study from a high-prevalence area, 27% of gastric cancer patients had none of the classic alarm symptoms 4
• As many as 24% of gastric cancer patients were under age 45 years, and three-quarters had symptom duration shorter than 6 months 4

Age Trumps Other Factors

• The absence of family history does not reduce the need for endoscopy in elderly patients 1
• The absence of palpable masses on examination does not exclude significant pathology requiring endoscopy 1
• Constant symptoms (even without vomiting) in an elderly patient warrant direct visualization 1, 5

The Algorithmic Approach

Step 1: Risk Stratification by Age

• Age >55 years = Proceed directly to EGD 1
• Age <55 years without alarm symptoms = Consider H. pylori test-and-treat or empiric PPI trial first 1

Step 2: What Endoscopy Accomplishes

• Direct visualization of esophageal, gastric, and duodenal mucosa 1
• Biopsy for H. pylori testing (rapid urease test, histology, culture) 1
• Tissue diagnosis if malignancy, gastritis, or peptic ulcer disease identified 1
• Therapeutic intervention if bleeding source identified 5

Step 3: Post-Endoscopy Management

• If H. pylori positive: Eradication therapy (PPI + amoxicillin + clarithromycin for one week) 6
• If peptic ulcer disease: Targeted acid suppression therapy 1
• If functional dyspepsia: PPI trial for 4-6 weeks 1
• If malignancy: Staging CT abdomen/pelvis with IV contrast for surgical planning 1

Evidence Quality Considerations

The American Gastroenterological Association guidelines (2005) provide the strongest framework for this decision, establishing age >55 as the clear threshold for endoscopy 1. While these guidelines are from 2005, they remain the definitive standard and are reinforced by the 2021 ACR Appropriateness Criteria, which position endoscopy as the reference standard over imaging 1. The more recent Praxis Medical Insights (2025) confirms that upper endoscopy is definitive for PUD, gastritis, and esophagitis when the patient is stable 2, 5.

The answer is B: Upper GI endoscopy is the correct initial workup for this elderly patient with constant epigastric pain and nausea.