What could be causing pulsating pain in the right upper epigastric region for 2 days?

Pulsating Right Upper Epigastric Pain for 2 Days

A pulsating sensation in the right upper epigastric region requires immediate exclusion of life-threatening vascular and cardiac causes, particularly abdominal aortic aneurysm and atypical myocardial infarction, before considering more common gastrointestinal etiologies.

Immediate Life-Threatening Causes to Rule Out

Cardiac Etiology

• Obtain an ECG within 10 minutes and measure cardiac troponins at 0 and 6 hours, as myocardial infarction presents atypically with epigastric pain in women, diabetics, and elderly patients with mortality rates of 10-20% if missed 1, 2.
• Never rely on a single troponin measurement; serial measurements at least 6 hours apart are necessary to exclude NSTEMI 2, 3.
• Atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea 2.

Vascular Emergencies

• A pulsatile mass with epigastric pain mandates urgent evaluation for abdominal aortic aneurysm, which can present with a palpable pulsating sensation and carries catastrophic mortality if ruptured 4.
• Order CT angiography emergently if you palpate a pulsatile mass or suspect aortic pathology 3.
• Nutcracker syndrome (left renal vein compression) can present with pulsatile abdominal mass and severe pain in the left epigastric area, though this is rare 4.

Perforated Viscus

• Check for sudden onset of severe pain, fever, abdominal rigidity, and absent bowel sounds, which indicate perforated peptic ulcer with 30% mortality if treatment is delayed 1, 2.
• CT with IV contrast shows extraluminal gas in 97% of cases 1, 3.

Physical Examination Priorities

• Check vital signs immediately: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict perforation, anastomotic leak, or sepsis 2, 3.
• Palpate for a pulsatile mass in the epigastric region to assess for abdominal aortic aneurysm or other vascular pathology 4.
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation requiring immediate surgical consultation 1, 2.
• Assess for cardiac findings including irregular pulse, jugular venous distension, and friction rub 2.

Common Gastrointestinal Causes (After Excluding Emergencies)

Peptic Ulcer Disease

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 3.
• Pain in the right upper epigastric region may indicate duodenal ulcer, which classically improves with meals 5.
• Ask specifically about NSAID use, as these worsen peptic ulcer disease and increase bleeding risk 1, 3.

Biliary Colic

• Consider abdominal ultrasound for epigastric pain <1 year with characteristics of biliary colic, particularly if pain is in the right upper quadrant 5.
• Biliary pain typically lasts 30 minutes to several hours, may radiate to the back or right shoulder, and is often postprandial 5.

Functional Dyspepsia

• Functional dyspepsia accounts for approximately 80% of patients with epigastric symptoms in the community but requires exclusion of structural disease 1.
• Rome IV clinical criteria require bothersome epigastric pain, burning, postprandial fullness, or early satiation present for at least 8 weeks 5.
• However, only 2 days of symptoms is too short to diagnose functional dyspepsia—this diagnosis requires at least 8 weeks of symptoms 5.

Diagnostic Algorithm

Step 1: Immediate Assessment

• Obtain ECG within 10 minutes 1, 2.
• Check vital signs for hemodynamic instability 2, 3.
• Perform focused physical examination for pulsatile mass, peritoneal signs, and cardiac abnormalities 2, 4.

Step 2: Laboratory Testing

• Cardiac troponins at 0 and 6 hours (never rely on single measurement) 2, 3.
• Complete blood count to assess for anemia or infection 2, 3.
• Serum amylase or lipase to exclude acute pancreatitis 1, 2.
• Liver function tests if biliary pathology suspected 2.

Step 3: Imaging

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2, 3.
• CT angiography if pulsatile mass palpated or vascular pathology suspected 3, 4.
• Abdominal ultrasound if biliary colic suspected based on pain characteristics 5.

Step 4: Empiric Management (If No Emergency Identified)

• 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 1, 2, 3.
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1, 3.
• Test for H. pylori with breath or stool testing before initiating acid suppression therapy 5, 2.

Critical Pitfalls to Avoid

• Never dismiss the pulsating quality of the pain—this may indicate vascular pathology requiring emergent intervention 4.
• Do not assume gastrointestinal disease without first excluding cardiac causes, even in younger patients 1, 2.
• Never rely on a single troponin measurement; serial measurements are mandatory 2, 3.
• Do not delay imaging in patients with peritoneal signs, as mortality from perforated ulcer increases significantly with delayed diagnosis 2, 3.
• Only 2 days of symptoms is insufficient to diagnose functional dyspepsia, which requires at least 8 weeks of symptoms 5.