What are the causes and management of epigastric pain that occurs during exertion?

Epigastric Pain on Exertion: Critical Cardiac Evaluation Required

Epigastric pain occurring during exertion is cardiac ischemia until proven otherwise and requires immediate ECG within 10 minutes and serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which carries a 10-20% mortality if missed. 1, 2, 3

Immediate Life-Threatening Assessment

The most critical error is dismissing cardiac causes in patients presenting with exertional epigastric pain. The American Heart Association explicitly states that myocardial infarction can present atypically with epigastric pain as the primary manifestation, particularly in women, diabetics, and elderly patients. 1, 2, 3

Key diagnostic steps within the first 10 minutes:

• Obtain 12-lead ECG immediately (within 10 minutes of presentation) 1, 2, 3
• Measure cardiac troponins at presentation (time 0) and repeat at 6 hours—never rely on a single measurement 2, 3
• Check vital signs for tachycardia ≥110 bpm, hypotension, or fever ≥38°C 2, 4
• Assess for anginal equivalents: jaw, neck, shoulder, back pain, or isolated dyspnea occurring with exertion 1

Distinguishing Cardiac from Gastrointestinal Causes

Characteristics strongly suggesting cardiac ischemia:

• Pain reproducibly associated with physical exertion or emotional stress 1
• Relief with rest within 5 minutes or with sublingual nitroglycerin 1
• Deep, poorly localized chest or epigastric discomfort 1
• Associated dyspnea, diaphoresis, or unexplained fatigue with exertion 1

Characteristics suggesting gastrointestinal pathology:

• Pain induced or relieved by meal ingestion 1, 5
• Associated heartburn, regurgitation, or postprandial fullness 1, 4
• Pain relieved by antacids or proton pump inhibitors 2, 4
• No clear relationship to physical exertion 1

Exercise-Associated Gastrointestinal Symptoms

If cardiac causes are definitively excluded, consider exercise-associated gastrointestinal symptoms (Ex-GIS). Core body temperatures ≥39.5°C during exercise consistently elicit intestinal epithelial injury and epigastric pain. 1

Contributing factors to exercise-induced epigastric pain:

• Hypohydration during exercise increases both incidence (82% vs 64%) and severity of gastrointestinal symptoms 1
• Excessive pre-exercise fluid ingestion (>1134 mL immediately before exercise) significantly increases exercise-related transient abdominal pain 1
• High-intensity exercise (≥70% VO2max) for prolonged duration (≥2 hours) in hot conditions 1

Management of exercise-associated epigastric pain:

• Commence exercise in euhydrated state but avoid excessive pre-exercise fluid loading 1
• Maintain euhydration during exercise with ad libitum fluid intake rather than forced programmed intake 1
• Implement heat mitigation strategies including pre-cooling and heat acclimatization 1

Functional Dyspepsia Considerations

Only after excluding cardiac ischemia and structural disease should functional dyspepsia be considered. The Rome IV criteria define epigastric pain syndrome as bothersome epigastric pain or burning at least 1 day per week, but this diagnosis requires symptoms to have been present for at least 6 months with active symptoms in the past 3 months. 1

Critical exclusion criteria for functional dyspepsia:

• Pain that occurs specifically with exertion suggests cardiac or exercise-induced pathology, not functional dyspepsia 1
• No evidence of structural disease on upper endoscopy is required before diagnosing functional dyspepsia 1

Diagnostic Algorithm for Exertional Epigastric Pain

Step 1: Cardiac evaluation (mandatory)

• ECG within 10 minutes 1, 2
• Serial troponins at 0 and 6 hours 2, 3
• Consider stress testing or coronary angiography if troponins negative but high clinical suspicion 1

Step 2: If cardiac workup negative, assess for structural GI disease

• Complete blood count, liver function tests, lipase/amylase 2, 3
• Upper endoscopy if alarm features present (age ≥55 years, weight loss, anemia, dysphagia) 4
• CT abdomen/pelvis with IV contrast if acute presentation with peritoneal signs 2, 3

Step 3: If structural disease excluded, consider exercise-associated GIS

• Evaluate hydration status and exercise intensity 1
• Implement hydration and heat mitigation strategies 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes regardless of patient age or "atypical" presentation—older age (males >55 years, females >65 years) outweighs all other historical factors including the nature of chest pain 1, 2
• Do not rely on single troponin measurement; serial measurements at 0 and 6 hours are mandatory 2, 3
• Avoid attributing exertional symptoms to functional dyspepsia without excluding cardiac ischemia first 1
• Do not delay cardiac evaluation to pursue gastrointestinal workup when pain occurs with exertion 1, 2