What is the differential diagnosis for a patient with emesis and epigastric pain, considering age, medical history, and severity of symptoms?

Differential Diagnosis for Emesis and Epigastric Pain

The differential diagnosis for emesis and epigastric pain must immediately prioritize life-threatening conditions—myocardial infarction, perforated peptic ulcer, and acute pancreatitis—before considering common gastrointestinal causes such as peptic ulcer disease, gastroesophageal reflux disease, gastritis, and gastric cancer. 1, 2

Immediate Life-Threatening Causes (Rule Out First)

Myocardial Infarction

• Myocardial infarction can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed. 1, 2
• Obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours—do not rely on a single measurement. 1, 2
• Atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea, particularly in elderly patients, women, and those with diabetes, chronic renal disease, or dementia. 2
• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation. 1, 2

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed. 1, 2
• CT abdomen/pelvis with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84%. 1, 2
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis. 1

Acute Pancreatitis

• Characteristically presents with epigastric pain radiating to the back, which may feel like waves or contractions. 1, 2
• Diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity. 1, 2
• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis. 2

Acute Aortic Syndromes

• Acute aortic dissection and leaking abdominal aortic aneurysm must be excluded, especially in patients over 50 years with vascular risk factors. 2
• Epigastric pain accompanied by pain radiating to the back requires immediate consideration of acute aortic syndromes. 3

Common Gastrointestinal Causes

Peptic Ulcer Disease (PUD)

• Has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases. 4, 1, 2
• Presents with epigastric pain not relieved by antacids, often accompanied by nausea and vomiting. 1, 2
• PUD-related perforation is a surgical emergency with a mortality rate of up to 30%. 4
• Bleeding is the most common complication (73% of complicated cases) and can present as hematemesis, with annual incidence of 0.02-0.06% and 30-day mortality of 8.6%. 3, 2
• Commonly caused by Helicobacter pylori infection (affecting approximately 42% of peptic ulcer patients) and NSAID use (36% of cases). 3

Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation. 4, 1, 2
• Approximately 66% of patients with GERD and heartburn also experience epigastric pain at baseline. 2
• Patients with heartburn and epigastric pain frequently cannot identify their predominant symptom, with 19% unable to choose between heartburn, regurgitation, or epigastric pain. 2
• Distal esophageal wall thickening ≥5 mm on CT has moderate association with reflux esophagitis (sensitivity 56%, specificity 88%). 4, 3

Gastritis

• Appears as enlarged areae gastricae, disruption of normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions. 2
• Often associated with NSAID use, alcohol, or H. pylori infection. 2
• CT findings include gastric wall thickening due to submucosal edema, mucosal hyperenhancement, and fat stranding from inflammation. 4, 3

Esophagitis

• Manifests as fine nodularity or granularity of mucosa, erosions or ulcers, thickened longitudinal folds, and scarring with strictures. 2
• Presence of air in the esophagus, especially the middle and lower parts, can suggest a diagnosis of GERD. 4

Gastric Cancer

• May present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds. 1, 2
• Now the most common cause of gastric outlet obstruction in adults. 1, 2

Hiatal Hernia

• Included in the differential diagnosis when epigastric pain is accompanied by symptoms such as heartburn, regurgitation, dysphagia, nausea, vomiting, and hematemesis. 4

Age-Specific Considerations

Children

• Eosinophilic esophagitis should be considered in young children with GERD-like symptoms, including feeding problems, and in older children with GERD-like symptoms, especially those with dysphagia or esophageal food impaction. 4
• Children most commonly have GERD-like symptoms (including heartburn and regurgitation), with estimates varying widely (range, 5%-82%). 4
• Emesis and abdominal pain are commonly reported (range, 8%-100% for emesis; 5%-68% for abdominal pain). 4
• In children aged 10 years and older, primary peptic ulcer disease becomes more common, with a high incidence of recurrent symptoms and potential need for surgery. 3

Pregnancy-Specific Emergencies

• HELLP syndrome presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients, with clinical signs including epigastric pain, upper abdominal tenderness, proteinuria, hypertension, jaundice, and nausea and vomiting, and requires immediate delivery after stabilization. 1

Rare but Important Causes

Small Bowel Obstruction from Jejunal Diverticulitis

• Can present with severe epigastric abdominal pain and nausea of several weeks' duration, escalating to projectile faeculent emesis. 5
• Abdominal CT demonstrates mechanical small bowel obstruction. 5

Celiac Trunk Compression Syndrome

• Rare cause presenting with strong epigastric pain, emesis, diarrhea, and weight reduction. 6
• Diagnosis made based on typical angiographic picture. 6

Gangrenous Gallbladder

• Older adults may present with covert signs and symptoms, requiring early diagnosis to prevent complications and poor outcomes including death. 7

Critical Diagnostic Algorithm

Initial Assessment

• Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict anastomotic leak, perforation, or sepsis with high specificity. 2
• Perform physical examination looking for peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds), cardiac murmurs, irregular pulse, jugular vein distension, friction rub, and pain reproduced by palpation. 2
• Assess timing and onset (sudden vs. gradual), severity (1-10 scale), and associated symptoms (nausea, vomiting, hematemesis, heartburn, regurgitation). 2

Laboratory Testing

• Order complete blood count, C-reactive protein, serum lactate, liver and renal function tests, and serum amylase or lipase. 2
• Obtain serum electrolytes and glucose testing. 2
• Measure cardiac troponins at 0 and 6 hours (do not rely on single measurement). 1, 2

Imaging

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies. 1, 2
• Although CT is not the test of choice for initial imaging if acid reflux, esophagitis, gastritis, peptic ulcer, or duodenal ulcer is strongly suspected, patients with these entities may present with nonspecific/overlapping symptoms and may undergo CT abdomen and pelvis as the initial diagnostic test. 4
• Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable. 1, 3

Common Pitfalls to Avoid

• Symptoms are nonspecific and overlap extensively between GERD, gastritis, esophagitis, and peptic ulcer disease, requiring careful history and often endoscopic evaluation. 3
• Clinical history, risk factors, and symptoms are important to consider narrowing the differential diagnosis, as symptoms associated with these diseases may overlap. 4
• Smoking and alcohol consumption have a synergistic dose-dependent effect on gastric ulcer risk, with risks increasing substantially when both habits are present. 2