What is the etiology of mid back pain and epigastric pain in a 42-year-old male?

Etiology of Mid Back Pain and Epigastric Pain in a 42-Year-Old Male

In a 42-year-old male presenting with mid back pain and epigastric pain, you must immediately exclude life-threatening causes—specifically myocardial infarction, perforated peptic ulcer, acute pancreatitis, and visceral artery dissection—before considering more common gastrointestinal etiologies.

Immediate Life-Threatening Causes to Exclude

Cardiovascular Emergencies

• Myocardial infarction can present atypically with epigastric pain as the primary manifestation, with mortality rates of 10-20% if missed, particularly in diabetics and those with cardiac risk factors 1, 2
• Obtain an ECG within 10 minutes of presentation and measure cardiac troponins in series at 0 and 6 hours—never rely on a single troponin measurement 1, 2
• Atypical presentations are common and include epigastric pain, indigestion-like symptoms, and isolated dyspnea 2

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 1, 2
• Mortality reaches 30% if treatment is delayed 1, 2
• CT abdomen 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

Acute Pancreatitis

• Characteristically presents with epigastric pain radiating to the back, which may feel like waves or contractions 1
• Diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 1
• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 3

Visceral Artery Dissection

• Spontaneous celiac artery dissection presents with epigastric pain radiating to the mid-back and is an increasingly recognized cause of this symptom pattern 4
• Risk factors include hypertension, smoking (relevant for this 42-year-old male), arteriosclerosis, and cystic medial necrosis 4
• Contrast-enhanced CT scan is diagnostic and reveals the dissection 4
• Sequential dissection can involve the superior mesenteric artery, presenting with recurrent abdominal pain and back pain 5

Common Gastrointestinal Causes

Peptic Ulcer Disease

• Has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 3
• Presents with epigastric pain not relieved by antacids 1, 3
• NSAIDs are a major risk factor—ibuprofen causes gastric or duodenal ulceration in 15-30% of patients on chronic therapy 6

Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily 1, 3, 2
• Presents with epigastric pain often accompanied by heartburn and regurgitation 1, 3, 2
• The burning sensation that starts in the epigastrium but radiates to the chest helps differentiate GERD heartburn from dyspeptic epigastric pain 7

Gastritis

• Often associated with NSAID use, alcohol, or H. pylori infection 2
• Appears on imaging as enlarged areae gastricae, disruption of normal polygonal pattern, thickened gastric folds, or erosions 2

Gastric Cancer

• May present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 1, 3, 2
• Now the most common cause of gastric outlet obstruction in adults 1, 3
• Alarm signs include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia 2

Musculoskeletal Causes

Nonspecific Low Back Pain

• The most common category of back pain, accounting for the majority of cases 7
• However, the possibility of low back pain due to problems outside the back, such as pancreatitis, nephrolithiasis, or aortic aneurysm, must be considered 7

Serious Spinal Causes (Less Likely in This Age Group)

• Cancer accounts for approximately 0.7% of back pain cases 7
• Compression fracture accounts for 4% of cases 7
• Spinal infection accounts for 0.01% of cases 7

Diagnostic Algorithm

Step 1: Immediate Assessment

• Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis with high specificity 2
• Perform physical examination seeking peritoneal signs (rigidity, rebound tenderness, absence of bowel sounds) 2
• Evaluate timing and onset (sudden vs. gradual), severity (1-10 scale), and associated symptoms (nausea, vomiting, hematemesis, heartburn) 2

Step 2: Laboratory Testing

• Complete blood count, C-reactive protein, serum lactate, liver and renal function tests 3, 2
• Serum amylase or lipase to exclude acute pancreatitis 3, 2
• Cardiac troponins at 0 and 6 hours (serial measurements are mandatory) 1, 2
• Serum electrolytes and glucose 3

Step 3: Imaging

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, vascular emergencies, and visceral artery dissection 1, 2
• ECG within 10 minutes to exclude myocardial ischemia 1, 2
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is stable 1

Initial Management

Stabilization

• Maintain the patient nil per os until surgical emergency is excluded 2
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2

Empiric Medical Treatment

• Start high-dose proton pump inhibitor therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• Avoid NSAIDs as they can exacerbate peptic ulcer disease and increase the risk of bleeding 2, 6

Symptomatic Treatment

• For nausea: ondansetron 8 mg sublingual every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 3, 2
• Obtain a baseline ECG before administering ondansetron due to QTc prolongation risk 3, 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age—this is a fatal mistake 1, 2
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 2
• Do not assume GERD without first excluding life-threatening causes, even in patients with known reflux disease 2
• Do not overlook visceral artery dissection in patients with epigastric pain radiating to the back, especially with vascular risk factors like smoking 4, 5
• Persistent vomiting with epigastric pain excludes functional dyspepsia and requires investigation for structural disease 3, 2