What is the appropriate management for a patient experiencing epigastric pain?

Management of Epigastric Pain and Discomfort

Immediate Life-Threatening Exclusions

Obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which 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, 3, 4

Critical Initial Assessment

• Check vital signs immediately for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis with high specificity 2, 3

• Assess for peritoneal signs including abdominal rigidity, rebound tenderness, and absent bowel sounds, which suggest perforated peptic ulcer with mortality reaching 30% if treatment is delayed 1, 2, 3, 4

• Evaluate pain characteristics: sudden onset of severe pain suggests perforation or acute vascular event, while gradual onset suggests peptic ulcer disease or gastroesophageal reflux disease 2, 3

• Inquire about associated symptoms: persistent vomiting excludes functional dyspepsia and mandates investigation for structural disease 2, 4

Essential Laboratory Testing

• Order complete blood count, C-reactive protein, serum lactate, liver and renal function tests, and serum amylase or lipase to exclude acute pancreatitis (diagnosed by amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity) 2, 3, 4

• Obtain serum electrolytes and glucose testing for all patients with epigastric pain and nausea 2, 4

• Measure cardiac troponins at 0 and 6 hours—do not rely on a single measurement 3, 4

Imaging Strategy

Order CT abdomen and pelvis with IV contrast when diagnosis is unclear or peritoneal signs are present, as this is the gold standard for identifying pancreatitis, perforation (showing extraluminal gas in 97% of cases), and vascular emergencies. 1, 2, 3, 4

• Bedside ultrasound is rapid, noninvasive, and appropriate as first-line imaging in stable patients to evaluate biliary pathology and detect free fluid 5

• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is hemodynamically stable 2

Immediate Empiric Management

Start high-dose proton pump inhibitor therapy with omeprazole 20-40 mg once daily before meals while awaiting diagnostic workup, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 2, 3, 4, 6

Symptomatic Treatment

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

• Maintain NPO status until surgical emergency is excluded 3

• Establish IV access and provide fluid resuscitation if hemodynamically unstable 3

• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 3

Alarm Features Requiring Urgent Endoscopy

The British Society of Gastroenterology recommends urgent evaluation for the following red flags:

• Dyspepsia with weight loss if age ≥55 years 1, 2

• Dysphagia or sensation of food sticking at a specific level 2, 3

• Anemia on complete blood count 2, 3

• Persistent vomiting (excludes functional dyspepsia and suggests structural disease) 2, 4

• Age >40 years from an area at increased risk of gastric cancer or with family history of gastro-oesophageal malignancy 1

Common Differential Diagnoses

Gastrointestinal Causes

• Peptic ulcer disease (incidence 0.1-0.3%, complications in 2-10% of cases): presents with epigastric pain not relieved by antacids; bleeding is the most common complication 2, 3, 4

• Gastroesophageal reflux disease (affects 42% of Americans monthly): presents with epigastric pain accompanied by heartburn and regurgitation; approximately 66% of GERD patients experience epigastric pain 2, 3, 4

• Acute pancreatitis: characteristically presents with epigastric pain radiating to the back; overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 2, 3, 4

• Gastric cancer: may present with ulcer associated with nodularity of adjacent mucosa, now the most common cause of gastric outlet obstruction in adults 2, 3, 4

Non-Gastrointestinal Causes

• Myocardial infarction: atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea, particularly in elderly patients, women, and those with diabetes 1, 2, 3, 4

• Perforated peptic ulcer: sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 1, 2, 3, 4

• Acute aortic dissection and leaking abdominal aortic aneurysm: must be excluded, especially in patients over 50 years with vascular risk factors 2, 3

Special Populations: Pregnancy

In pregnant patients presenting with epigastric pain, immediately consider:

• Preeclampsia: epigastric or right upper quadrant pain with headaches, visual changes, or swelling 2

• HELLP syndrome: epigastric pain, nausea, vomiting, malaise, upper abdominal tenderness, proteinuria, hypertension, and jaundice; requires immediate delivery after stabilization 2, 4

• Acute fatty liver of pregnancy: malaise, headache, nausea, vomiting, jaundice, and epigastric pain 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation 2, 3, 4

• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 3, 4

• Delaying endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia) can lead to poor outcomes 1, 2

• Missing mesenteric ischemia, particularly in elderly patients with vascular risk factors and pain out of proportion to examination 2

Lifestyle Modifications

Once acute pathology is excluded:

• Advise immediate smoking cessation and counsel on alcohol reduction or cessation, as smoking and alcohol have a synergistic dose-dependent effect on gastric ulcer risk 3

• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 3

• Antacids may be used concomitantly with omeprazole 6

Follow-Up and Further Management

• For treatment-resistant dyspepsia in patients ≥55 years, consider non-urgent endoscopy 1, 2

• Test for H. pylori via breath or stool testing; if positive, initiate triple therapy: omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg twice daily for 10 days 6

• Check coeliac serology in patients with overlap of IBS-type symptoms 1

• Establish an effective and empathic doctor-patient relationship and explain the diagnosis of functional dyspepsia in the context of the gut-brain axis if all investigations are normal 1