What is the diagnosis and management for an older adult patient with persistent epigastric pain and vomiting, considering potential conditions such as peptic ulcer disease or pancreatitis?

Diagnosis and Management of Persistent Epigastric Pain and Vomiting

Immediately obtain an ECG within 10 minutes and serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which presents atypically with epigastric pain in 10-20% of cases, especially in older adults, women, and diabetics. 1, 2

Immediate Life-Threatening Causes to Exclude First

Cardiac causes must be ruled out before pursuing gastrointestinal workup, regardless of how "typical" the GI symptoms appear. 1, 2

• Myocardial infarction kills 10-20% of patients when missed and commonly masquerades as epigastric pain in elderly patients, diabetics, and women 1, 2
• Obtain ECG within 10 minutes of presentation per American College of Cardiology guidelines 1
• Measure cardiac troponins at 0 and 6 hours—never rely on a single measurement 2

Perforated peptic ulcer presents with sudden severe epigastric pain becoming generalized, with fever, abdominal rigidity, and absent bowel sounds, carrying 30% mortality if treatment is delayed. 1, 2

• Order CT abdomen/pelvis with IV contrast immediately if peritoneal signs are present 1, 2
• CT shows extraluminal gas in 97%, fluid/fat stranding in 89%, ascites in 89%, and focal wall defect in 84% of perforations 3, 1, 2
• Immediate surgical consultation is required for laparoscopic or open repair with omental patch 4

Acute pancreatitis characteristically radiates to the back and requires serum lipase ≥2x normal or amylase ≥4x normal for diagnosis, with 80-90% sensitivity and specificity. 1, 2, 4

• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 2
• Use non-aggressive IV fluid resuscitation (<10 ml/kg/hour) as aggressive protocols triple mortality in non-severe cases 4

Physical Examination Priorities

Check for these specific findings immediately: 2

• Vital signs: Hypotension, tachycardia ≥110 bpm, or fever ≥38°C predict perforation, anastomotic leak, or sepsis with high specificity 2
• Peritoneal signs: Abdominal rigidity, rebound tenderness, absent bowel sounds indicate surgical emergency 1, 2
• Cardiac examination: Irregular pulse, jugular vein distension, friction rub suggest cardiac etiology 2

Diagnostic Algorithm When Diagnosis Unclear

CT abdomen and pelvis with IV contrast is the gold standard imaging study when the diagnosis remains uncertain after initial evaluation, per American College of Radiology guidelines. 3, 1, 2

• CT identifies pancreatitis, perforation, and vascular emergencies with 97% sensitivity for extraluminal gas 3, 1, 4
• Perform with IV contrast and neutral oral contrast (water or dilute barium) to assess for gastric cancer, which now causes most gastric outlet obstruction in adults 3
• CT shows nodular/irregular wall thickening, soft tissue attenuation, perforation with ulcerated mass, lymphadenopathy, and distant metastases in gastric cancer 3

Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis once the patient is hemodynamically stable. 1

Common Gastrointestinal Causes in Older Adults

Peptic ulcer disease has 0.1-0.3% incidence but causes complications in 2-10% of cases, presenting with epigastric pain not relieved by antacids. 3, 1, 2

• Bleeding is the most common complication and presents as hematemesis 2
• CT findings include gastric/duodenal wall thickening, mucosal hyperenhancement, fat stranding, focal outpouching from ulcerations, or focal perforation with free air 3

Gastric cancer must be considered in older adults with new-onset persistent symptoms. 3, 1, 2

• Gastric adenocarcinoma has 7.3 per 100,000 incidence with only 32% five-year survival 3
• CT shows nodular/irregular wall thickening, soft tissue attenuation rather than edema, ulcerated mass, lymphadenopathy 3
• Malignancy is now the most common cause of gastric outlet obstruction because PUD incidence has decreased with widespread H2 blocker use 3, 1

Gastroesophageal reflux disease affects 42% of Americans monthly and 7% daily, often presenting with epigastric pain alongside heartburn. 3, 1, 2

• 66% of GERD patients with heartburn also experience epigastric pain 2
• 19% of patients cannot identify their predominant symptom between heartburn, regurgitation, or epigastric pain 2

Initial Management Protocol

Start high-dose PPI therapy immediately (omeprazole 20-40 mg once daily) for suspected acid-related pathology while awaiting diagnostic workup. 3, 1, 2, 5

• Healing rates are 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• Most duodenal ulcer patients heal within 4 weeks; some require additional 4 weeks 5
• Omeprazole is FDA-approved for short-term treatment (4-8 weeks) of active benign gastric ulcer and duodenal ulcer in adults 5

Test for H. pylori infection in all patients with peptic ulcer disease using stool test or breath test. 3

• Eradication reduces duodenal ulcer recurrence risk 5
• Triple therapy: omeprazole + clarithromycin + amoxicillin for H. pylori-positive patients with duodenal ulcer disease 5
• Dual therapy (omeprazole + clarithromycin) is more likely to cause clarithromycin resistance compared to triple therapy 5

For symptomatic nausea/vomiting relief: 2, 4

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 2, 4
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 2
• Prochlorperazine 5-10 mg every 6-8 hours 2

Maintain NPO status until surgical emergency is excluded. 2

Avoid NSAIDs as they worsen peptic ulcer disease and increase bleeding risk. 2

Critical Pitfalls to Avoid

Never dismiss cardiac causes based on age alone or "atypical" presentation—obtain ECG within 10 minutes for all patients with epigastric pain per American College of Cardiology guidelines. 1, 2, 4

Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis per American College of Surgeons. 1

Do not use aggressive fluid resuscitation in acute pancreatitis unless severe disease with persistent organ failure is present, as this triples mortality in non-severe cases per American College of Emergency Physicians. 4

Subsequent Management Based on Response

If symptoms persist after initial PPI therapy: 3

• Switch from PPI to prokinetic agent (or vice versa) if initial classification was incorrect 3
• Consider high-dose PPI therapy (omeprazole 40 mg once daily) to confirm acid-related nature 3
• Refer for endoscopy if symptoms persist despite therapy switch 3

If symptoms resolve with initial therapy: 3

• Trial withdrawal of therapy with repeat treatment if symptoms recur 3
• Consider on-demand therapy with the successful agent 3