What is the emergency treatment for a patient with severe epigastric pain of a pricking nature?

Emergency Treatment of Severe Pricking Epigastric Pain

Immediately obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which can present with epigastric pain and carries a 10-20% mortality if missed. 1

Immediate Life-Threatening Causes to Exclude First

The priority in the emergency setting is to rapidly identify conditions that require immediate intervention:

Cardiac Causes

• Myocardial infarction must be ruled out first in any patient with severe epigastric pain, as it frequently presents atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients 1
• Obtain ECG within 10 minutes of presentation and measure cardiac troponins at 0 and 6 hours (do not rely on a single measurement) 1, 2
• Never dismiss cardiac causes based on age or "atypical" presentation 1

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 1
• Mortality reaches 30% if treatment is delayed 1, 3
• Order CT abdomen/pelvis with IV contrast immediately, which shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 1, 3

Acute Pancreatitis

• Characterized by epigastric pain radiating to the back 1
• Diagnose with serum amylase ≥4x normal or lipase ≥2x normal (80-90% sensitivity and specificity) 1
• Overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 1

Vascular Emergencies

• Acute aortic dissection and leaking abdominal aortic aneurysm must be excluded, especially in patients over 50 years with vascular risk factors 1, 3
• Mesenteric ischemia presents with pain out of proportion to examination findings 3

Initial Assessment and Vital Signs

Check vital signs immediately for alarming clinical signs:

• Tachycardia ≥110 bpm predicts anastomotic leak, perforation, or sepsis 2, 1
• Fever ≥38°C indicates infection or perforation 2, 1
• Hypotension suggests shock or bleeding 2
• Respiratory distress with tachypnea and hypoxia (exclude pulmonary embolism) 2

Physical Examination Priorities

Perform focused examination looking for:

• Peritoneal signs (rigidity, rebound tenderness, guarding) indicating perforation 1
• Cardiac murmurs, irregular pulse, jugular vein distension suggesting cardiac pathology 1
• Abdominal tenderness location and severity 4

Immediate Laboratory Workup

Order the following tests stat:

• Complete blood count (anemia suggests bleeding) 1, 4
• Cardiac troponins at 0 and 6 hours 1
• Serum amylase or lipase (exclude pancreatitis) 1, 4
• C-reactive protein and serum lactate (markers of inflammation and ischemia) 1
• Liver and renal function tests 1
• Serum electrolytes and glucose 1, 4

Initial Management While Awaiting Diagnosis

Immediate Interventions

• Maintain NPO status until surgical emergency is excluded 1, 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 3
• Start high-dose PPI 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, 4

Symptomatic Relief

For nausea/vomiting:

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 1, 4
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Critical Medications to Avoid

• Avoid NSAIDs as they worsen peptic ulcer disease and increase bleeding risk 1, 3

Imaging Strategy

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 3

Alternative imaging if CT unavailable:

• Bedside ultrasound can rapidly identify gallbladder pathology, free fluid, or aortic aneurysm 5
• Chest and abdominal plain x-rays can help exclude perforated viscus and intestinal obstruction 3

Common Pitfalls to Avoid

• Missing cardiac causes in patients with "atypical" epigastric pain can be fatal with 10-20% mortality 1
• Delaying surgical consultation in patients with peritoneal signs and hemodynamic instability increases mortality to 30% in perforated ulcer 1, 3
• Relying on single troponin measurement instead of serial measurements at 0 and 6 hours 1
• Dismissing serious pathology in younger patients—perforated ulcer and pancreatitis occur at all ages 3

Disposition Based on Findings

Immediate Surgical Consultation Required

• Hemodynamic instability with peritoneal signs 2
• CT evidence of perforation or free air 1
• Suspected mesenteric ischemia or aortic emergency 3

Admit for Observation and Further Workup

• Elevated cardiac biomarkers 1
• Acute pancreatitis (even mild cases) 1
• Persistent pain with alarming vital signs despite negative initial workup 2