What is the initial approach to a 47-year-old woman presenting with epigastric pain?

Initial Approach to Epigastric Pain in a 47-Year-Old Woman

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

Immediate Life-Threatening Exclusions (First Priority)

Cardiac Causes

• Myocardial infarction must be ruled out first in any patient with epigastric pain, particularly in women who frequently present atypically without classic chest pain 2, 1
• Obtain ECG within 10 minutes of presentation 2, 1
• Measure serial cardiac troponins at 0 and 6 hours—never rely on a single troponin measurement 2, 1
• Look for ST-segment changes, which indicate high-risk features requiring immediate intervention 2

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 3, 1
• Mortality reaches 30% if treatment is delayed 2, 1
• Order CT abdomen/pelvis with IV contrast immediately if peritoneal signs are present—shows extraluminal gas in 97% of cases 2, 1

Acute Pancreatitis

• Characteristically presents with epigastric pain radiating to the back 2, 1
• Check 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 1

Vascular Emergencies

• Acute aortic dissection and leaking abdominal aortic aneurysm must be excluded, especially in patients over 50 years with vascular risk factors 2, 1

Initial Assessment and Vital Signs

Check vital signs immediately for:

• Hypotension or tachycardia ≥110 bpm, which predict hemorrhage, perforation, or sepsis with high specificity 1, 4
• Fever ≥38°C, which suggests infection or perforation 1, 4

Physical examination must assess:

• Peritoneal signs (rigidity, rebound tenderness, guarding) 2
• Epigastric tenderness, which suggests organic pathology rather than functional disease 4
• Cardiac murmurs, irregular pulse, jugular vein distension 1

Laboratory Testing (Order Immediately)

• Complete blood count to detect anemia (alarm feature) 1, 4
• C-reactive protein and serum lactate levels 1, 4
• Liver and renal function tests 1, 4
• Serum amylase or lipase 1, 4
• Serum electrolytes and glucose 1, 4
• Cardiac troponins at 0 and 6 hours 2, 1

Imaging Strategy

Ultrasound as first-line imaging:

• Bedside ultrasound is rapid, noninvasive, and can identify biliary pathology, free fluid, and some masses 3, 5

CT abdomen/pelvis with IV contrast is the gold standard when:

• Diagnosis remains unclear after initial assessment 2, 1
• Peritoneal signs are present 2
• Patient has high-risk features (age >50, new-onset symptoms, hemodynamic instability) 2
• CT identifies pancreatitis, perforation, and vascular emergencies with high accuracy 2, 1

Common Gastrointestinal Causes (After Excluding Life-Threatening Conditions)

Peptic Ulcer Disease

• Incidence of 0.1-0.3%, with complications in 2-10% of cases 2, 1
• Presents with epigastric pain not relieved by antacids 1, 4
• Bleeding is the most common complication and can present as hematemesis 1

Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily 1, 4
• Presents with epigastric pain often accompanied by heartburn and regurgitation 1, 4
• Approximately 66% of patients with GERD and heartburn also experience epigastric pain 1

Acute Gastritis

• Often associated with NSAID use, alcohol, or H. pylori infection 2, 4
• Appears on endoscopy as enlarged areae gastricae, thickened gastric folds, or erosions 1, 4

Gastric Cancer

• Should be considered with alarm symptoms: weight loss, dysphagia, hematemesis, anemia 1, 4
• May present with an ulcer associated with nodularity of adjacent mucosa 1, 4

Empiric Management While Awaiting Diagnosis

Immediate interventions:

• Maintain NPO status until surgical emergency is excluded 2, 1
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2, 1
• Start high-dose PPI therapy immediately: omeprazole 20-40 mg once daily before meals 1, 6
• Healing rates are 80-90% for duodenal ulcers and 70-80% for gastric ulcers with PPI therapy 1

For symptomatic relief of nausea:

• 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, 4
• Prochlorperazine 5-10 mg every 6-8 hours 1, 4

Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2, 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain—myocardial infarction can present with epigastric pain as the primary manifestation, especially in women 2, 1
• Do not delay imaging in patients with peritoneal signs—perforated ulcer mortality increases significantly with delayed diagnosis 2
• Never rely on a single troponin measurement—requires serial measurements at least 6 hours apart to exclude NSTEMI 2, 1
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 2
• Persistent vomiting with epigastric pain is a red flag that excludes functional dyspepsia and mandates investigation for structural disease 4

When to Perform Upper Endoscopy

Urgent endoscopy is indicated for:

• Alarm features: weight loss, anemia, dysphagia, persistent vomiting, hematemesis 1, 4
• Age ≥55 years with treatment-resistant symptoms 4
• Epigastric tenderness on examination with prolonged symptom duration 4

Lifestyle Modifications (Once Serious Pathology Excluded)

• Advise immediate smoking cessation and alcohol reduction, as both have a synergistic dose-dependent effect on gastric ulcer risk 1
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 1