Urgent Evaluation for Life-Threatening Causes is Mandatory
This 14-year-old patient with migrating abdominal pain (lower to upper abdomen) accompanied by nausea requires immediate exclusion of surgical emergencies, particularly perforated peptic ulcer and acute pancreatitis, before considering less serious diagnoses.
Immediate Assessment (Within 10 Minutes)
Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation, sepsis, or other surgical emergencies with high specificity 1, 2.
Obtain an ECG within 10 minutes to exclude myocardial infarction, which can present atypically with epigastric pain as the primary manifestation, particularly in females and diabetics, with mortality rates of 10-20% if missed 1, 2.
Perform focused physical examination looking for:
- Peritoneal signs (rigidity, rebound tenderness, guarding) suggesting perforation 1, 2
- Absent bowel sounds indicating ileus or perforation 2
- Epigastric tenderness suggesting organic pathology 3
Critical Laboratory Testing
Order immediately:
- Complete blood count to assess for anemia or leukocytosis 1, 2
- Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, which has 80-90% sensitivity and specificity 1, 2
- C-reactive protein and serum lactate levels 1, 2
- Liver and renal function tests 1, 2
- Serum electrolytes and glucose 3
- Cardiac troponins at 0 and 6 hours (do not rely on single measurement) 1, 2
Imaging Strategy
CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, as it identifies:
- Extraluminal gas in 97% of perforated peptic ulcers 1, 3
- Fluid or fat stranding in 89% 1, 3
- Ascites in 89% 1, 3
- Focal wall defect in 84% 1, 3
- Acute pancreatitis and vascular emergencies 1, 2
Life-Threatening Diagnoses to Exclude
Perforated Peptic Ulcer
Presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed 1, 2. Requires emergent surgical consultation for laparoscopic or open repair with omental patch 2.
Acute Pancreatitis
Characterized by epigastric pain radiating to the back with elevated serum amylase or lipase, with overall mortality <10% but reaching 30-40% in necrotizing pancreatitis 1, 2. The migrating nature of this patient's pain (lower to upper abdomen) does not exclude pancreatitis 4.
Acute Appendicitis
The initial lower abdominal pain that migrated to the upper abdomen raises concern for atypical appendicitis presentation, though classic migration is from periumbilical to right lower quadrant 5. However, appendicitis can cause pain throughout the abdomen and requires surgical consultation if confirmed 5.
Initial Management While Awaiting Diagnosis
Maintain NPO status until surgical emergency is excluded 1, 2.
Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 2.
Start high-dose PPI therapy immediately (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, 3.
Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1, 2.
For symptomatic relief of nausea, use 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, with baseline ECG obtained before administering ondansetron due to QTc prolongation risk 1, 3.
Common Pitfalls to Avoid
Never dismiss cardiac causes based on age alone, as atypical presentations of myocardial infarction occur in adolescents, particularly females and diabetics 2.
The presence of persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease 3.
Delaying endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia) can lead to poor outcomes 3.
Missing perforated peptic ulcer is catastrophic, with mortality reaching 30% if treatment is delayed 1, 2.
If Initial Workup is Negative
Consider upper endoscopy if symptoms persist beyond initial management, as gastritis, peptic ulcer disease, or gastroesophageal reflux disease are common causes of epigastric pain in adolescents 6, 1, 3.
Fluoroscopy upper GI series can detect ulcers, gastritis, and hiatal hernias if endoscopy is not immediately available 3.
Continue PPI therapy for 4-8 weeks if peptic ulcer disease or gastritis is confirmed, with reevaluation if symptoms persist 1, 7.