What is the differential diagnosis and recommended investigation for a 53-year-old male with right-sided chest pain radiating to the back and right hypochondrium (RHC) associated with gastritis and epigastric burning, and electrocardiogram (ECG) findings of tall T waves in lead 2?

Differential Diagnosis and Investigations for Right-Sided Chest Pain with Gastritis and Tall T Waves

Immediate Life-Threatening Conditions to Exclude First

This 53-year-old male with right-sided chest pain radiating to the back, epigastric symptoms, and ECG changes requires urgent evaluation for acute coronary syndrome (ACS) first, despite the atypical features, followed by assessment for aortic dissection and biliary/pancreatic pathology. 1

Acute Coronary Syndrome (Priority #1)

• Age, male sex, and pain radiating to the back are significant risk factors for ACS, even with right-sided predominance 1
• Atypical presentations including epigastric pain, indigestion, and right-sided chest pain occur more frequently in older patients and can represent ACS 1
• Tall T waves in lead II can represent hyperacute T waves of early myocardial infarction or posterior wall involvement 1
• The one-week history with acute exacerbation in the last day fits the pattern of unstable angina progressing to acute myocardial injury 1

Aortic Dissection (Priority #2)

• Right-sided chest pain radiating to the back is a classic presentation for aortic dissection 1
• Physical examination must assess for pulse differentials between extremities, blood pressure differences ≥15 mm Hg between arms, and aortic regurgitation murmur 1
• This diagnosis carries extremely high mortality if missed 1

Acute Pancreatitis (Priority #3)

• Epigastric pain radiating to the back is the hallmark presentation of pancreatitis 1, 2
• The right hypochondrium involvement and gastritis symptoms could represent pancreatic inflammation 1

Upper Gastrointestinal Differential Diagnoses

Peptic Ulcer Disease with Potential Perforation

• The combination of one-week gastritis symptoms with sudden exacerbation raises concern for peptic ulcer perforation, which carries mortality rates up to 30% 2, 3
• Right upper quadrant pain can occur with duodenal ulcer disease 2, 4
• Warning signs of perforation include sudden severe pain, fever, tachycardia, and abdominal rigidity 2

Gastroesophageal Reflux Disease/Esophagitis

• Epigastric burning and chest pain are consistent with GERD, but this typically does not cause acute exacerbation or ECG changes 1, 3
• GERD-related chest pain can mimic cardiac ischemia but usually worsens after meals and when supine 1, 5

Biliary Pathology

• Right hypochondrium pain with epigastric symptoms suggests possible cholecystitis or biliary colic 1
• Murphy's sign and right upper quadrant tenderness should be assessed 1

Critical Immediate Investigations

Within 10 Minutes of Presentation

• 12-lead ECG must be obtained and interpreted within 10 minutes to assess for STEMI or NSTE-ACS 1
• Serial ECGs at 15-30 minute intervals if initial ECG is nondiagnostic but clinical suspicion remains high 1
• Right-sided leads (V3R-V4R) and posterior leads (V7-V9) should be obtained given the atypical location 1

Immediate Laboratory Testing

• High-sensitivity cardiac troponin should be measured immediately upon presentation 1
• Serial troponin measurements (at presentation, 1-3 hours, and potentially 6 hours depending on assay sensitivity) 1
• Complete blood count, comprehensive metabolic panel, lipase, and liver function tests 1, 2

Urgent Imaging Based on Clinical Findings

If cardiac workup is negative or equivocal:

• Chest CT with IV contrast to evaluate for aortic dissection if pulse differentials, blood pressure discrepancies, or high clinical suspicion exist 1
• Abdominal CT if peritoneal signs develop or if lipase is elevated to assess for pancreatitis or perforated ulcer 1, 2
• Chest radiograph to assess for widened mediastinum (dissection), free air under diaphragm (perforation), or pneumonia 1

If gastrointestinal pathology is suspected after cardiac exclusion:

• Upper endoscopy is the gold standard for diagnosing peptic ulcer disease and can simultaneously assess for H. pylori 2, 3
• Right upper quadrant ultrasound for biliary pathology if Murphy's sign is positive 1

Critical Pitfalls to Avoid

• Never assume gastrointestinal etiology based solely on epigastric symptoms in a 53-year-old male with chest pain and ECG changes 1
• Do not delay cardiac troponin testing or transfer to emergency department for definitive evaluation 1
• Tall T waves should never be dismissed as benign without serial ECGs and troponin measurements, as they can represent hyperacute changes of evolving MI 1
• The presence of "gastritis" symptoms does not exclude ACS—approximately 10-20% of chest pain has gastrointestinal causes, but cardiac causes must be excluded first in this age group 1
• If peritoneal signs develop (rigidity, rebound tenderness), immediate surgical consultation is mandatory for possible perforation 2

Algorithmic Approach

1. Activate emergency medical services if not already in emergency department 1
2. Obtain 12-lead ECG within 10 minutes, including right-sided and posterior leads 1
3. Draw high-sensitivity troponin immediately 1
4. Perform focused cardiovascular examination assessing for pulse differentials, blood pressure discrepancies, heart sounds (S3, S4, murmurs), and signs of heart failure 1
5. Assess abdomen for peritoneal signs, Murphy's sign, and epigastric tenderness 1, 2
6. If ECG shows STEMI or troponin positive: activate cardiac catheterization laboratory 1
7. If pulse differential or BP discrepancy present: urgent CT angiography for aortic dissection 1
8. If peritoneal signs present: urgent surgical consultation and CT abdomen/pelvis 2
9. If initial cardiac workup negative but symptoms persist: serial ECGs and troponins, consider stress testing or coronary CT angiography 1
10. Only after cardiac and life-threatening causes excluded: pursue gastrointestinal evaluation with upper endoscopy or empiric PPI trial 1, 2, 3