What is the appropriate workup for an adult patient with no significant medical history presenting with epigastric pain?

Workup for Epigastric Pain in Adults

Immediate Life-Threatening Exclusions

First, obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours to exclude acute coronary syndrome, as myocardial infarction can present atypically with epigastric pain and carries a 10-20% mortality if missed. 1

• Never rely on a single troponin measurement; serial measurements at least 6 hours apart are mandatory to exclude NSTEMI 2, 1
• Atypical cardiac presentations are particularly common in women, diabetics, and elderly patients, who may present with epigastric pain, indigestion-like symptoms, or isolated dyspnea without classic chest pain 2, 1
• The absence of chest pain does not exclude cardiac disease 2

Initial Clinical Assessment

Check vital signs immediately for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis with high specificity. 1

Perform a focused physical examination assessing for:

• Peritoneal signs: rigidity, rebound tenderness, absent bowel sounds (suggests perforation with 30% mortality if treatment delayed) 1
• Cardiac findings: murmurs, irregular pulse, jugular venous distension 1
• Pain characteristics: sudden onset suggests perforation; gradual onset suggests inflammatory or acid-related disease 1

Evaluate accompanying symptoms to narrow differential:

• Heartburn and regurgitation suggest GERD (affects 42% of Americans monthly) 3, 1
• Dysphagia suggests esophageal pathology 3, 4
• Hematemesis suggests bleeding ulcer or malignancy 3, 4
• Nausea and vomiting indicate gastritis, peptic ulcer disease, or obstruction 3, 4
• Pain radiating to back suggests pancreatitis or aortic pathology 3, 4

Laboratory Workup

Obtain the following tests:

• Complete blood count and C-reactive protein 1
• Serum amylase or lipase to exclude acute pancreatitis 2, 1
• Liver and renal function tests 2, 1
• Electrolyte and glucose levels 2, 1
• H. pylori testing if peptic ulcer disease is suspected 4

Imaging Strategy

Upper endoscopy is the standard test of choice for suspected GERD, esophagitis, gastritis, peptic ulcer disease, or duodenal ulcer. 3, 4

• Endoscopy should be prioritized in patients with alarm symptoms: weight loss, dysphagia, recurrent vomiting, GI bleeding, or family history of upper GI cancer 4
• Ultrasonography is the first-line imaging in the emergency setting because it is rapid, noninvasive, and can identify biliary, pancreatic, and vascular pathology 5

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis remains unclear after initial workup, identifying pancreatitis, perforation (97% sensitivity for extraluminal gas), and vascular emergencies. 3, 1

• CT should be performed with IV contrast and neutral oral contrast (water or dilute barium) to assess mucosal enhancement and detect intraluminal bleeding 3
• CT findings for perforation include: extraluminal gas (97%), fluid or fat stranding (89%), ascites (89%), focal wall defect (84%), and wall thickening (72%) 3
• CT is not the initial test of choice for suspected acid reflux or peptic ulcer disease, but patients with nonspecific symptoms may undergo CT as the initial diagnostic test 3

Fluoroscopy with upper GI series is beneficial for evaluating structural and functional abnormalities, particularly hiatal hernia 4

Initial Management

Maintain the patient nil per os until surgical emergency is excluded. 1

• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1
• Start high-dose proton pump inhibitor therapy (omeprazole 20-40 mg once daily) for suspected acid-related disease, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2, 1
• Avoid NSAIDs as they exacerbate peptic ulcer disease and increase bleeding risk 1
• Symptomatic treatment for nausea: ondansetron 8 mg sublingually every 4-6 hours (obtain baseline ECG due to QTc prolongation risk), promethazine 12.5-25 mg every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based solely on absence of chest pain or "atypical" presentation, regardless of age 2, 1
• Do not delay imaging in patients with peritoneal signs, as mortality from perforated ulcer increases significantly with delayed diagnosis 1
• Do not assume GERD without first excluding life-threatening causes, even in patients with known reflux disease 1
• Persistent vomiting with epigastric pain excludes functional dyspepsia and requires investigation for structural disease 1
• Do not rely solely on CT for initial diagnosis of GERD or peptic ulcer disease, as it has limited sensitivity for these conditions 4
• Older adults may present with atypical or covert signs and symptoms, increasing risk of delayed diagnosis and poor outcomes 6