What is the best course of action for a patient with epigastric pain when swallowing?

Epigastric Pain When Swallowing: Diagnostic and Management Approach

Obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, then proceed with upper endoscopy as the standard test of choice for evaluating esophageal and gastric pathology causing pain with swallowing. 1, 2

Immediate Life-Threatening Exclusions

Rule out cardiac causes first - myocardial infarction can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed. 1

• Measure cardiac troponins at 0 and 6 hours (do not rely on single measurement) 1
• Cardiac causes should never be dismissed in patients with "atypical" epigastric pain regardless of age or presentation 1
• Look for associated shortness of breath, pain radiating to arm or jaw, or symptoms occurring with exertion 2, 3

Assess for 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

• CT abdomen/pelvis with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 1

Consider acute pancreatitis - characteristically presents with epigastric pain radiating to the back and is diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity. 1

Primary Esophageal and Gastric Causes

Dysphagia (pain when swallowing) suggests esophageal pathology and requires specific evaluation distinct from simple epigastric pain. 2

Upper endoscopy is the standard test of choice for suspected GERD, esophagitis, gastritis, peptic ulcer disease, or duodenal ulcer causing pain with swallowing. 2

• Endoscopy allows direct visualization and biopsy capability for tissue diagnosis 4
• Esophagitis manifests as fine nodularity or granularity of mucosa, erosions or ulcers, thickened longitudinal folds, and scarring with strictures 1
• Gastritis appears as enlarged areae gastricae, disruption of normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions 1

Fluoroscopy with biphasic esophagram is an alternative initial diagnostic study that can guide management when endoscopy is not immediately available. 4, 2

• Biphasic esophagrams have a sensitivity of about 95% for detecting lower esophageal rings and peptic strictures 4
• Double-contrast views best detect mucosal lesions (tumors, esophagitis), while prone single-contrast views best detect lower esophageal rings or strictures 4
• Videofluoroscopy has an overall sensitivity of 80-89% and specificity of 79-91% for diagnosing esophageal motility disorders compared with esophageal manometry 4

Initial Clinical Assessment

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

Perform focused physical examination looking for:

• Peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) 1
• Cardiac findings (murmurs, irregular pulse, jugular vein distension, friction rub) 1
• Pain reproduced by palpation 1

Assess specific symptom characteristics:

• Timing and onset (sudden vs. gradual) 1
• Severity on 1-10 scale 1
• Associated symptoms: nausea, vomiting, hematemesis (suggests bleeding ulcer or malignancy), heartburn, regurgitation 1, 2
• Pain radiating to the back (suggests pancreatic disease or aortic pathology) 2

Laboratory and Imaging Workup

Order initial laboratory tests:

• Complete blood count, C-reactive protein, serum lactate 1
• Liver and renal function tests 1
• Serum amylase or lipase 1
• Serum electrolytes and glucose 1
• H. pylori testing if peptic ulcer disease is suspected 2

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

• Do not rely solely on CT for initial diagnosis of GERD or peptic ulcer disease, as it has limited sensitivity for these conditions 2

Initial Management

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, 5

• Take omeprazole delayed-release capsules before meals 5
• Most patients with duodenal ulcers heal within 4 weeks; some may require an additional 4 weeks 5
• For gastric ulcers, treat for 4-8 weeks 5

Maintain NPO status until surgical emergency is excluded. 1

Provide IV access and fluid resuscitation if hemodynamically unstable. 1

Avoid NSAIDs as they can worsen peptic ulcer disease and bleeding risk. 1

For symptomatic relief of nausea:

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

Red Flag Symptoms Requiring Urgent Endoscopy

Prioritize endoscopy in patients with alarm symptoms:

• Weight loss 2
• Dysphagia (difficulty swallowing) 2
• Recurrent vomiting 2
• GI bleeding (hematemesis or melena) 2
• Family history of upper GI cancer 2

Gastric cancer may present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds, and is now the most common cause of gastric outlet obstruction in adults. 1

Special Considerations for Immunocompromised Patients

In immunocompromised patients with dysphagia or odynophagia (painful swallowing), the major consideration is infectious esophagitis, most commonly due to Candida albicans or herpes simplex virus. 4

• Endoscopy is preferred because of the ability to obtain specimens (histology, cytology, immunostaining, or culture) 4
• The endoscopic or radiographic appearance alone usually does not accurately predict diseases other than Candida esophagitis; diagnosis requires specimen acquisition 4
• Patients with radiographically diagnosed Candida or herpes esophagitis may be treated with antifungal or antiviral agents, respectively, without endoscopic evaluation 4

Critical Lifestyle Modifications

Advise immediate smoking cessation and counsel on alcohol reduction or cessation - smoking and alcohol 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

Remain upright for at least 30 minutes after meals to reduce reflux symptoms. 3

Common Pitfalls

Do not assume all epigastric pain with swallowing is acid-related - serious conditions like myocardial infarction, pancreatitis, or aortic dissection must be considered. 2

Symptoms of different conditions often overlap - approximately 19% of people with upper abdominal symptoms cannot distinguish their predominant symptom, making clinical history, risk factors, and associated symptoms crucial for narrowing the differential diagnosis. 2, 3

Normal-appearing tissue on endoscopy does not always rule out disease - biopsies may still show inflammation. 3

Endoscopy may miss lower esophageal rings - biphasic esophagrams detect about 95% of all lower esophageal rings, whereas endoscopy detected only 76% in one study. 4