What is the appropriate initial evaluation and management for a patient, particularly those over 50 years of age or with a history of gastrointestinal disease, presenting with epigastric pain?

Epigastric Pain: Initial Evaluation and Management

Immediate Life-Threatening Exclusions

Obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which carries 10-20% mortality if missed and can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients. 1, 2

• Look specifically for associated symptoms: shortness of breath, pain radiating to arm or jaw, or symptoms occurring with exertion 3, 1
• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation 1

Assess immediately for perforated peptic ulcer, which 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

• Examine specifically for peritoneal signs: abdominal rigidity, rebound tenderness, and absent bowel sounds 2
• 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% 4, 1

Risk-Stratified Diagnostic Approach

High-Risk Patients (Age >50 or Alarm Symptoms)

Proceed directly to upper endoscopy if any alarm symptoms are present: weight loss, dysphagia, recurrent vomiting, GI bleeding, or family history of upper GI cancer. 3, 1

• Endoscopy is the standard test of choice for suspected GERD, esophagitis, gastritis, peptic ulcer disease, or duodenal ulcer, allowing direct visualization and biopsy capability 3, 1
• Gastric cancer has a 5-year survival rate of only 32% and may present with nonspecific symptoms 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

Moderate-Risk Patients (Stable, No Alarm Symptoms)

Order H. pylori testing and initiate high-dose PPI therapy (omeprazole 40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 3, 2, 5

• If empiric PPI therapy fails after 4-8 weeks, proceed to upper endoscopy regardless of age 2
• Take omeprazole before meals; most patients with duodenal ulcers heal within 4 weeks, though some may require an additional 4 weeks 5

Initial Laboratory and Imaging Workup

Obtain complete blood count, C-reactive protein, serum lactate, liver and renal function tests, serum amylase or lipase, and serum electrolytes and glucose. 1

• Obtain serum amylase and lipase immediately to exclude acute pancreatitis, which is diagnosed by amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 2

Order CT abdomen and pelvis with IV contrast when diagnosis is unclear, peritoneal signs are present, hemodynamic instability exists, or severe pain is present—this is the gold standard for identifying perforation, pancreatitis, and vascular emergencies. 1, 2

• When gastric disease is suspected, perform CT with IV contrast and neutral oral contrast (water or dilute barium) to assess for nodular wall thickening and soft tissue attenuation 4
• Do not rely solely on CT for initial diagnosis of GERD or peptic ulcer disease, as it has limited sensitivity for these conditions 3, 1

Consider fluoroscopy with biphasic esophagram as an alternative initial diagnostic study when endoscopy is not immediately available, with sensitivity of about 95% for detecting lower esophageal rings and peptic strictures. 1

• Double-contrast views best detect mucosal lesions, while prone single-contrast views best detect lower esophageal rings or strictures 1
• Upper GI series is beneficial for evaluating structural and functional abnormalities of the esophagus, stomach, and duodenum 4

Symptom-Specific Diagnostic Clues

Evaluate specific accompanying symptoms to narrow the differential diagnosis: 3

• Heartburn and regurgitation suggest GERD 3
• Dysphagia suggests esophageal pathology 3
• Nausea and vomiting may indicate gastritis, PUD, or obstruction 3
• Hematemesis suggests bleeding ulcer or malignancy 3
• Pain radiating to the back may indicate pancreatic disease or aortic pathology 3
• Postprandial fullness and early satiation present for at least 3 days per week with symptom onset at least 6 months prior meets Rome IV criteria for Postprandial Distress Syndrome 2

Initial Management Priorities

Maintain NPO status until surgical emergency is excluded, provide IV access and fluid resuscitation if hemodynamically unstable, and avoid NSAIDs as they can worsen peptic ulcer disease and bleeding risk. 1

For perforated peptic ulcer with adequate source control in immunocompetent, non-critically ill patients, use amoxicillin/clavulanate 2 g/0.2 g q8h for 4 days. 4

• For critically ill or immunocompromised patients with adequate source control, use piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h or 16 g/2 g by continuous infusion 4
• If septic shock is present, use meropenem 1 g q6h by extended infusion or continuous infusion 4
• Laparoscopic/open simple or double-layer suture with or without an omental patch is safe and effective for small perforated ulcers 4

Follow-Up and Monitoring

Monitor weight closely—any weight loss mandates repeat endoscopy and cross-sectional imaging. 2

• For maintenance of healing of erosive esophagitis, continue omeprazole 20 mg once daily, though controlled studies do not extend beyond 12 months 5
• If there is recurrence of erosive esophagitis or GERD symptoms, additional 4 to 8 week courses of omeprazole may be considered 5

Special Considerations for Immunocompromised Patients

Consider infectious esophagitis, most commonly due to Candida albicans or herpes simplex virus, in immunocompromised patients with dysphagia or odynophagia, and perform endoscopy to obtain specimens for histology, cytology, immunostaining, or culture. 1

Common Pitfalls to Avoid

• Do not assume all epigastric pain is due to acid-related disorders—always consider serious conditions like myocardial infarction, pancreatitis, or aortic dissection 3
• Symptoms of different conditions often overlap, making clinical history, risk factors, and associated symptoms crucial for narrowing the differential diagnosis 3
• Do not perform CT abdomen and pelvis without IV contrast for suspected peptic ulcer disease, as it will be less sensitive in establishing the diagnosis 4
• Multiphase contrast-enhanced examinations are not routinely performed except when acute GI bleeding as a complication of PUD is suspected 4