What are the causes of epigastric pain in an adult with no known medical history?

Causes of Epigastric Pain in Adults

Immediate Life-Threatening Causes (Must Exclude First)

Myocardial infarction is the most critical diagnosis to exclude immediately, as it presents with epigastric pain in up to 20% of cases—particularly in women, diabetics, and elderly patients—with mortality rates of 10-20% if missed. 1

• Obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours (never rely on a single measurement) 1, 2
• Atypical presentations include epigastric pain mimicking indigestion, isolated dyspnea, and nausea without chest pain 1
• Never dismiss cardiac causes based on "atypical" presentation regardless of patient age 1

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

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension 1, 2
• Perform physical examination specifically looking for peritoneal signs (rebound tenderness, guarding, rigidity) 1, 2
• CT abdomen/pelvis with IV contrast shows extraluminal gas in 97% of cases 1

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

• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 1, 2
• Order serum lipase or amylase immediately in all patients with epigastric pain 2

Acute aortic dissection and leaking abdominal aortic aneurysm must be excluded, especially in patients over 50 years with vascular risk factors. 1, 3

Common Gastrointestinal Causes

Peptic Ulcer Disease and Gastritis

Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases, and presents with epigastric pain not relieved by antacids. 1, 2

• Bleeding is the most common complication (73% of complicated cases) and can present as hematemesis or melena (dark stools) 1, 3, 2
• Hemorrhage has an annual incidence of 0.02-0.06% with 30-day mortality of 8.6% 3
• Commonly caused by Helicobacter pylori infection (42% of cases) and NSAID use (36% of cases) 3, 2

Gastritis appears as enlarged areae gastricae, disruption of normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions, and is often associated with NSAID use, alcohol, or H. pylori infection. 1, 2

Gastroesophageal Reflux Disease (GERD)

GERD affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation. 1

• Approximately 66% of patients with GERD and heartburn also experience coexisting epigastric pain 4, 1
• In patients with upper abdominal pain where heartburn is only a secondary symptom, GERD is still present in approximately 30% 1
• Patients with heartburn and epigastric pain frequently cannot identify their predominant symptom, with 19% unable to choose between heartburn, regurgitation, or epigastric pain 4, 1
• Esophagitis manifests as fine nodularity or granularity of mucosa, erosions or ulcers, thickened longitudinal folds, and scarring with strictures 1

Functional Dyspepsia

Functional dyspepsia is the underlying cause in most individuals with dyspepsia in the community, with prevalence estimated at 7% using Rome IV criteria. 4

• Diagnostic criteria require one or more of: bothersome epigastric pain, bothersome epigastric burning, bothersome postprandial fullness, or bothersome early satiation 4
• Symptom onset must be at least 6 months prior to diagnosis, with symptoms active within the past 3 months 4
• No evidence of structural disease (including at upper endoscopy) likely to explain the symptoms 4
• Risk factors include female sex, smoking, use of NSAIDs, and H. pylori infection 4

Gastric Cancer

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, 2

• Has an incidence of 7.3 per 100,000 with 5-year survival of 32% 2
• Age ≥55 years with persistent symptoms warrants endoscopy, but alarm features mandate urgent evaluation regardless of age 2

Biliary and Hepatic Causes

Gangrenous gallbladder can present with epigastric pain in older adults with atypical signs and symptoms, requiring early diagnosis to prevent complications and death. 5

• Abdominal ultrasound is the first-line imaging modality for evaluating biliary pathology 6
• Older adults may present with covert signs and symptoms, increasing risk of delayed diagnosis 5

Rare but Important Causes

Gastric stromal tumors can present with acute epigastric pain due to torsion of pedunculated exophytic masses. 7

• Abdominal ultrasound may reveal multi-cystic heterogeneous masses between the stomach and liver 7
• CT scan confirms gastric origin and shows torsion signs requiring urgent surgical excision 7

Initial Diagnostic Workup

Order complete blood count, C-reactive protein, serum lactate, liver and renal function tests, serum amylase or lipase, serum electrolytes, and glucose testing immediately. 1, 2

• Measure cardiac troponins at 0 and 6 hours (do not rely on single measurement) 1, 2
• Check for anemia (alarm feature requiring urgent endoscopy) 2
• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2

Initial Management

Start high-dose PPI therapy (omeprazole 20-40 mg once daily before meals) immediately for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers. 1, 2

• Maintain NPO status until surgical emergency is excluded 1
• Provide IV access and fluid resuscitation if hemodynamically unstable 1
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1
• For 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 1, 2
• Obtain baseline ECG before administering ondansetron due to QTc prolongation risk 1

When to Perform Urgent Endoscopy

Perform upper endoscopy immediately in patients with alarm features: melena (dark stools indicating GI bleeding), hematemesis, persistent vomiting, anemia, or age ≥55 years with new-onset symptoms. 3, 2

• Endoscopy directly visualizes ulcers, obtains tissue for histopathology, performs H. pylori testing from biopsies, and rules out malignancy 3, 2
• At least two biopsy samples from both antrum and body should be obtained to improve H. pylori detection sensitivity 3

Critical Lifestyle Modifications

Advise immediate smoking cessation and counsel on alcohol reduction or cessation, as 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