What is the appropriate diagnosis and treatment for a patient with upper abdominal burning pain radiating to the back, potentially indicating pancreatitis or a perforated peptic ulcer?

Upper Abdominal Burning Pain Radiating to Back: Diagnostic and Treatment Approach

For a patient with upper abdominal burning pain radiating to the back, immediately obtain CT scan of the abdomen/pelvis with IV contrast as the first-line diagnostic test, as this presentation suggests either perforated peptic ulcer or acute pancreatitis—both life-threatening conditions requiring urgent differentiation. 1, 2

Immediate Diagnostic Workup

Priority Imaging

• CT scan with IV contrast is the gold standard initial test for suspected perforated peptic ulcer or pancreatitis, with superior sensitivity over plain radiography 1, 2
• CT findings for perforation include pneumoperitoneum, unexplained intraperitoneal fluid, bowel wall thickening, mesenteric fat streaking, and extraluminal contrast 2
• If CT is unavailable, obtain chest/abdominal X-ray immediately, though free air is detected in only 30-85% of perforations 2
• Up to 12% of perforations may have normal initial CT, requiring clinical correlation and possible repeat imaging 2

Essential Laboratory Studies

• Obtain complete blood count, comprehensive metabolic panel, and arterial blood gas analysis immediately 3, 2
• Check serum amylase and lipase to evaluate for pancreatitis 3, 2
• Leukocytosis, metabolic acidosis, and elevated amylase are commonly associated with perforation but are non-specific 3, 4
• Hypoalbuminemia is the strongest single predictor of mortality in perforated peptic ulcer 2

Critical Clinical Differentiation

Pain Characteristics That Guide Diagnosis

• Perforated peptic ulcer: Sudden onset of severe upper abdominal pain with tachycardia and abdominal rigidity, though peritonitis may be present in only two-thirds of patients 4
• Gastric ulcer (non-perforated): Pain occurs immediately after eating, localized to epigastrium, radiates to back 5
• Chronic pancreatitis: Pain radiating to back is the typical symptom 5
• Important caveat: Physical examination findings may be equivocal, and peritonitis may be minimal or absent in contained perforations 4

Resuscitation Priorities for Unstable Patients

Hemodynamic Targets

• Restore physiological parameters with mean arterial pressure ≥ 65 mmHg, urine output ≥ 0.5 ml/kg/h, and lactate normalization 1
• Perform rapid ABC (airway, breathing, circulation) evaluation simultaneously with surgical consultation 1
• Utilize hemodynamic monitoring (invasive or non-invasive) to optimize fluid/vasopressor therapy 1
• Resuscitation must occur within 1 hour to reduce mortality in septic perforated peptic ulcer patients 1

Risk Stratification

Severity Assessment Tools

• Use SOFA or qSOFA scores to evaluate disease severity in perforated peptic ulcer 2
• Apply Boey, PULP, or ASA scores for risk stratification 2
• Recognize that scoring systems help guide management but should not delay definitive treatment 2

Management Algorithm Based on Diagnosis

If Perforated Peptic Ulcer Confirmed

• Surgery is the standard treatment; non-operative management should NOT be routinely used 1
• Non-operative management may be considered only in extremely selected cases where perforation has sealed as confirmed on water-soluble contrast study 1
• Peritonitis from perforation is a surgical emergency requiring patient resuscitation, laparotomy, peritoneal toilet, and omental patch placement 6

If Non-Perforated Peptic Ulcer Disease

• Initiate proton pump inhibitor therapy (omeprazole or lansoprazole), which heals 80-100% of ulcers within 4 weeks 7
• Gastric ulcers >2 cm may require 8 weeks of treatment 7
• All patients must undergo H. pylori testing using urea breath test (sensitivity 88-95%, specificity 95-100%) or stool antigen test (sensitivity 94%, specificity 92%) 3
• Stop PPIs, antibiotics, and bismuth for at least 2 weeks before H. pylori testing to avoid false-negatives 3
• If H. pylori positive, eradicate infection to reduce recurrence from 50-60% to 0-2% 7
• Discontinue NSAIDs if applicable, which heals 95% of ulcers and reduces recurrence from 40% to 9% 7

Endoscopic Evaluation

• Upper endoscopy (EGD) with biopsy is the definitive diagnostic test for suspected gastric ulcer 3
• Biopsy all gastric ulcers from both base and edges to exclude malignancy, as gastric ulcers can harbor adenocarcinoma 3
• Obtain additional biopsies from antrum (2 within 2-3 cm of pylorus) and body (2 biopsies) for H. pylori testing 3
• Repeat endoscopy at 6-8 weeks to document healing and obtain additional biopsies if not done initially 3

Common Pitfalls to Avoid

• Do not rely on plain radiography alone—CT is far superior for detecting perforation 2
• Do not assume normal CT excludes perforation—12% of perforations have normal initial CT 2
• Do not forget to test for H. pylori in all peptic ulcer patients—this is mandatory for preventing recurrence 3
• Do not perform H. pylori testing while patient is on PPIs—this is the most common cause of false-negative results 3
• Do not use serology alone for H. pylori treatment decisions—it cannot confirm active infection 3
• Do not delay surgical consultation in unstable patients—resuscitation and surgical evaluation must occur simultaneously 1