What is the appropriate workup for a patient presenting with epigastric pain?

Workup for Epigastric Pain

Immediately obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which carries a 10-20% mortality if missed and frequently presents atypically as epigastric pain, especially in women, diabetics, and elderly patients. 1

Immediate Life-Threatening Exclusions

Cardiac Assessment

• Never rely on a single troponin measurement—serial measurements at least 6 hours apart are mandatory to exclude NSTEMI 1
• Atypical presentations include epigastric pain mimicking indigestion, particularly in elderly patients, women, and diabetics 1
• Do not dismiss cardiac causes regardless of how "typical" the gastrointestinal symptoms appear 1

Vital Signs and Physical Examination

• Check immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis with high specificity 2, 1
• Examine for peritoneal signs: rigidity, rebound tenderness, absent bowel sounds indicating perforated viscus 1
• Perforated peptic ulcer presents with sudden severe epigastric pain becoming generalized, with mortality reaching 30% if treatment is delayed 1
• Assess for cardiac findings: irregular pulse, jugular venous distension, friction rub 1

Essential Laboratory Testing

Order the following immediately:

• Complete blood count to detect anemia (alarm feature requiring urgent endoscopy) 2, 1
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis, which has 30-40% mortality in necrotizing forms 2
• C-reactive protein and serum lactate for inflammatory markers 2, 1
• Liver and renal function tests 2, 1
• Serum electrolytes and glucose 2, 1
• Cardiac troponins at 0 and 6 hours (never single measurement) 1

Imaging Strategy

When to Image Urgently

• CT abdomen with IV contrast is the gold standard when diagnosis is unclear or peritoneal signs are present 1
• CT detects perforation with 97% sensitivity (extraluminal gas), plus fluid/fat stranding (89%), ascites (89%), focal wall defect (84%) 2, 1
• Do not delay imaging in patients with peritoneal signs—mortality from perforated ulcer increases significantly with delayed diagnosis 1
• Consider mesenteric ischemia in elderly patients with vascular risk factors and pain out of proportion to examination 2
• Exclude leaking abdominal aortic aneurysm in patients over 50 with vascular risk factors 2

Ultrasound Role

• Bedside ultrasound is rapid, noninvasive, and can detect biliary, pancreatic, and hepatic pathology 3
• Useful as first-line imaging but CT is superior for comprehensive evaluation 3

Risk Stratification for Endoscopy

Alarm Features Requiring Urgent Endoscopy

• Persistent vomiting (excludes functional dyspepsia and mandates investigation for structural disease) 2
• Weight loss (requires objective evidence) 2
• Anemia on CBC 2
• Dysphagia or food sticking sensation 2
• Hematemesis 2
• Age ≥55 years for average-risk populations OR ≥40 years for high-risk populations (family history of gastric/esophageal cancer) 4
• Epigastric tenderness on examination with prolonged symptom duration suggests organic pathology 2

Test-and-Treat Strategy for Low-Risk Patients

For patients without alarm features and age <55 years (or <40 years in high-risk populations):

• Test for H. pylori infection and treat if positive before considering endoscopy 4
• This strategy is cost-effective and eliminates peptic ulcer mortality risk 4
• Approximately 10% of dyspepsia patients have peptic ulcer disease 4

Initial Management While Awaiting Workup

• Keep patient nil per os until surgical emergency is excluded 1
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1
• Start high-dose PPI therapy immediately: omeprazole 20-40 mg once daily before meals, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2, 1
• Avoid NSAIDs—they exacerbate peptic ulcer disease and increase bleeding risk 1

Antiemetic Therapy (if vomiting present)

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 2, 1
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 2, 1
• Prochlorperazine 5-10 mg every 6-8 hours 2, 1

Critical Pitfalls to Avoid

• Delaying endoscopy in patients with alarm features leads to poor outcomes, including missed gastric cancer 2, 1
• Missing cardiac causes by assuming GERD without ECG and troponins can be fatal 1
• Persistent vomiting with epigastric pain is never functional—requires investigation for peptic ulcer disease or acute coronary syndrome 2
• Delaying imaging when peritoneal signs are present—perforated ulcer mortality reaches 30% with delayed treatment 1
• Failing to organize systematic follow-up after test-and-treat strategy to identify patients requiring escalation to endoscopy 4

Pregnancy-Specific Considerations

If patient is pregnant, also consider:

• Preeclampsia: epigastric/RUQ pain with headaches, visual changes, swelling 2
• HELLP syndrome: epigastric pain with nausea, vomiting, malaise 2
• Acute fatty liver of pregnancy: malaise, headache, nausea, vomiting, jaundice, epigastric pain 2