What is the initial approach to a patient presenting with epigastric pain in a primary care setting?

Initial Workup of Epigastric Pain in Primary Care

Immediately obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which can present atypically as epigastric pain with mortality rates of 10-20% if missed, particularly in women, diabetics, and elderly patients. 1

Immediate Life-Threatening Exclusions (First Priority)

Cardiac causes must never be dismissed regardless of how "typical" the gastrointestinal presentation appears. 1, 2 The following require urgent evaluation:

• Myocardial infarction: Obtain ECG immediately and serial troponins at 0 and 6 hours—never rely on a single troponin measurement 1, 2
• Perforated peptic ulcer: Look for sudden severe pain becoming generalized, fever, abdominal rigidity, and absent bowel sounds (mortality 30% if delayed) 1
• Acute pancreatitis: Check serum lipase ≥2x normal or amylase ≥4x normal (80-90% sensitivity/specificity); mortality reaches 30-40% in necrotizing pancreatitis 1
• Aortic dissection/leaking AAA: Especially in patients >50 years with vascular risk factors 1, 2

Focused History Elements

Document these specific features systematically:

• Onset pattern: Sudden (suggests perforation/vascular) vs. gradual (suggests inflammatory/functional) 1
• Pain severity: Use 1-10 scale for documentation 1
• Radiation: To back (pancreatitis), to shoulder (diaphragmatic irritation from perforation), substernal (cardiac/GERD) 1, 2
• Associated symptoms: Hematemesis (bleeding ulcer), heartburn/regurgitation (GERD affects 42% of Americans monthly), inability to distinguish predominant symptom between heartburn and epigastric pain (occurs in 19% of GERD patients) 1
• NSAID/alcohol/smoking use: Synergistic dose-dependent effect on gastric ulcer risk 1
• Duration: Symptoms <4 weeks may warrant watchful waiting; ≥4 weeks requires active workup 3

Physical Examination Priorities

• Vital signs: Hypotension, tachycardia ≥110 bpm, or fever ≥38°C predict perforation, anastomotic leak, or sepsis with high specificity 1, 2
• Peritoneal signs: Rigidity, rebound, guarding indicate surgical emergency 1, 2
• Cardiac examination: Murmurs, irregular pulse, JVD, friction rub 1
• Reproducibility: Pain reproduced by palpation suggests musculoskeletal or functional etiology 1

Initial Laboratory Testing

Order this panel for all patients with epigastric pain:

• Cardiac troponins at 0 and 6 hours (mandatory even if ECG normal) 1, 2
• Complete blood count (anemia suggests bleeding; leukocytosis suggests infection/inflammation) 1
• Serum lipase or amylase (lipase preferred, ≥2x normal diagnostic for pancreatitis) 1
• C-reactive protein and serum lactate (elevated in ischemia, perforation, severe inflammation) 1
• Liver and renal function tests 1
• Serum electrolytes and glucose 1

Imaging Strategy

CT abdomen/pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis (89% sensitivity for ascites/fat stranding), perforation (97% sensitivity for extraluminal gas), and vascular emergencies. 1, 2

• Bedside ultrasound can be performed immediately by trained providers to evaluate gallbladder, aorta, and free fluid 4
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis once patient is stable and surgical emergency excluded 2

Age-Based Risk Stratification

Patients above local age cutoff (typically 45-55 years depending on gastric cancer incidence) with new-onset dyspepsia require endoscopy. 3 Among patients >50 years with reflux symptoms >5 years, the annual yield of endoscopy for detecting esophageal adenocarcinoma is <1 in 1000, but alarm symptoms mandate immediate evaluation. 3

Alarm Features Requiring Urgent Endoscopy

Refer immediately if any present:

• Dysphagia or odynophagia 3
• Unintentional weight loss 3, 2
• Hematemesis or melena 3, 1
• Persistent vomiting 3
• Palpable abdominal mass 3
• Age >45-55 years with new-onset symptoms 3

Initial Management While Establishing Diagnosis

• Maintain NPO status until surgical emergency excluded 1, 2
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 2
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology; healing rates 80-90% for duodenal ulcers, 70-80% for gastric ulcers 1
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1
• Antiemetics if needed: Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk), promethazine 12.5-25 mg every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 1

H. pylori Testing Strategy for Low-Risk Patients

For patients without alarm symptoms who have had symptoms ≥4 weeks, test for H. pylori and treat if positive. 3 This approach is cost-effective and eliminates peptic ulcer mortality risk, though it may not resolve symptoms in all functional dyspepsia patients. 3

• Use locally validated serological test with ≥90% sensitivity and specificity, or urea breath test 3
• Most whole blood tests are inadequate 3
• After successful H. pylori eradication, manage residual symptoms with empirical PPI therapy 3

Symptom-Based Empirical Therapy (After Excluding Emergencies)

For ulcer-like dyspepsia (predominant epigastric pain): Full-dose PPI therapy (omeprazole 20 mg once daily) is first-line; response confirms acid-related etiology 3

For dysmotility-like symptoms (fullness, bloating, early satiety): Prokinetic agents are an option, though cisapride is contraindicated due to cardiac toxicity 3

If symptoms controlled: Trial withdrawal of therapy and use on-demand treatment for recurrence 3

Follow-Up and Reassessment

• Symptoms <4 weeks: Reassurance, over-the-counter antacids, and watchful waiting with organized follow-up 3
• Persistent symptoms despite PPI therapy: Consider endoscopy to exclude structural pathology 3
• Functional dyspepsia diagnosis: After confidently excluding organic pathology, avoid repetitive testing and refer for psychological support (cognitive therapy) with pharmacological options 5

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain regardless of age or presentation 1, 2
• Do not rely on single troponin measurement; requires serial measurements at least 6 hours apart 1, 2
• Do not delay imaging in patients with peritoneal signs; perforated ulcer mortality increases significantly with delayed diagnosis 1, 2
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 2
• Recognize that 66% of GERD patients have both heartburn and epigastric pain, and 19% cannot identify their predominant symptom 1