What is the best approach for diagnosing and managing epigastric pain in a patient, considering factors such as age, sex, and medical history?

Evaluation of Epigastric Pain

Immediate Life-Threatening Exclusions

Obtain an ECG within 10 minutes of presentation and measure serial cardiac troponins at 0 and 6 hours to exclude acute coronary syndrome, as myocardial infarction can present atypically with epigastric pain, particularly in women, diabetics, and the elderly, with mortality rates of 10-20% if missed. 1, 2

Critical Initial Assessment

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis with high specificity 1, 2
• Examine for peritoneal signs including rigidity, rebound tenderness, and absent bowel sounds, which indicate perforation requiring emergent surgical consultation 2, 3
• Never rely on a single troponin measurement; serial measurements at least 6 hours apart are mandatory to exclude NSTEMI 2, 3
• Never dismiss cardiac causes based on "atypical" presentation or age alone, as atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea 2, 3

Other Emergent Conditions to Exclude

• Perforated peptic ulcer presents with sudden, severe epigastric pain becoming generalized, accompanied by fever and abdominal rigidity, with mortality reaching 30% if treatment is delayed 1, 2, 3
• Order CT abdomen with IV contrast if perforation suspected, which shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 1, 2, 3
• Acute pancreatitis characteristically presents with epigastric pain radiating to the back; check serum amylase (≥4x normal) or lipase (≥2x normal) with 80-90% sensitivity and specificity 1, 3
• Acute aortic dissection causes sudden, severe epigastric pain radiating to the back or shoulders and requires emergent CT angiography 3
• Mesenteric ischemia presents with severe epigastric pain out of proportion to examination findings, particularly in elderly patients with vascular risk factors 1, 3

Essential Laboratory Testing

• Complete blood count, C-reactive protein, serum lactate levels 1, 2, 3
• Cardiac troponins at 0 and 6 hours (never rely on single measurement) 1, 2, 3
• Serum amylase or lipase to exclude acute pancreatitis 1, 2, 3
• Liver and renal function tests 1, 2
• Serum electrolytes and glucose 1

Common Gastrointestinal Causes

GERD and Esophagitis

• GERD affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitation 1, 2, 3
• Esophagitis manifests as fine nodularity or granularity of the mucosa, erosions or ulcers, thickened longitudinal folds, and strictures 1, 2, 3
• Distal esophageal wall thickening (≥5 mm) on CT has moderate association with reflux esophagitis with 56% sensitivity and 88% specificity 4

Peptic Ulcer Disease and Gastritis

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 2, 3
• Bleeding is the most common complication of duodenal ulcers, presenting as hematemesis 1, 3
• Gastritis appears as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 1, 2, 3
• CT findings suggestive of gastritis or PUD include gastric or duodenal wall thickening, mucosal hyperenhancement, fat stranding, and focal outpouching from ulcerations 4

Gastric Cancer

• Gastric cancer may present with ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 1, 2, 3
• Now the most common cause of gastric outlet obstruction in adults 2, 3
• Alarm features mandating urgent endoscopy include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia 1, 2, 3

Diagnostic Imaging Algorithm

When to Order CT Abdomen with IV Contrast

• CT abdomen with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 2, 3
• Order emergently if peritoneal signs present, as mortality from perforated ulcer increases significantly with delayed diagnosis 2, 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 3

Role of Upper Endoscopy

• Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable 3
• Urgent endoscopy is mandated for alarm features: persistent vomiting, weight loss, anemia, dysphagia, or age ≥55 years with treatment-resistant dyspepsia 1
• Delaying endoscopy in patients with alarm features leads to poor outcomes 1, 2

Fluoroscopic Studies

• Fluoroscopic upper GI series evaluates structural and functional abnormalities of esophagus, stomach, and duodenum 2, 3
• Barium esophagram has 88% sensitivity for detecting esophagitis using combined technique 2, 3
• Less sensitive than endoscopy but can detect ulcers, gastritis, and hiatal hernias 1

Initial Management While Awaiting Diagnosis

Immediate Interventions

• Maintain NPO status until surgical emergency is excluded 2, 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 2, 3

Empiric Medical Therapy

• Start high-dose PPI therapy with omeprazole 20-40 mg once daily before meals immediately while awaiting diagnostic workup, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2, 3, 5
• Most duodenal ulcer patients heal within four weeks; some may require an additional four weeks 5
• Avoid NSAIDs as they worsen PUD and increase bleeding risk 2, 3

Symptomatic Treatment

• For nausea: 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, 2

Special Considerations Based on Presentation

Persistent Vomiting with Epigastric Pain

• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer disease or acute coronary syndrome 1, 2, 3
• Persistent vomiting is a red flag suggesting serious organic pathology beyond functional disease 1

Pain Radiating to Back

• Epigastric pain radiating to back strongly suggests acute pancreatitis, requiring serum amylase or lipase measurement 3
• Also consider acute aortic dissection and perforated posterior gastric ulcer 3

Pregnancy-Specific Considerations

• Preeclampsia can present with epigastric or right upper quadrant pain, headaches, visual changes, or swelling 1
• HELLP syndrome should be considered with epigastric pain, nausea, vomiting, and malaise in pregnant patients 1
• Acute fatty liver of pregnancy may present with malaise, headache, nausea, vomiting, jaundice, and epigastric pain 1

Critical Pitfalls to Avoid

• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 3
• Do not assume GERD without first excluding life-threatening causes, even in patients with known reflux disease 2, 3
• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age or presentation pattern 2, 3
• Do not delay endoscopy in patients with alarm features (persistent vomiting, weight loss, anemia, dysphagia), as this leads to poor outcomes 1, 2, 3
• Never rely on single troponin measurement; serial measurements at least 6 hours apart are required to exclude NSTEMI 2, 3