What is the appropriate initial evaluation and management for a patient presenting with new‑onset epigastric pain and vomiting?

Evaluation of New-Onset Epigastric Pain and Vomiting

For patients presenting with new-onset epigastric pain and vomiting, immediately assess for life-threatening conditions (perforation, pancreatitis, mesenteric ischemia, acute coronary syndrome) through vital signs, ECG, and urgent laboratory testing, followed by CT abdomen/pelvis with IV contrast if any alarm features are present. 1, 2

Immediate Assessment and Risk Stratification

Vital Signs and Red Flags

• Check vital signs immediately: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict perforation, anastomotic leak, or sepsis with high specificity 1
• The combination of sudden onset severe pain, tachycardia, and leukocytosis indicates a surgical emergency requiring urgent CT evaluation 2
• Persistent vomiting is a red flag that excludes functional dyspepsia and mandates investigation for serious organic pathology 1, 3

Cardiac Evaluation

• Obtain an ECG immediately to exclude myocardial ischemia, particularly in women, diabetics, and elderly patients who may present atypically with epigastric pain and vomiting 1
• Myocardial infarction can present with epigastric pain and has a mortality rate of 10-20% if missed 1

Essential Laboratory Testing

Order the following tests immediately 1:

• Complete blood count (leukocytosis with severe pain suggests significant intra-abdominal pathology)
• Serum lipase or amylase (≥4x normal for amylase or ≥2x normal for lipase has 80-90% sensitivity/specificity for acute pancreatitis) 1, 3
• C-reactive protein and serum lactate (elevated lactate suggests mesenteric ischemia or sepsis)
• Liver and renal function tests
• Serum electrolytes and glucose 1

Critical pitfall: Do not rely on normal amylase/lipase to exclude surgical emergencies, as these values are frequently normal in perforated ulcer and early mesenteric ischemia 2

Imaging Strategy

When to Order CT Abdomen/Pelvis with IV Contrast

Proceed directly to CT imaging if any of the following are present 2:

• Sudden, severe epigastric pain (suggests perforation or acute mesenteric ischemia)
• Tachycardia with leukocytosis
• Pain out of proportion to examination (classic for mesenteric ischemia, which has 30-70% mortality if diagnosis is delayed)
• Age >50 with vascular risk factors (to exclude leaking abdominal aortic aneurysm)
• Persistent vomiting beyond 24-48 hours

CT with IV contrast is superior to plain films and detects 2:

• Extraluminal gas (97% of perforations)
• Fluid or fat stranding along gastroduodenal region (89%)
• Focal wall defect and/or ulcer (84%)
• Bowel wall thickening and mesenteric fat streaking

Note: Up to 12% of perforations may have normal CT, but it remains the most sensitive test available 2

Age-Stratified Management Approach

Patients ≥55 Years or With Alarm Features

Alarm features include 4, 1:

• Persistent vomiting
• Weight loss (requires objective evidence)
• Anemia on CBC
• Dysphagia
• Hematemesis
• Epigastric tenderness on examination

Management: Urgent upper endoscopy after CT excludes surgical emergencies 4, 1

Patients <55 Years Without Alarm Features

If CT and laboratory testing exclude surgical emergencies 4:

1. Test for H. pylori using 13C-urea breath test or stool antigen test (not serology)
2. If H. pylori positive: Treat with eradication therapy
3. If H. pylori negative or symptoms persist after eradication: Start empirical PPI therapy (omeprazole 20-40 mg once daily before meals) for 4-8 weeks 4, 1

However, the presence of persistent vomiting warrants endoscopy regardless of age, as vomiting suggests structural disease rather than functional dyspepsia 1, 3

Immediate Symptomatic Management

While awaiting diagnostic workup 1:

• Antiemetics: Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk), promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours
• IV fluid resuscitation: Rapid restoration of intravascular volume to address tachycardia
• High-dose PPI: Omeprazole 20-40 mg once daily (healing rate 80-90% for duodenal ulcers, 70-80% for gastric ulcers)

Life-Threatening Differential Diagnoses

Acute Pancreatitis

• Presents with persistent, severe vomiting that accompanies upper abdominal pain radiating to the back 3
• Vomiting does not provide relief (unlike peptic ulcer disease) 3
• Overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 1

Perforated Peptic Ulcer

• Sudden, severe epigastric pain that may generalize, accompanied by fever and abdominal rigidity 1
• Requires immediate surgical intervention
• Mortality rate up to 30% 1

Acute Mesenteric Ischemia

• "Abdominal pain out of proportion to physical examination" 2
• Requires CT angiography as soon as possible 2
• Mortality 30-70% if diagnosis is delayed 2

Critical Pitfalls to Avoid

• Delaying CT imaging in patients with alarm features or severe presentation (administering empiric acid suppression without establishing diagnosis delays potentially life-saving intervention) 2
• Missing cardiac causes (always obtain ECG first) 1
• Attributing persistent vomiting to functional dyspepsia (Rome IV criteria exclude functional dyspepsia when persistent vomiting is present) 1, 3
• Proceeding to endoscopy before CT when surgical emergency is suspected (diagnostic imaging must precede endoscopy to exclude perforation or ischemia) 2

Surgical Consultation

Notify surgical team immediately if 2:

• CT shows perforation, obstruction, or ischemia
• Clinical presentation suggests surgical pathology (sudden severe pain, peritoneal signs, hemodynamic instability)
• High likelihood of surgical pathology based on vital signs and laboratory findings