I have epigastric pain that started shortly after plasma donation; what are the likely causes and how should it be managed?

Epigastric Pain After Plasma Donation

Your epigastric pain following plasma donation is most likely related to a vasovagal reaction with associated gastrointestinal hypoperfusion, though cardiac causes must be excluded immediately given the potentially fatal consequences of missing acute coronary syndrome. 1, 2

Immediate Life-Threatening Causes to Exclude First

Obtain an ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to rule out myocardial infarction, which can present atypically with epigastric pain as the primary manifestation, carrying a 10-20% mortality if missed. 2, 3 This is critical because cardiac causes should never be dismissed based on age or "atypical" presentation, especially given the temporal relationship to a procedure that can cause transient hypotension. 2

Check your vital signs immediately for:

• Tachycardia ≥110 bpm
• Fever ≥38°C
• Hypotension 2, 3

These findings predict serious complications with high specificity and require urgent intervention. 2

Most Likely Diagnosis: Vasovagal-Related Gastrointestinal Hypoperfusion

Vasovagal reactions are the most common adverse event after blood donation, occurring in approximately 1.2% of donors. 4, 5 The temporal relationship between your plasma donation and epigastric pain strongly suggests this mechanism.

Pathophysiology and Complications

The transient hypotension during a vasovagal reaction can lead to:

• Ischemic colitis - documented in a 55-year-old woman who developed persistent abdominal pain and bloody diarrhea after plasma donation-related vasovagal syncope 4
• Mesenteric hypoperfusion causing epigastric pain without frank ischemia 4
• Gastric mucosal ischemia from reduced splanchnic blood flow 1

If you develop persistent left-sided or diffuse abdominal pain, watery diarrhea, or bloody diarrhea, ischemic colitis must be considered and requires CT abdomen/pelvis with IV contrast. 4

Diagnostic Workup

Essential Laboratory Tests

Order immediately:

• Complete blood count to assess for anemia or bleeding 1, 2
• Serum electrolytes and glucose 1, 2
• Serum lipase or amylase (≥3x upper limit of normal diagnoses pancreatitis with 80-90% sensitivity) 2, 3
• Liver function tests and C-reactive protein 1, 2

Imaging Considerations

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis (sensitivity 97%), perforation, and vascular emergencies. 2, 3 This should be obtained if:

• Pain persists beyond 24-48 hours
• You develop peritoneal signs on examination
• Vital signs are abnormal
• Laboratory tests suggest serious pathology 1, 2

Initial Management

Immediate Treatment

Start high-dose proton pump inhibitor therapy with omeprazole 20-40 mg once daily before meals while awaiting diagnostic workup, as this achieves 80-90% healing rates for duodenal ulcers and 70-80% for gastric ulcers. 1, 2

Symptomatic Relief

For nausea (if present):

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 1, 3
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Supportive Care

• Maintain adequate hydration - the vasovagal reaction may have caused volume depletion 4
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 2

Alternative Diagnoses to Consider

Common Gastrointestinal Causes

If symptoms persist beyond 48 hours despite PPI therapy, consider:

• Peptic ulcer disease (incidence 0.1-0.3%, presents with epigastric pain not relieved by antacids) 1, 2
• Gastroesophageal reflux disease (affects 42% of Americans monthly, often with heartburn and regurgitation) 1, 2
• Gastritis (associated with NSAID use, alcohol, or H. pylori infection) 1, 2
• Acute pancreatitis (characteristically radiates to the back) 2, 3

When to Pursue Endoscopy

Non-urgent endoscopy is warranted if symptoms persist beyond 8 weeks with epigastric tenderness, regardless of age. 1 However, urgent endoscopy is required if you develop:

• Persistent vomiting (red flag excluding functional disease) 1
• Unexplained weight loss 1
• Dysphagia 1
• Hematemesis 1
• Anemia on complete blood count 1

Critical Pitfalls to Avoid

1. Never dismiss cardiac causes based on young age or "atypical" presentation - myocardial infarction can present with isolated epigastric pain, especially in women and diabetics 2, 3

2. Do not attribute persistent symptoms to anxiety or functional disease without excluding organic pathology - persistent vomiting or pain suggests structural disease requiring investigation 1

3. Consider ischemic colitis if pain persists after transient hypotension - this rare but serious complication requires CT imaging and may necessitate bowel rest 4

4. Avoid aggressive fluid resuscitation unless severe disease is confirmed - this triples mortality in non-severe acute pancreatitis 3

Expected Clinical Course

Most vasovagal-related symptoms resolve within 24-48 hours with supportive care and PPI therapy. 4, 5 If your pain persists beyond this timeframe, worsens, or you develop new symptoms (fever, vomiting, bloody stools), seek immediate medical evaluation for the diagnostic workup outlined above. 1, 2