How should I evaluate and manage a patient presenting with epigastric pain?

Evaluation and Management of Epigastric Pain

Immediately exclude myocardial infarction in any patient with epigastric pain by obtaining an ECG within 10 minutes and serial cardiac troponins at 0 and 6 hours, as cardiac causes present atypically with epigastric pain in 10-20% of cases and carry mortality rates of 10-20% if missed. 1, 2

Immediate Life-Threatening Causes to Exclude First

Cardiac Evaluation (Never Skip This)

• Obtain ECG within 10 minutes of presentation for all patients with epigastric pain, regardless of how "typical" for GI pathology it appears 1, 2
• Measure serial cardiac troponins at 0 and 6 hours—do not rely on a single measurement 1, 2
• Atypical presentations are especially common in women, diabetics, elderly patients, and those with chronic renal disease or dementia 1, 2
• Never dismiss cardiac causes based on age or "atypical" presentation 1, 2

Surgical Emergencies Requiring Immediate Imaging

• Check vital signs immediately: hypotension, tachycardia ≥110 bpm, or fever ≥38°C predict perforation, anastomotic leak, or sepsis 1
• Perform focused physical examination looking for peritoneal signs (rigidity, rebound, absent bowel sounds), which indicate perforation with 30% mortality if treatment is delayed 1, 2
• Order CT abdomen/pelvis with IV contrast when diagnosis is unclear—this is the gold standard for identifying pancreatitis, perforation (97% sensitivity for extraluminal gas), and vascular emergencies 1, 2

Critical Laboratory Testing

• Serum amylase ≥4x normal or lipase ≥2x normal diagnoses acute pancreatitis with 80-90% sensitivity/specificity 1, 2
• Complete blood count, C-reactive protein, serum lactate, liver and renal function tests 1
• Serum electrolytes and glucose 1

Common Gastrointestinal Causes (After Excluding Emergencies)

GERD and Acid-Related Pathology

• GERD affects 42% of Americans monthly and commonly presents with epigastric pain, with or without heartburn 1, 2
• Approximately 66% of GERD patients experience both heartburn and epigastric pain, and 19% cannot distinguish their predominant symptom 3, 1
• Even when heartburn is only a secondary symptom, GERD is still present in approximately 30% of cases 3, 1

Peptic Ulcer Disease

• Incidence of 0.1-0.3% with complications in 2-10% of cases 1, 2
• Presents with epigastric pain not relieved by antacids 1, 2
• Smoking and alcohol have synergistic dose-dependent effects on gastric ulcer risk 1
• Bleeding is the most common complication, presenting as hematemesis 1

Gastric Cancer

• May present with ulcer associated with nodularity, mass effect, or irregular radiating folds 1, 2
• Now the most common cause of gastric outlet obstruction in adults 1, 2

Initial Management Algorithm

Immediate Stabilization

• Maintain NPO status until surgical emergency is excluded 1
• Provide IV access and fluid resuscitation if hemodynamically unstable 1
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 1

Empiric Pharmacologic Therapy

• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• For nausea: 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 1

Critical Lifestyle Modifications

• Advise immediate smoking cessation and alcohol reduction/cessation due to synergistic effects on ulcer risk 1
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 1
• Remain upright for at least 30 minutes after meals to reduce reflux symptoms 3
• Small, frequent meals and avoiding trigger foods 3

Red Flag Symptoms Requiring Urgent Evaluation

• Severe sudden-onset pain 3
• Vomiting, inability to eat, or weight loss 3
• Signs of bleeding (hematemesis, melena) 3, 1
• Pain radiating to arm, jaw, or occurring with exertion 3
• Shortness of breath 3
• Peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) 1, 2

Definitive Diagnostic Testing (When Patient is Stable)

• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is stable 2
• Normal-appearing tissue on endoscopy does not rule out disease—biopsies may still show inflammation 3
• Multiple conditions can cause similar symptoms, making accurate diagnosis challenging and requiring patience with the diagnostic process 3

Special Population Considerations

Elderly Patients

• Monitor blood pressure as elevated BP may exacerbate symptoms 3
• Discuss potential interactions with anticoagulation therapy 3
• Higher risk for atypical cardiac presentations 1, 2

Pediatric Patients

• Younger children may have non-specific symptoms 3
• Older children are more likely to describe abdominal pain clearly 3

Pregnant Patients

• HELLP syndrome presents with epigastric pain, nausea, vomiting, and malaise—requires immediate delivery after stabilization 2

Critical Pitfalls to Avoid

• Do not delay imaging in patients with peritoneal signs—perforated ulcer mortality increases significantly with delayed diagnosis 2
• Do not rely on single troponin measurement—serial measurements at 0 and 6 hours are required 1, 2
• Do not assume "typical GI symptoms" exclude cardiac causes—atypical presentations are common 1, 2
• Not all epigastric pain is acid-related—persistent or severe pain requires medical evaluation for other serious conditions 3