In a 56‑year‑old woman with brief (≈4 minutes) sharp, stabbing epigastric pain that begins shortly after eating, is rapidly relieved, is associated with nausea without vomiting, and has no exertional dyspnea, cardiac history, or abnormal GI/GU findings, what are the likely differential diagnoses and appropriate initial work‑up?

Differential Diagnosis and Initial Work-Up

In this 56-year-old woman with brief, sharp postprandial epigastric pain that resolves within 4 minutes, the most likely diagnoses are biliary colic, peptic ulcer disease, or functional dyspepsia (epigastric pain syndrome), and the initial work-up must prioritize excluding cardiac ischemia and peptic ulcer perforation before considering functional disorders.

Immediate Priority: Exclude Life-Threatening Conditions

Cardiac Evaluation

• Obtain a 12-lead ECG within 10 minutes to exclude atypical myocardial infarction, which can present with epigastric pain in women, diabetics, and elderly patients; missed MI carries 10–20% mortality. 1
• Order serial troponins at 0 and 6 hours even without exertional dyspnea, because women frequently present with atypical symptoms. 1

Perforation Assessment

• Check vital signs immediately: tachycardia ≥110 bpm, fever ≥38°C, or hypotension are highly specific for perforation, anastomotic leak, or sepsis. 1, 2
• Examine for peritoneal signs: abdominal rigidity, rebound tenderness, or absent bowel sounds indicate possible perforation, which carries ~30% mortality if treatment is delayed. 1, 2
• The brief 4-minute duration and complete resolution argue against perforation, but the 8/10 severity and "takes her breath away" quality mandate exclusion. 3

Most Likely Diagnoses Based on Clinical Pattern

1. Biliary Colic (Primary Consideration)

• The postprandial timing (develops after eating), sharp/stabbing quality, 4-minute duration, crescendo-decrescendo pattern, and 8/10 severity are classic for biliary colic. 3
• One case report documents a 56-year-old woman with perforated duodenal ulcer presenting identically as biliary colic with right upper quadrant pain radiating to the shoulder and alleviated by food. 3
• Order right upper quadrant ultrasound as the initial imaging test to identify gallstones, gallbladder wall thickening, or pericholecystic fluid. 4

2. Peptic Ulcer Disease

• Approximately 10% of patients presenting with upper abdominal pain in primary care have peptic ulcer disease as the cause. 5
• Duodenal ulcer pain characteristically appears 1–3 hours after meals, occurs at night, and is relieved by food or antacids—this patient's pain develops after eating but resolves spontaneously in 4 minutes, which is atypical for classic duodenal ulcer. 6, 7
• The sharp, stabbing quality and brief duration are less typical for peptic ulcer, which usually presents as gnawing or burning discomfort. 6

3. Functional Dyspepsia (Epigastric Pain Syndrome)

• Rome IV criteria require bothersome epigastric pain at least 1 day per week, with pain that may be induced by meals, and no evidence of structural disease on endoscopy. 4
• The 8/10 severity qualifies as "bothersome" (severe enough to impact usual activities). 4
• However, the Rome Foundation's clinical criteria require symptoms present for ≥8 weeks before diagnosis; functional dyspepsia is a diagnosis of exclusion after structural disease is ruled out. 4

Structured Diagnostic Algorithm

Step 1: Immediate Laboratory Work-Up

• Complete blood count to detect anemia (an alarm feature mandating urgent endoscopy). 1
• Comprehensive metabolic panel including liver function tests to assess for hepatobiliary pathology. 1
• Serum lipase (≥2× normal) to exclude acute pancreatitis, which has 80–90% sensitivity and specificity. 1, 2
• Helicobacter pylori testing using ^13^C-urea breath test or stool antigen (serology is not recommended) as part of a test-and-treat strategy. 1, 5

Step 2: Initial Imaging

• Right upper quadrant ultrasound is the first-line test for suspected biliary colic. 4
• If ultrasound is negative and symptoms persist, order CT abdomen and pelvis with IV contrast to evaluate for peptic ulcer complications (perforation shows extraluminal gas in 97%, fluid/fat stranding in 89%, and focal wall defect in 84% of cases). 1, 2

Step 3: Age-Based Endoscopy Decision

• At age 56 with new-onset dyspeptic symptoms, this patient meets the alarm-feature threshold (age ≥55 years) that mandates urgent endoscopy within 2 weeks. 1
• The British Society of Gastroenterology specifies that age ≥55–60 years with new-onset dyspepsia is an alarm feature requiring prompt endoscopic evaluation to exclude gastric cancer. 1
• Do not delay endoscopy based on the absence of other alarm features; age alone is sufficient indication. 1

Step 4: Empirical Therapy While Awaiting Endoscopy

• Start high-dose proton pump inhibitor therapy immediately with omeprazole 20–40 mg once daily before meals. 1, 5
• Full-dose PPI achieves 80–90% healing of duodenal ulcers and 70–80% healing of gastric ulcers within 4 weeks. 1, 5
• If H. pylori is positive, initiate standard eradication therapy (clarithromycin-based triple therapy or bismuth-based quadruple therapy). 1

Red-Flag Features Present in This Case

• Age 56 years = alarm feature requiring urgent endoscopy regardless of other symptoms. 1
• Epigastric tenderness on examination (if present) suggests organic pathology rather than functional disease and warrants timely endoscopic investigation. 1

Red-Flag Features Absent (Reassuring)

• No persistent vomiting (single episode of nausea without vomiting does not meet the threshold for alarm feature). 4, 1
• No dysphagia, weight loss, or hematemesis. 1
• No exertional dyspnea or cardiac history. 1

Common Pitfalls to Avoid

• Do not attribute symptoms to functional dyspepsia without first performing endoscopy in a 56-year-old patient; delaying endoscopy in patients ≥55 years is a frequent error. 1
• Do not assume the brief 4-minute duration excludes serious pathology; perforated peptic ulcer can present as biliary colic in a 56-year-old woman. 3
• Do not order upper GI barium series as the initial diagnostic test; it is less sensitive than endoscopy and unsupported by guidelines for routine diagnosis of dyspepsia or peptic ulcer. 1
• Do not miss cardiac causes; women frequently present with atypical symptoms, and ECG is mandatory. 1

Summary of Initial Orders

1. ECG and serial troponins (0 h, 6 h) 1
2. CBC, CMP, lipase, H. pylori breath test or stool antigen 1, 2, 5
3. Right upper quadrant ultrasound 4
4. Urgent endoscopy referral (2-week wait) based on age ≥56 years 1
5. Start omeprazole 20–40 mg daily before meals while awaiting endoscopy 1, 5