What is the appropriate emergency department approach to a patient with new‑onset epigastric pain and a single episode of vomiting that was not relieved by an antacid?

Emergency Department Approach to New-Onset Epigastric Pain with Vomiting Unrelieved by Antacid

Immediately rule out life-threatening cardiac and vascular causes first, then systematically evaluate gastrointestinal etiologies, as epigastric pain can represent atypical presentations of acute coronary syndrome or mesenteric ischemia.

Immediate Life-Threatening Exclusions

Cardiac Evaluation (Priority #1)

• Obtain a 12-lead ECG immediately upon arrival, as epigastric pain represents an atypical presentation of acute coronary syndrome, particularly in women and elderly patients who may present with nausea, vomiting, and midepigastric discomfort rather than classic chest pain 1.
• The initial evaluation must answer: What is the likelihood that symptoms represent ACS secondary to obstructive CAD, and what is the likelihood of adverse clinical outcome including death, MI, or serious arrhythmia? 1.
• Patients with symptoms lasting more than 20 minutes require immediate assessment given the strong relationship between treatment delay and mortality 1.
• Check cardiac biomarkers (troponin) as part of the initial workup 1.

Mesenteric Ischemia Evaluation (Priority #2)

• Maintain high suspicion for acute mesenteric ischemia (AMI) when severe abdominal pain appears out of proportion to physical examination findings 1.
• The clinical scenario of abrupt onset abdominal pain with acidosis and organ failure should prompt immediate CT angiography (CTA) 1.
• Elevated lactate and D-dimer may assist in diagnosis, though no laboratory studies are sufficiently accurate to definitively identify or exclude ischemic bowel 1.

Perforation Assessment

• Check immediately for signs of perforation, as duodenal pathology with severe pain and vomiting requires evaluation for extraluminal gas, fluid or fat stranding, ascites, and focal wall defect 2.
• Perforation carries mortality rates up to 30% if treatment is delayed, and peritonitis requires emergent surgical intervention 2.

Initial Diagnostic Workup

Laboratory Studies

• Complete blood count with differential to assess for leukocytosis or anemia 3.
• Comprehensive metabolic panel to evaluate electrolyte abnormalities and organ function 3.
• Lipase/amylase for pancreatic pathology.
• C-reactive protein as a marker of inflammation 3.
• Lactate and D-dimer if mesenteric ischemia suspected 1.

Imaging

• Plain abdominal radiography during acute episode to exclude bowel obstruction and other abdominal pathology 1.
• CT angiography should be performed as soon as possible for any patient with suspicion for AMI 1.

Gastrointestinal Differential After Exclusion of Emergencies

When Cardiac and Vascular Causes Ruled Out

• The fact that symptoms were unrelieved by antacid suggests either severe GERD, complicated peptic ulcer disease, or alternative pathology 1, 4.
• In patients with recurrent acute chest pain or epigastric pain without evidence of cardiac or pulmonary cause, evaluation for gastrointestinal causes is reasonable 1.

Upper GI Pathology Considerations

• Never assume benign peptic ulcer disease without histologic confirmation when severe presentation occurs, particularly with bilious vomiting and unresponsiveness to antacids 2.
• Duodenal adenocarcinoma, gastrinoma, or severe complicated ulcer disease should be considered with severe presentations 2.
• Upper endoscopy should be considered when esophageal cause is suspected, particularly with alarm symptoms including recurrent vomiting 1.

Immediate Management While Evaluating

Resuscitation

• Fluid resuscitation should commence immediately to enhance visceral perfusion if any concern for ischemia exists 1.
• Correct electrolyte abnormalities and initiate nasogastric decompression 1.
• Adequate enteral and/or IV hydration is necessary 1.

Empiric Therapy

• Broad-spectrum antibiotics should be administered immediately if peritonitis or mesenteric ischemia suspected 1.
• Antiemetics should be given on a prophylactic basis 1.
• Do not rely on PPI trial as diagnostic tool in the acute setting—objective testing is required when presentation is severe or atypical 1.

Anticoagulation Consideration

• Unless contraindicated, patients with suspected mesenteric ischemia should be anticoagulated with intravenous unfractionated heparin 1.

Disposition Decision Points

Immediate Surgical Consultation Required If:

• Overt peritonitis present 1.
• Hemodynamic instability 1.
• Signs of perforation on imaging 2.
• CT findings suggest mesenteric ischemia 1.

Admission Warranted If:

• Persistent severe pain despite treatment.
• Inability to tolerate oral intake with ongoing vomiting 2.
• Abnormal laboratory values suggesting serious pathology.
• High-risk features for adverse outcomes 1.

Outpatient Follow-up Acceptable Only If:

• All life-threatening causes excluded.
• Pain controlled and able to tolerate oral intake.
• Reliable patient with clear return precautions.
• Arranged endoscopy within appropriate timeframe if GI cause suspected 1.

Critical Pitfalls to Avoid

• Never dismiss epigastric pain as simple GERD without excluding cardiac ischemia, especially in patients with risk factors, as anginal pain can radiate to the epigastrium 1.
• Do not delay imaging or surgical consultation if peritoneal signs develop 2.
• Avoid assuming antacid failure simply means "more severe GERD"—this presentation warrants comprehensive evaluation 1, 2.
• Do not overlook gastrinoma in patients with severe duodenal symptoms, particularly if multiple ulcers or recurrent disease 2.
• Laboratory findings early in disease course may be normal or nonspecific, particularly in mesenteric ischemia or early perforation 3.