What is the appropriate evaluation and management for a patient with epigastric pain above the umbilicus and loss of appetite?

Epigastric Pain with Loss of Appetite: Evaluation and Management

Start high-dose proton pump inhibitor therapy (omeprazole 20-40 mg once daily before meals) immediately while pursuing urgent diagnostic workup to exclude life-threatening causes, particularly myocardial infarction, perforated peptic ulcer, and acute pancreatitis. 1, 2, 3

Immediate Life-Threatening Exclusions (First Priority)

Cardiac Causes

• Obtain an ECG within 10 minutes of presentation to exclude myocardial infarction, which presents atypically with epigastric pain in 10-20% of cases, particularly in women, diabetics, and elderly patients 1, 3
• Measure cardiac troponins serially at 0 and 6 hours—never rely on a single measurement, as NSTEMI requires serial measurements at least 6 hours apart for exclusion 1, 3
• Atypical presentations include isolated epigastric pain, indigestion-like symptoms, and dyspnea without chest pain 3

Perforated Peptic Ulcer

• Check for sudden, severe epigastric pain with fever, abdominal rigidity, and absent bowel sounds—mortality reaches 30% if treatment is delayed 1, 2, 3
• Order CT abdomen/pelvis with IV contrast, which shows extraluminal gas in 97% of perforations, fluid/fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 1, 2, 3
• Requires emergent surgical consultation for laparoscopic or open repair 1

Acute Pancreatitis

• Measure serum amylase (≥4× normal) or lipase (≥2× normal), which have 80-90% sensitivity and specificity for acute pancreatitis 1
• Characteristically presents with epigastric pain radiating to the back 1
• Can progress to necrotizing pancreatitis with 30-40% mortality 2

Essential Initial Assessment

Vital Signs and Physical Examination

• Check for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis with high specificity 1, 3
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation 1, 3
• Assess for epigastric tenderness, which suggests organic pathology rather than functional disease and warrants investigation regardless of age 2

Mandatory Laboratory Tests

• Complete blood count to identify anemia (an alarm feature mandating urgent endoscopy) 2, 3
• C-reactive protein and serum lactate levels 1, 3
• Liver and renal function tests 1, 3
• Serum electrolytes and glucose 2, 3
• Cardiac troponins at 0 and 6 hours 1, 3
• Serum amylase or lipase 1, 3

Age-Stratified Diagnostic Algorithm

Patients ≥55 Years or With Alarm Features

Urgent upper endoscopy within 2 weeks is mandatory for any of the following: 2

• Age ≥55 years with new-onset symptoms 2
• Loss of appetite with unintentional weight loss 1, 2
• Anemia on complete blood count 2
• Dysphagia or food sticking sensation 2
• Persistent vomiting (excludes functional dyspepsia) 1, 2
• Hematemesis or melena 2
• Epigastric tenderness on examination 2

Patients <55 Years Without Alarm Features

After excluding surgical emergencies with CT and laboratory studies: 2

1. Perform non-invasive H. pylori testing using ¹³C-urea breath test or stool antigen (serology is not recommended) 2
2. If H. pylori positive: initiate standard eradication regimen (clarithromycin-based triple therapy or bismuth-based quadruple therapy) 2
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 2
4. If symptoms persist beyond 8 weeks despite PPI therapy: schedule non-urgent endoscopy 2

Empiric Management While Awaiting Diagnosis

Immediate Interventions

• Maintain NPO status until surgical emergency is excluded 1, 3
• Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 3
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily), which achieves 80-90% healing rates for duodenal ulcers and 70-80% for gastric ulcers 1, 2, 3

Symptomatic Treatment

• For nausea: ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first 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 2, 3
• Avoid NSAIDs completely, as they worsen peptic ulcer disease and increase bleeding risk 1, 2, 3

Common Gastrointestinal Causes

Peptic Ulcer Disease

• Incidence of 0.1-0.3%, with complications in 2-10% of cases 1, 2
• Symptoms include epigastric pain relieved by food or antacids, pain causing nighttime awakening, and loss of appetite 4
• H. pylori infection is the principal cause when not NSAID-related 2
• Bleeding is the most common complication, presenting as hematemesis 1, 4

GERD and Esophagitis

• Affects 42% of Americans monthly and 7% daily 1, 2, 3
• Presents with heartburn, regurgitation, and epigastric pain 1, 2
• More than 50% of GERD patients have normal endoscopy (non-erosive reflux disease) 2

Gastritis

• Often associated with NSAID use, alcohol, or H. pylori infection 3
• Appears on imaging as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 1, 3

Gastric Cancer

• Now the most common cause of gastric outlet obstruction in adults with 5-year survival of 32% 1, 3
• May present with ulcer, adjacent mucosal nodularity, mass effect, or irregular radiating folds 1, 3
• Loss of appetite is a key alarm feature 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on "atypical" presentation or age alone—myocardial infarction mortality is 10-20% if missed 1, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 3
• Never rely on single troponin measurement; serial measurements at least 6 hours apart are required 1, 3
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 1
• Persistent vomiting excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer or acute coronary syndrome 1, 2
• Do not delay endoscopy in patients with alarm features (loss of appetite, weight loss, anemia, dysphagia, persistent vomiting), as this leads to poor outcomes 1, 2
• Delaying endoscopy in patients ≥55 years with new-onset symptoms is a frequent error—age alone is an alarm feature 2