What is the appropriate evaluation and management of epigastric pain?

Evaluation and Management of Epigastric Pain

The appropriate evaluation of epigastric pain begins with immediate exclusion of life-threatening conditions—obtain an ECG within 10 minutes and check vital signs for peritoneal signs, then proceed with a structured diagnostic algorithm based on alarm features, age, and symptom characteristics. 1, 2

Immediate Life-Threatening Exclusions (First Priority)

Before considering any gastrointestinal diagnosis, you must rule out three conditions that can kill your patient:

• Obtain an ECG within 10 minutes of presentation to exclude acute coronary syndrome, which presents atypically with epigastric pain in up to 20% of cases, particularly in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 2, 3, 4
• Order serial cardiac troponins at 0 and 6 hours—never rely on a single measurement, as this is a common pitfall that leads to missed NSTEMI 2, 3
• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis with high specificity 2, 4
• Perform focused physical examination for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforated peptic ulcer, which carries 30% mortality if treatment is delayed 2, 3, 4

Essential Laboratory Workup

Order these tests immediately while awaiting imaging:

• Complete blood count to identify anemia, which is an alarm feature mandating urgent endoscopy 2, 4
• Serum lipase (≥2x normal) or amylase (≥4x normal) with 80-90% sensitivity and specificity to exclude acute pancreatitis, which has overall mortality <10% but reaches 30-40% in necrotizing pancreatitis 2, 3, 4
• Liver and renal function tests, serum electrolytes, and glucose to assess organ involvement and guide management 1, 2
• C-reactive protein and serum lactate levels to distinguish infection from ischemia and assess tissue perfusion 2, 3

Alarm Features Requiring Urgent Endoscopy (Within 2 Weeks)

The following features mandate urgent upper endoscopy regardless of other considerations:

• Age ≥55-60 years with new-onset dyspepsia or heartburn 1, 2
• Unintentional weight loss (requires objective documentation) 1, 2
• Dysphagia or sensation of food sticking at a specific level 1, 2
• Persistent vomiting—this is a red-flag symptom that excludes functional dyspepsia and signals possible organic disease such as peptic ulcer, gastric outlet obstruction, or malignancy 1, 2
• Evidence of gastrointestinal bleeding (hematemesis, melena, anemia on CBC) 1, 2, 4
• Palpable epigastric mass 1, 2
• Epigastric tenderness on examination—this indicates organic pathology rather than functional disease and warrants investigation irrespective of age 1, 2
• Family history of gastro-esophageal malignancy in patients from high-risk regions 1

Diagnostic Imaging Algorithm

When to Order CT Abdomen/Pelvis with IV Contrast

CT with IV contrast is the gold standard when the diagnosis is unclear or when you suspect complications:

• Suspected perforated peptic ulcer—CT shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 2, 3
• Suspected acute pancreatitis with unclear diagnosis 2, 3
• Suspected mesenteric ischemia—order CT angiography specifically, as pain is often out of proportion to examination findings 2, 3
• Suspected acute aortic dissection—order CT angiography emergently 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected, as positive oral contrast impedes assessment of mucosal enhancement and intraluminal bleeding 1

When to Order Fluoroscopic Studies

• Biphasic esophagram (combined double-contrast and single-contrast technique) has 88% sensitivity for detecting esophagitis and provides anatomic and functional information on hiatal hernia, strictures, and reflux events 1, 2
• Upper GI series evaluates structural and functional abnormalities of stomach and duodenum, detecting ulcers, gastritis, and hiatal hernias, though it is less sensitive than endoscopy 1, 2

Management Algorithm for Patients WITHOUT Alarm Features

Step 1: Test for Helicobacter pylori

• Perform non-invasive H. pylori testing using ¹³C-urea breath test or stool antigen assay—serology is not recommended 1, 2
• If H. pylori is positive, initiate standard eradication regimen (clarithromycin-based triple therapy or bismuth-based quadruple therapy) 2
• Confirm eradication with repeat stool antigen or breath test 4 weeks after completing therapy 2

Step 2: Initiate Empiric PPI Therapy

• Start high-dose proton-pump inhibitor therapy immediately (omeprazole 20-40 mg once daily before meals) while awaiting diagnostic workup 2, 4
• Full-dose PPI therapy achieves 80-90% healing of duodenal ulcers and 70-80% healing of gastric ulcers within 4 weeks 2, 4
• If symptoms persist after 4-8 weeks of standard-dose PPI, escalate to twice-daily dosing and schedule endoscopy 2

Step 3: Lifestyle Modifications

• Advise patients to remain upright for at least 2-3 hours after meals (avoid lying down within 45 minutes) to reduce gastro-esophageal reflux 2
• Reduce regular coffee consumption, as caffeine increases gastric acid secretion and worsens reflux 2
• Limit intake of citrus fruits, which commonly trigger dyspeptic symptoms 2
• Encourage weight loss in patients with severe obesity, as this markedly improves reflux and lowers intra-abdominal pressure 2

Step 4: Follow-Up and Re-Evaluation

• If symptoms resolve within 4-8 weeks, consider tapering and withdrawing PPI therapy, reserving on-demand use for recurrence 2
• If symptoms persist beyond 4-8 weeks despite therapy, refer for non-urgent endoscopy to exclude peptic ulcer disease, gastritis, or malignancy 1, 2
• Re-evaluate for any newly emerging alarm features (weight loss, anemia, persistent vomiting)—their presence upgrades the indication to urgent endoscopy 2

Symptomatic Management

• 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 2, 4
• Avoid NSAIDs (including over-the-counter ibuprofen), as they worsen peptic ulcer disease and increase gastrointestinal bleeding risk 2, 4

Establishing the Diagnosis of Functional Dyspepsia

Functional dyspepsia is a positive diagnosis made only after organic disease is excluded:

• Rome IV criteria define functional dyspepsia as bothersome epigastric pain, epigastric burning, post-prandial fullness, or early satiation for at least 6 months, with no structural disease on endoscopy 1, 2
• Functional dyspepsia accounts for approximately 80% of patients undergoing endoscopy for dyspepsia after organic causes are excluded 2
• Persistent vomiting excludes functional dyspepsia—this is a critical pitfall to avoid, as vomiting signals another disorder and mandates investigation for structural disease 1, 2
• Epigastric pain in functional dyspepsia is unrelated to defecation, which helps differentiate it from irritable bowel syndrome 1
• Up to 50% of functional dyspepsia patients have overlapping IBS, and approximately one-third have coexisting gastro-oesophageal reflux symptoms 1

Patient Education and Shared Decision-Making

• Establish an empathic doctor-patient relationship and explain the diagnosis of functional dyspepsia, its underlying pathophysiology in the context of the gut-brain axis, and the natural history of the condition, including common symptom triggers 1
• Explain that functional dyspepsia is a disorder of gut-brain interaction impacted by diet, stress, cognitive and behavioral responses to symptoms, and postinfective changes 1
• This approach may reduce healthcare utilization and improve quality of life 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on age alone or "atypical" presentation patterns—myocardial infarction presents atypically with epigastric pain in up to 20% of cases 2, 3
• Never rely on a single troponin measurement—serial measurements at least 6 hours apart are required to exclude NSTEMI 2, 3
• Never delay endoscopy in patients aged ≥55-60 years with new-onset symptoms—age alone is an alarm feature 1, 2
• Never attribute persistent vomiting to functional dyspepsia—this ignores its status as a red-flag for organic disease 1, 2
• Never delay imaging in patients with peritoneal signs—perforated ulcer mortality increases significantly with delayed diagnosis 2, 3
• Delaying endoscopy in high-risk patients with persistent symptoms beyond 8 weeks with epigastric tenderness is a common error—endoscopy is warranted regardless of age 2