What is the appropriate evaluation and initial management for epigastric pain in an adult?

Evaluation and Initial Management of Epigastric Pain in Adults

Immediately obtain a 12-lead ECG within 10 minutes and measure serial cardiac troponins at 0 and 6 hours to exclude myocardial infarction, which can present as isolated epigastric pain—especially in women, diabetics, and elderly patients—and carries a 10-20% mortality if missed. 1, 2, 3

Immediate Life-Threatening Causes to Exclude First

Cardiac Ischemia

• Myocardial infarction presents atypically as epigastric pain in approximately one-third of cases, particularly in women, diabetics, and older adults who may lack classic chest discomfort 1, 2, 3
• Never dismiss cardiac causes regardless of age or "atypical" presentation—concurrent epigastric pain and dyspnea doubles mortality risk and raises sudden cardiac death risk four-fold 1
• Obtain ECG within 10 minutes and measure troponins at 0 and 6 hours; a single troponin measurement is insufficient 1, 2, 3
• Pain radiating to the neck, jaw, or shoulder—even if described as "burning" rather than pressure—is a classic ischemic sign 1

Perforated Peptic Ulcer

• Presents with sudden, severe epigastric pain that rapidly generalizes, accompanied by fever, abdominal rigidity, and absent bowel sounds 1, 2, 3
• Delayed treatment carries a 30% mortality rate 1, 2, 3
• CT abdomen/pelvis with IV contrast shows extraluminal gas in 97%, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% of cases 1, 2, 3
• When CT is unavailable, obtain chest and abdominal X-ray to detect free intraperitoneal air 1

Acute Pancreatitis

• Epigastric pain radiating to the back is the hallmark presentation 1, 2, 3
• Diagnose with serum amylase ≥4× normal or lipase ≥2× normal (80-90% sensitivity and specificity) 1, 3
• Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 1, 2

Vascular Emergencies

• Acute aortic dissection or leaking abdominal aortic aneurysm causes sudden, severe epigastric pain in patients >50 years with vascular risk factors 1, 2, 3
• Mesenteric ischemia presents with pain out of proportion to examination, especially in elderly patients with vascular disease 1

Initial Diagnostic Workup

Vital Signs and Physical Examination

• Check for hypotension, tachycardia ≥110 bpm, or fever ≥38°C—these predict perforation, anastomotic leak, or sepsis with high specificity 1, 2
• Assess for peritoneal signs (rigidity, rebound tenderness), epigastric tenderness, cardiac murmurs, irregular pulse, and jugular vein distension 2
• Epigastric tenderness on examination suggests organic pathology rather than functional disease and warrants further investigation regardless of age 1

Laboratory Testing

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

Imaging Strategy

• CT abdomen/pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, malignancy, and vascular emergencies 1, 2, 3
• Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis once the patient is stable 3

Common Gastrointestinal Causes

Peptic Ulcer Disease

• Incidence of 0.1-0.3%, with complications in 2-10% of cases 1, 2, 3
• Presents with epigastric pain not relieved by antacids 1, 2, 3
• Approximately 42% are caused by H. pylori infection and 36% by NSAID use 4
• Bleeding is the most common complication (73% of patients), followed by perforation (9%) and pyloric obstruction (3%) 1, 4
• Approximately 10% of patients with upper abdominal pain in primary care have peptic ulcer disease 4

Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily 1, 2, 3
• Approximately 66% of patients with GERD and heartburn also experience epigastric pain 5, 2
• Patients with both heartburn and epigastric pain frequently cannot identify their predominant symptom (19% unable to choose) 5, 2
• More than 50% of GERD patients have normal endoscopy (non-erosive reflux disease) 1

Gastritis

• Appears on imaging as enlarged areae gastricae, disruption of normal polygonal pattern, thickened gastric folds, or erosions 1, 2
• Often associated with NSAID use, alcohol, or H. pylori infection 1, 2

Gastric Cancer

• May present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 1, 2, 3
• Now the most common cause of gastric outlet obstruction in adults 1, 2, 3

Alarm Features Requiring Urgent Endoscopy (Within 2 Weeks)

• Age ≥55 years with new-onset dyspepsia or heartburn 1
• Unintentional weight loss 1
• Anemia on complete blood count 1, 3
• Dysphagia (food sticking at a specific level) 1
• Persistent vomiting (excludes functional dyspepsia and mandates investigation for structural disease) 1
• Hematemesis or melena 1
• Palpable epigastric mass 1
• Epigastric tenderness on examination with persistent symptoms beyond 8 weeks 1

Initial Management

Empiric Therapy

• Start high-dose proton pump inhibitor therapy immediately (omeprazole 20-40 mg once daily before meals) while awaiting diagnostic workup 1, 2, 3
• Full-dose PPI therapy achieves 80-90% healing of duodenal ulcers and 70-80% healing of gastric ulcers within 4 weeks 1, 2, 3
• Gastric ulcers >2 cm may require 8 weeks of treatment 4

H. pylori Testing and Eradication

• Perform non-invasive testing using ¹³C-urea breath test or stool antigen; serology is not recommended 1
• If H. pylori is detected, initiate standard eradication regimen (clarithromycin-based triple therapy or bismuth-based quadruple therapy) 1
• Eradication decreases peptic ulcer recurrence from 50-60% to 0-2% 4
• Confirm eradication with repeat stool antigen or breath test 4 weeks after completing therapy 1

Symptomatic Relief

• For nausea: ondansetron 8 mg sublingual every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 1
• Obtain baseline ECG before administering ondansetron due to QTc prolongation risk 1

NSAID Management

• Avoid all NSAIDs (including over-the-counter ibuprofen) as they worsen peptic ulcer disease and increase bleeding risk 1, 2
• Discontinuing NSAIDs heals 95% of ulcers and reduces recurrence from 40% to 9% 4
• When discontinuing NSAIDs is not possible, change to a less ulcerogenic agent, add a PPI, and eradicate H. pylori 4

Lifestyle Modifications

• Advise immediate smoking cessation and alcohol reduction or cessation—smoking and alcohol have a synergistic dose-dependent effect on gastric ulcer risk 1
• Avoid late meals and maintain upright position for 2-3 hours after eating to reduce nocturnal acid exposure 1
• Reduce regular coffee consumption, as caffeine increases gastric acid secretion 1
• Limit intake of citrus fruits, which commonly trigger dyspeptic symptoms 1
• Encourage weight loss in patients with severe obesity to improve reflux symptoms 1

Follow-Up Strategy

• If symptoms resolve within 4-8 weeks, consider tapering and withdrawing PPI therapy, reserving on-demand use for recurrence 1
• If symptoms persist after 4-8 weeks of standard-dose PPI, escalate to twice-daily dosing and schedule endoscopy 1
• Re-evaluate for newly emerging alarm features (weight loss, anemia, persistent vomiting); their presence upgrades the indication to urgent endoscopy 1

Critical Pitfalls to Avoid

• Missing cardiac causes is fatal in 10-20% of cases—always obtain ECG and troponins when epigastric pain is accompanied by exertional symptoms, dyspnea, or cardiovascular risk factors 1, 2, 3
• Delaying endoscopy in patients ≥55 years with new-onset symptoms is a frequent error; age alone is an alarm feature 1
• Attributing persistent vomiting to functional dyspepsia ignores its status as a red-flag for organic disease 1
• Delaying imaging in patients with peritoneal signs significantly increases mortality from perforated ulcer 3
• Not asking which symptom is most bothersome leads to misclassification and inappropriate therapy 1