What are the possible diagnoses for a 55-year-old man with upper abdominal pain, severe hypertension (185/103 mmHg), normal heart rate (61 bpm), normal temperature and respiratory rate, and a history of hyperlipidemia?

Differential Diagnosis for a 55-Year-Old Male with Upper Abdominal Pain, Severe Hypertension, and Hyperlipidemia

This patient presenting with upper abdominal pain, blood pressure 185/103 mmHg, and a history of hyperlipidemia requires immediate assessment for hypertensive emergency versus urgency, with particular attention to acute target organ damage that would mandate ICU admission and intravenous therapy.

Immediate Classification: Hypertensive Emergency vs. Urgency

The critical first step is determining whether this represents a hypertensive emergency (BP >180/120 mmHg WITH acute target organ damage) or hypertensive urgency (severe BP elevation WITHOUT organ damage), as this distinction—not the absolute BP value—dictates management 1, 2.

Rapid Bedside Assessment for Target Organ Damage

Perform a focused evaluation within minutes to identify acute organ injury:

• Gastrointestinal/Vascular: The upper abdominal pain could represent acute aortic dissection (sudden severe chest/back pain radiating to abdomen), acute mesenteric ischemia, or acute pancreatitis—all potential hypertensive emergencies 1, 2
• Cardiac: Assess for chest pain, dyspnea, or pulmonary edema suggesting acute coronary syndrome, myocardial infarction, or acute left ventricular failure 1, 2
• Neurologic: Check for altered mental status, severe headache with vomiting, visual disturbances, or focal deficits indicating hypertensive encephalopathy or stroke 1, 2
• Renal: Evaluate for oliguria or acute rise in creatinine suggesting acute kidney injury 1, 2

Primary Differential Diagnoses

1. Acute Aortic Dissection (Most Critical to Exclude)

This is the most life-threatening diagnosis that must be ruled out immediately given the combination of severe hypertension and upper abdominal pain.

• Aortic dissection commonly presents with severe hypertension and can manifest as upper abdominal pain when the dissection extends to involve the abdominal aorta 1, 2
• Requires immediate CT angiography of chest/abdomen and emergent surgical consultation 2
• If confirmed, target SBP <120 mmHg within 20 minutes using esmolol plus nitroprusside/nitroglycerin 2

2. Acute Coronary Syndrome/Myocardial Infarction

• The combination of severe hypertension, hyperlipidemia, and upper abdominal pain (which can be an atypical presentation of cardiac ischemia) raises concern for ACS 1, 2
• Obtain immediate ECG and cardiac troponin 1, 2
• If confirmed, target SBP <140 mmHg immediately using IV nitroglycerin ± labetalol 2

3. Hypertensive Emergency with Acute Renal Failure

• Malignant hypertension can present with acute kidney injury and abdominal pain from renal ischemia 1
• Check serum creatinine, urinalysis for proteinuria, and assess for thrombotic microangiopathy (CBC, LDH, haptoglobin) 1, 2
• 20-40% of malignant hypertension cases have secondary causes including renal artery stenosis and renal parenchymal disease 1

4. Acute Pancreatitis

• Hypertriglyceridemia (common with hyperlipidemia) can cause acute pancreatitis presenting with upper abdominal pain 3, 4
• Check serum lipase/amylase and triglyceride levels 2
• Severe pancreatitis can trigger hypertensive crisis through sympathetic activation 1

5. Peptic Ulcer Disease/Gastritis

• Upper abdominal pain with severe hypertension may represent peptic ulcer disease, though less likely to cause hypertensive emergency unless complicated by perforation or hemorrhage 5
• NSAIDs (if used) can both cause gastric ulcers and precipitate acute hypertension 1

6. Hypertensive Urgency with Incidental Abdominal Pain

• If no acute target organ damage is identified, this may represent hypertensive urgency with unrelated abdominal pathology 1, 2, 6
• Many patients with acute pain have transiently elevated BP that normalizes when the underlying condition is treated 2

Essential Immediate Diagnostic Workup

Laboratory tests to perform immediately:

• Cardiac: ECG, troponin (to exclude ACS) 1, 2
• Renal: Creatinine, BUN, electrolytes, urinalysis for protein and sediment 1, 2
• Hematologic: CBC (hemoglobin, platelets), LDH, haptoglobin (to assess for thrombotic microangiopathy) 1, 2
• Lipid panel: Triglycerides (if pancreatitis suspected) 3
• Pancreatic enzymes: Lipase/amylase (if upper abdominal pain suggests pancreatitis) 2

Imaging studies:

• CT angiography chest/abdomen if aortic dissection suspected (sudden severe pain, pulse differential, widened mediastinum) 2
• Fundoscopy: Essential to detect bilateral retinal hemorrhages, cotton-wool spots, or papilledema indicating malignant hypertension 1, 2, 6

Management Algorithm Based on Findings

If Acute Target Organ Damage Present (Hypertensive Emergency):

• Immediate ICU admission with continuous arterial line monitoring (Class I recommendation) 2
• IV antihypertensive therapy: Nicardipine 5 mg/hr (titrate by 2.5 mg/hr every 15 min, max 15 mg/hr) OR labetalol 10-20 mg IV bolus 1, 2
• BP target: Reduce MAP by 20-25% within first hour, then to ≤160/100 mmHg over 2-6 hours, avoid drops >70 mmHg systolic 1, 2

If No Acute Target Organ Damage (Hypertensive Urgency):

• Outpatient management with oral antihypertensives 1, 2, 6
• Extended-release nifedipine 30-60 mg PO OR captopril 12.5-25 mg PO 2, 6
• Gradual BP reduction to <160/100 mmHg over 24-48 hours, then <130/80 mmHg over weeks 2, 6
• Follow-up within 2-4 weeks 2, 6

Secondary Hypertension Screening (Post-Stabilization)

Given the severe, potentially uncontrolled hypertension with hyperlipidemia, screen for secondary causes after stabilization:

• Renal artery stenosis: Renal duplex ultrasound or CT/MR angiography 1
• Primary aldosteronism: Aldosterone-to-renin ratio 1
• Pheochromocytoma: Plasma metanephrines or 24-hour urine catecholamines 1
• Renal parenchymal disease: Serum creatinine, urinalysis, renal ultrasound 1

Critical Pitfalls to Avoid

• Do not assume the upper abdominal pain is benign without excluding aortic dissection and acute coronary syndrome 1, 2
• Do not rapidly lower BP if no target organ damage is present—this can cause cerebral, renal, or coronary ischemia 1, 2
• Do not discharge without fundoscopy—missing malignant hypertension would be a critical error 2, 6
• Do not use immediate-release nifedipine—it causes unpredictable precipitous drops and increases stroke risk 2
• Do not overlook that medication non-adherence is the most common trigger for hypertensive emergencies 1, 2

Prognosis Context

Untreated hypertensive emergencies carry >79% one-year mortality and median survival of only 10.4 months, emphasizing the critical importance of rapid, appropriate classification and management 2.