What is the appropriate emergency department management for a patient presenting with severe gastric pain?

Emergency Department Management of Severe Gastric Pain

Immediately obtain an ECG within 10 minutes of presentation to exclude myocardial infarction, which can present atypically as isolated epigastric pain and carries 10-20% mortality if missed 1, 2.

Immediate Life-Threatening Exclusions

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, as these predict perforation or sepsis with high specificity 1.
• Perform abdominal examination for peritoneal signs including rigidity, absent bowel sounds, and guarding, which suggest perforated peptic ulcer with 30% mortality if treatment is delayed 1.
• Obtain serial troponins at 0 and 6 hours, as myocardial infarction can present with epigastric pain as the primary manifestation 1.

Urgent Laboratory Workup

• Order complete blood count, comprehensive metabolic panel, serum amylase or lipase, and C-reactive protein to evaluate for pancreatitis and other acute conditions 2, 1.
• Check serum lactate to assess disease severity 1.
• Obtain liver and renal function tests to identify underlying organ dysfunction 1.
• Serum amylase ≥4x normal or lipase ≥2x normal excludes acute pancreatitis with 80-90% sensitivity and specificity 1.

Imaging Strategy

• Perform CT abdomen and pelvis with IV contrast as the gold standard for diagnosing perforated peptic ulcer 1, 3.
• CT findings for perforation include extraluminal gas (97% sensitivity), fluid or fat stranding along gastroduodenal region (89%), ascites (89%), and focal wall defect (84%) 1.
• Bedside ultrasound can be used as first-line imaging for rapid, noninvasive evaluation of acute epigastric pain when available 4.

Immediate Empiric Treatment

• Start high-dose proton-pump inhibitor therapy immediately (omeprazole 40 mg IV or pantoprazole 40 mg IV once daily) while awaiting diagnostic workup, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2, 1, 5.
• Administer appropriate analgesia with intravenous paracetamol, dipyrone, or piritramide; combinations of non-opioids and opioids should be given for moderate to severe pain 6.
• Initiate intravenous fluid resuscitation in patients with hemodynamic instability or signs of dehydration 7.

History and Physical Examination Priorities

• Ask specifically about last bowel movement/gas passage, previous abdominal surgery (85% sensitivity for adhesive small bowel obstruction), chronic constipation, rectal bleeding, unexplained weight loss, and NSAID use 7, 2.
• Document alarm features including persistent vomiting (excludes functional dyspepsia), progressive pain, decreased oral intake, dysphagia, and family history of GI malignancy 2, 1.
• Previous abdominal surgery has 85% sensitivity and 78% specificity for predicting adhesive small bowel obstruction 7.

Surgical Consultation Criteria

• Immediate surgical consultation required for signs of perforation, hemodynamic instability, peritoneal signs, or CT evidence of perforation or free air 1, 3.
• Consider early surgical consultation (within 12-24 hours) for stable patients with persisting acute abdominal pain after inconclusive laboratory, radiological, and endoscopic results 7.
• Surgical intervention for perforated ulcer includes laparoscopic or open simple/double-layer suture with omental patch for small perforations, and distal gastrectomy for large perforations near the pylorus 1.

Antibiotic Therapy if Perforation Confirmed

• Administer broad-spectrum antibiotics if perforation is confirmed: amoxicillin/clavulanate 2 g/0.2 g IV q8h for 4 days in immunocompetent patients with adequate source control 1.
• Alternative for beta-lactam allergy: eravacycline 1 mg/kg IV q12h or tigecycline 100 mg loading dose then 50 mg IV q12h 1.

Helicobacter pylori Testing

• Test for H. pylori infection in all patients without alarm features using non-invasive testing, as eradication eliminates peptic ulcer mortality risk 2, 1.
• Provide eradication therapy if positive, as this approach is cost-effective, safe, and prevents ulcer-related mortality 2.

Endoscopy Indications

• Urgent upper endoscopy indicated for alarm features including persistent vomiting, unintentional weight loss, progressive epigastric pain, decreased oral intake, dysphagia, or family history of gastric/esophageal cancer 2.
• Perform endoscopy in stable patients with symptoms of proximal small bowel obstruction after bariatric surgery 7.
• During endoscopy, grade erosive esophagitis using Los Angeles classification, document hiatal hernia size and Hill grade, and evaluate Barrett's esophagus with Prague classification 2.

Management of Bowel Obstruction

• Assess for bowel obstruction if patient reports no bowel movement or gas passage for ≥2 days 7.
• Perform exploratory laparoscopy within 12-24 hours in stable patients with history of abdominal surgery presenting with persisting acute pain after inconclusive results 7.
• Consider limited intestinal resection in hemodynamically stable patients with clear segmental ischemia, or damage control surgery with open abdomen in unstable patients with extended ischemia/peritonitis 7.

Critical Pitfalls to Avoid

• Never dismiss cardiac causes regardless of patient age, as myocardial infarction can present atypically with isolated epigastric pain 2, 1.
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 3.
• Never attribute persistent symptoms with alarm features to functional dyspepsia without excluding malignancy 2.
• Avoid NSAIDs completely, as they worsen peptic ulcer disease and increase bleeding risk 3.

Disposition and Follow-Up

• Admit patients with peritoneal signs, hemodynamic instability, severe pain requiring parenteral analgesia, or imaging findings requiring surgical evaluation 7, 1.
• Re-evaluate after 4 weeks of PPI therapy if symptoms persist; proceed to upper endoscopy if H. pylori testing is negative, especially when alarm features are present 2.
• Taper PPI to lowest effective dose once adequate symptom control is achieved 2.