Evaluation and Management of Intermittent Right Epigastric Pulsation

Immediate Life-Threatening Causes to Exclude

• The American College of Radiology recommends ultrasound as the initial screening test of choice for suspected abdominal aortic aneurysm (AAA), with population-based screening proven effective for patients over 65 years of age 1
• Clinical palpation of a pulsating abdominal mass alerts the clinician to possible AAA, making imaging studies essential for diagnosis and categorization 1
• If ultrasound confirms AAA, proceed to CT angiography or multidetector CT for detailed characterization and pre-intervention evaluation 1

Alternative Diagnoses if Vascular Causes Excluded

• The American College of Radiology states that CT abdomen and pelvis with IV contrast is the gold standard for diagnosing perforation, with 97% sensitivity for extraluminal gas 5
• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation with 30% mortality if treatment is delayed 2, 3
• Characteristically, acute pancreatitis presents with epigastric pain radiating to the back, requiring serum lipase or amylase ≥3 times the upper limit of normal for diagnosis 2
• CT abdomen and pelvis with IV contrast has 97% sensitivity for diagnosis of acute pancreatitis 2

Diagnostic Algorithm

• Immediate vital signs assessment should be done within the first 10 minutes to check for tachycardia, hypotension, or respiratory distress 3
• An ECG should be performed within 10 minutes to exclude cardiac ischemia regardless of age or typical presentation, as recommended by the American Heart Association 2, 3
• Ultrasound of the abdomen is the first-line imaging to evaluate for AAA and assess liver size/congestion, according to the American College of Radiology 1
• If ultrasound shows AAA, proceed to CT angiography for detailed characterization and surgical planning 1
• If ultrasound is negative for AAA, obtain contrast-enhanced CT abdomen/pelvis to evaluate for celiac artery dissection, pancreatitis, perforation, or hepatic pathology 5, 2

Critical Pitfalls to Avoid

• Do not delay imaging with ultrasound while pursuing other diagnostic tests, as AAA rupture is immediately life-threatening 1
• Do not dismiss cardiac causes based on the pulsatile nature of the pain, as myocardial infarction mortality reaches 10-20% if missed, according to the American College of Cardiology 2, 4