Differential Diagnosis for Epigastric Pain with Nausea

Immediate Life-Threatening Causes

Myocardial infarction can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 1, 2, 3
The American College of Cardiology recommends obtaining an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours to rule out myocardial infarction 1, 2, 3
Perforated peptic ulcer presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed 1, 2, 3
CT with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% for perforated peptic ulcer 1, 2
Acute pancreatitis characteristically presents with epigastric pain radiating to the back, which may feel like waves or contractions, and is diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 1, 2, 3

HELLP syndrome presents with epigastric pain, nausea, vomiting, and malaise in pregnant patients, with clinical signs including epigastric pain, upper abdominal tenderness, proteinuria, hypertension, jaundice, and nausea and vomiting, and requires immediate delivery after stabilization 4, 1

Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases, and presents with epigastric pain not relieved by antacids 1, 2
Gastroesophageal reflux disease affects 42% of Americans monthly and 7% daily, and presents with epigastric pain often accompanied by heartburn and regurgitation 1, 2
Gastric cancer may present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds, and is now the most common cause of gastric outlet obstruction in adults 5, 1, 2

The American College of Radiology recommends CT abdomen and pelvis with IV contrast as the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2, 3
Upper endoscopy is definitive for PUD, gastritis, and esophagitis when patient is stable 2

The American College of Gastroenterology recommends starting high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2

Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age, as recommended by the American Heart Association 1, 2, 3
Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis, as stated by the American College of Surgeons 2, 3