Epigastric Pain Evaluation and Management

Differential Diagnosis

• The American College of Radiology suggests that epigastric pain can be caused by various conditions, including gastroesophageal reflux disease (GERD), peptic ulcer disease (PUD), gastritis, and more serious conditions like myocardial infarction, pancreatitis, or acute aortic syndromes 1, 2
• Gastric cancer may present with nonspecific symptoms 3
• Hiatal hernia may cause reflux symptoms 4
• Myocardial infarction should be considered, especially with shortness of breath with exertion 1
• Acute aortic syndromes may present with pain radiating to the back 1

Initial Clinical Assessment

• The American College of Radiology recommends evaluating specific symptoms accompanying epigastric pain, such as heartburn and regurgitation (suggesting GERD) 1
• Dysphagia suggests esophageal pathology 1, 5
• Nausea and vomiting may indicate gastritis, PUD, or obstruction 1
• Hematemesis suggests bleeding ulcer or malignancy 1
• Shortness of breath or chest pain may indicate a cardiac etiology 1
• Pain radiating to the back may indicate pancreatic disease or aortic pathology 1

Diagnostic Workup

• H. pylori testing is recommended if PUD is suspected 2
• Upper endoscopy is the standard test of choice for suspected GERD, esophagitis, gastritis, PUD, or duodenal ulcer 2
• Fluoroscopy with upper GI series is beneficial for evaluating structural and functional abnormalities 6
• For suspected gastric cancer, upper GI series or CT abdomen and pelvis with IV contrast are usually appropriate 7
• For suspected hiatal hernia, fluoroscopy with biphasic esophagram, single-contrast esophagram, or upper GI series is recommended 4

Initial Treatment Approach

• Endoscopic lumen enhancement, such as wire-guided dilation or balloon dilation, may be used for gastric outlet obstruction 5
• Endoscopy or fluoroscopy-guided placement of covered expandable metal stents may be used for severe cases of gastric outlet obstruction 5

Common Pitfalls and Caveats

• The American College of Radiology warns against assuming all epigastric pain is due to acid-related disorders, and considers serious conditions like myocardial infarction, pancreatitis, or aortic dissection 1
• Symptoms of different conditions often overlap, making clinical history, risk factors, and associated symptoms crucial for narrowing the differential diagnosis 1
• Endoscopy should be prioritized in patients with alarm symptoms (weight loss, dysphagia, recurrent vomiting, GI bleeding, or family history of upper GI cancer) 2
• The American College of Radiology advises against relying solely on CT for initial diagnosis of GERD or PUD, as it has limited sensitivity for these conditions 2