Initial Evaluation of Acute Epigastric Pain in Adults

Immediate Cardiac Exclusion

Obtain a 12‑lead electrocardiogram within 10 minutes to rule out atypical myocardial infarction, which carries a 10–20 % mortality when missed. American College of Cardiology recommendation. 1
Perform serial cardiac troponin measurements at presentation and at 6 hours, even in the absence of exertional dyspnea, because women often present with atypical symptoms. American College of Cardiology recommendation. 1

Check vital signs promptly; tachycardia ≥ 110 bpm, fever ≥ 38 °C, or hypotension are highly specific indicators of perforation, anastomotic leak, or sepsis. American College of Surgeons guidance. [1][2]
Look for peritoneal signs (abdominal rigidity, rebound tenderness, absent bowel sounds); their presence suggests perforation, which has an approximate 30 % mortality if treatment is delayed. American College of Surgeons guidance. [1][2]

Order a complete blood count to identify anemia, an alarm feature that mandates urgent endoscopic evaluation. American College of Gastroenterology guideline. 1
Obtain a comprehensive metabolic panel, including liver function tests, to evaluate hepatobiliary disease. American College of Gastroenterology guideline. 1
Measure serum lipase; a level ≥ 2 × upper limit of normal excludes acute pancreatitis with 80–90 % sensitivity and specificity. American College of Gastroenterology guideline. [1][2]
Perform non‑invasive Helicobacter pylori testing (¹³C‑urea breath test or stool antigen) as part of a test‑and‑treat strategy; serology is not recommended. American College of Gastroenterology guideline. 1

Conduct a right upper‑quadrant ultrasound as the first‑line test for suspected biliary colic to detect gallstones, wall thickening, or pericholecystic fluid. American College of Radiology recommendation. 3
If ultrasound is negative and symptoms persist, obtain a contrast‑enhanced CT of the abdomen and pelvis to assess for peptic‑ulcer complications; extraluminal gas is seen in 97 % of perforations, fluid/fat stranding in 89 %, and focal wall defects in 84 %. American College of Gastroenterology guideline. [1][2]

Age ≥ 55 years with new‑onset dyspeptic symptoms is an alarm feature that requires urgent upper‑GI endoscopy within 2 weeks to exclude malignancy. British Society of Gastroenterology recommendation. 1
Do not defer endoscopy solely because other alarm features are absent; age alone suffices for prompt referral. British Society of Gastroenterology recommendation. 1

Rome IV criteria define functional dyspepsia as bothersome epigastric pain occurring ≥ 1 day per week, possibly meal‑related, with no structural disease on endoscopy. Rome Foundation (Gut). [4][5]
Pain severity must be “bothersome” (e.g., ≥ 8/10) to meet the criteria. Rome Foundation (Gut). [4][5]
Symptoms must be present for ≥ 8 weeks before a functional dyspepsia diagnosis is made; it remains a diagnosis of exclusion after structural causes are ruled out. Rome Foundation (Gut). 5

Initiate high‑dose proton‑pump inhibitor therapy (omeprazole 20–40 mg once daily before meals). American College of Gastroenterology recommendation. 1
Full‑dose PPI therapy achieves ulcer healing in 80–90 % of duodenal ulcers and 70–80 % of gastric ulcers within 4 weeks. American College of Gastroenterology data. 1
If H. pylori testing is positive, start standard eradication therapy (clarithromycin‑based triple regimen or bismuth‑based quadruple regimen). American College of Gastroenterology guideline. 1

The Rome IV criteria define functional dyspepsia as bothersome epigastric pain occurring at least 1 day per week and persisting for a total of > 8 weeks (often over years), after exclusion of structural disease. 6
Endoscopic evaluation that shows only mild gastric inflammation without ulceration can be used to rule out peptic ulcer disease in the diagnostic work‑up. 6
The absence of alarm features—such as unexplained weight loss, anemia, dysphagia, or persistent vomiting—supports a functional rather than an organic etiology. 6

Repeat upper endoscopy is not required in patients < 55 years old who lack alarm features and have had a recent (≤ 2 years) endoscopy showing only mild inflammation. 6
Endoscopy should be reconsidered if any of the following occur:

A full‑dose PPI (e.g., omeprazole 40 mg daily before breakfast) for 4–8 weeks provides rapid acid suppression and is the first‑line therapy for suspected acid‑related dyspepsia. (Evidence from guideline‑based studies.) 6
NSAID use should be minimized because chronic NSAID exposure markedly increases the risk of peptic ulcer disease. 7

Strict avoidance of identified trigger foods—particularly coffee, high‑fat dairy products, and other fatty meals—reduces post‑prandial epigastric distress. 7
Eating smaller, more frequent meals (5–6 times daily) and avoiding food intake within 3 hours of bedtime lessen gastric distension and nocturnal acid exposure. 7
A modest weight loss of 5–10 % of body weight improves insulin sensitivity, decreases hepatic steatosis, and alleviates gastro‑esophageal reflux symptoms. 7
Adoption of a Mediterranean dietary pattern (olive oil, whole grains, lean protein, vegetables) is associated with lower dyspepsia symptom burden. 7
Elevating the head of the bed by 6–8 inches and avoiding late‑night snacking help control nighttime reflux and dyspeptic symptoms. 7
Stress‑management and relaxation techniques are recommended because psychological factors can exacerbate functional dyspepsia. 7

Schedule a clinical review in 2–4 weeks to assess:
If symptoms remain uncontrolled after 8 weeks of optimal medical therapy, refer for gastroenterology evaluation and consider repeat endoscopy, prokinetic agents, neuromodulators, or behavioral therapy. 6