Differential Diagnosis for Epigastric Pain Radiating to Shoulder

Critical Life-Threatening Diagnoses (Rule Out First)

The American College of Cardiology recommends considering myocardial infarction as a primary presentation of cardiac ischemia, particularly in women, diabetics, and elderly patients who may present atypically 3
Acute aortic dissection can present with severe epigastric pain and requires emergent imaging, as suggested by the American College of Radiology 1, 2
Obtain immediate ECG and cardiac biomarkers (troponin at presentation and 6 hours later) for any patient with epigastric pain and shoulder radiation, according to the American College of Cardiology 3
Perforated peptic ulcer has a mortality rate of up to 30% if untreated, and can be diagnosed with imaging, as recommended by the American College of Radiology 1, 2

Peptic ulcer disease (PUD) has an incidence of 0.1-0.3%, and complications occur in 2-10% of cases, according to the American College of Radiology 1, 2
Gastroesophageal reflux disease (GERD) affects 42% of Americans monthly, and presents with heartburn, regurgitation, and epigastric pain, as reported by the American College of Radiology 1, 4
Acute gastritis is often associated with NSAID use, alcohol, or H. pylori infection, as suggested by the American College of Radiology 1, 2
Gastric cancer should be considered in patients with alarm symptoms (weight loss, dysphagia, hematemesis), according to the American College of Radiology 1, 2
Acute pancreatitis presents with epigastric pain radiating to the back, as recommended by the American College of Radiology 1, 2

The American College of Cardiology recommends obtaining vital signs, including hypotension and tachycardia, which suggest hemorrhage or shock 3
ECG should be obtained within 10 minutes of presentation for any epigastric pain, as suggested by the American College of Cardiology 3
Cardiac biomarkers, including troponin at 0 and 6 hours, should be used to rule out NSTEMI, according to the American College of Cardiology 3
High-risk features requiring immediate intervention include ST-segment changes on ECG, peritoneal signs on examination, and age >50 with new-onset symptoms, as recommended by the American College of Cardiology 3

CT abdomen/pelvis with IV contrast is the gold standard for acute abdomen when diagnosis is unclear, and can identify pancreatitis, perforation, and vascular emergencies, as suggested by the American College of Radiology 1, 2
Upper endoscopy is the definitive test for PUD, gastritis, and esophagitis when the patient is stable, according to the American College of Radiology and Gut 1, 5

NPO status should be maintained until surgical emergency is excluded, as recommended by the American College of Cardiology 3
IV access and fluid resuscitation should be provided if the patient is hemodynamically unstable, according to the American College of Cardiology 3
Proton pump inhibitor therapy, such as omeprazole 20 mg, should be used for suspected acid-related pathology, as suggested by Gut 5
NSAIDs should be avoided, as they can worsen PUD and bleeding risk, according to Gut 5

Cardiac causes should not be dismissed in patients presenting with "atypical" epigastric pain, as recommended by the American College of Cardiology 3
Imaging should not be delayed in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis, according to the American College of Radiology 1, 2
A single troponin measurement should not be relied upon, and requires serial measurements at least 6 hours apart to exclude NSTEMI, as suggested by the American College of Cardiology 3
GERD should not be assumed without excluding life-threatening causes first, even in patients with known reflux disease, according to the American College of Radiology 1, 4