Diagnostic Approach to Mid Back Pain and Epigastric Pain

Immediate Life-Threatening Causes to Exclude

Myocardial infarction can present atypically with epigastric pain as the primary manifestation, with mortality rates of 10-20% if missed, particularly in diabetics and those with cardiac risk factors 1, 2
Obtain an ECG within 10 minutes of presentation and measure cardiac troponins in series at 0 and 6 hours—never rely on a single troponin measurement 1, 2
Atypical presentations are common and include epigastric pain, indigestion-like symptoms, and isolated dyspnea 2
Perforated peptic ulcer presents with sudden, severe epigastric pain that becomes generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds 1, 2
Mortality reaches 30% if treatment is delayed for perforated peptic ulcer 1, 2
CT abdomen 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 1
Diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity for acute pancreatitis 1
Overall mortality is <10% but reaches 30-40% in necrotizing pancreatitis 3

Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 3
Presents with epigastric pain not relieved by antacids for peptic ulcer disease 1, 3
Gastroesophageal reflux disease (GERD) affects 42% of Americans monthly and 7% daily 1, 2, 3
Presents with epigastric pain often accompanied by heartburn and regurgitation for GERD 1, 2, 3
The burning sensation that starts in the epigastrium but radiates to the chest helps differentiate GERD heartburn from dyspeptic epigastric pain 4
Gastritis is often associated with NSAID use, alcohol, or H. pylori infection 2
Appears on imaging as enlarged areae gastricae, disruption of normal polygonal pattern, thickened gastric folds, or erosions for gastritis 2
Gastric cancer may present with an ulcer associated with nodularity of adjacent mucosa, mass effect, or irregular radiating folds 1, 2, 3
Now the most common cause of gastric outlet obstruction in adults for gastric cancer 1, 3
Alarm signs include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia for gastric cancer 2

Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict perforation or sepsis with high specificity 2
Perform physical examination seeking peritoneal signs (rigidity, rebound tenderness, absence of bowel sounds) 2
Evaluate timing and onset (sudden vs. gradual), severity (1-10 scale), and associated symptoms (nausea, vomiting, hematemesis, heartburn) 2
Complete blood count, C-reactive protein, serum lactate, liver and renal function tests are necessary laboratory tests 2, 3
Serum amylase or lipase to exclude acute pancreatitis 2, 3
Cardiac troponins at 0 and 6 hours (serial measurements are mandatory) 1, 2
CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, vascular emergencies, and visceral artery dissection 1, 2
ECG within 10 minutes to exclude myocardial ischemia 1, 2
Upper endoscopy is definitive for peptic ulcer disease, gastritis, and esophagitis when the patient is stable 1

Maintain the patient nil per os until surgical emergency is excluded 2
Establish IV access and provide fluid resuscitation if hemodynamically unstable 2
Start high-dose proton pump inhibitor 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
Avoid NSAIDs as they can exacerbate peptic ulcer disease and increase the risk of bleeding 2
For nausea: ondansetron 8 mg sublingual every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 2, 3
Obtain a baseline ECG before administering ondansetron due to QTc prolongation risk 2, 3

Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age—this is a fatal mistake 1, 2
Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 2
Do not assume GERD without first excluding life-threatening causes, even in patients with known reflux disease 2
Persistent vomiting with epigastric pain excludes functional dyspepsia and requires investigation for structural disease 2, 3