Diagnostic Approach to Epigastric Pain

Causes Threatening Vital Prognosis

The American College of Cardiology recommends immediate exclusion of myocardial infarction in patients presenting with epigastric pain, as it can manifest atypically with a mortality rate of 10-20% if missed, particularly in women, diabetics, and the elderly 1
Obtain an ECG within 10 minutes of presentation and measure cardiac troponins in series at 0 and 6 hours to exclude acute coronary syndrome 1, 2
Never rely on a single troponin measurement; serial measurements at least 6 hours apart are necessary to exclude NSTEMI 2
Atypical presentations include epigastric pain, indigestion-like symptoms, and isolated dyspnea, particularly in elderly patients, women, and diabetics 1
Never dismiss cardiac causes in patients presenting with "atypical" epigastric pain, regardless of age or presentation 1, 2, 3
Perforated peptic ulcer presents with sudden and severe epigastric pain becoming generalized, accompanied by fever, abdominal rigidity, and absence of bowel sounds 1, 2, 3
Mortality reaches 30% if treatment is delayed 1, 2
CT scan of the abdomen with IV contrast shows extraluminal gas in 97% of cases, fluid collection or fat infiltration in 89%, ascites in 89%, and focal parietal defect in 84% 1, 2, 3
Requires urgent surgical consultation for laparoscopic or open repair 2

Gastroesophageal reflux disease (GERD) affects 42% of Americans monthly and 7% daily, presenting with epigastric pain often accompanied by heartburn and regurgitations 1, 3
Esophagitis manifests as fine nodularity or granularity of the mucosa, erosions or ulcers, thickened longitudinal folds, and scars with strictures 1, 2
The oesophagogram has a sensitivity of 88% for detecting esophagitis using a combined technique 4, 2
Gastritis appears as enlarged areae gastricae, disruption of the normal polygonal pattern by multiple uniform nodules, thickened gastric folds, or erosions 1, 2
Often associated with NSAID use, alcohol, or H. pylori infection 1
Gastric cancer may present with an associated ulcer, adjacent mucosal nodularity, mass effect, or irregular radiating folds 1, 2, 3
Now the most common cause of gastric outlet obstruction in adults 1, 2
Alarm signs include weight loss, dysphagia, hematemesis, persistent vomiting, and anemia 2

Check vital signs for hypotension, tachycardia ≥110 bpm, or fever ≥38°C, which predict anastomotic leak, perforation, or sepsis with high specificity 1, 2
Perform a physical examination seeking peritoneal signs (rigidity, rebound tenderness, absence of bowel sounds), cardiac murmurs, irregular pulse, jugular venous distension, friction rub, and pain reproduced by palpation 1, 2
Evaluate the timing and onset (sudden vs. gradual), severity (1-10 scale), and associated symptoms (nausea, vomiting, hematemesis, heartburn, regurgitations) 1
Laboratory tests include complete blood count, C-reactive protein, serum lactate, liver and renal function tests 1, 2
Amylase or lipase serum levels to exclude acute pancreatitis 1, 2
Electrolyte and glucose levels 1
Troponin levels at 0 and 6 hours (do not rely on a single measurement) 1, 2, 3
CT scan of the abdomen with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2, 3

Maintain the patient nil per os until surgical emergency is excluded 1, 2
Establish IV access and provide fluid resuscitation if hemodynamically unstable 1, 2
Empiric medical treatment with high-dose proton pump inhibitors (PPIs) (omeprazole 20-40 mg once daily) for suspected acid-related disease, 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 1, 2
Symptomatic treatment for nausea includes ondansetron 8 mg sublingually every 4-6 hours, promethazine 12.5-25 mg orally/rectally every 4-6 hours, or prochlorperazine 5-10 mg every 6-8 hours 1
Obtain a baseline ECG before administering ondansetron due to the risk of QTc prolongation 1

Do not delay imaging in patients with peritoneal signs, as mortality from perforated ulcer increases significantly with delayed diagnosis 2, 3
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 such as peptic ulcer disease or acute coronary syndrome 2
Do not delay endoscopy in patients with alarm signs (persistent vomiting, weight loss, anemia, dysphagia), as this leads to poor outcomes 2

The American College of Cardiology notes that medication history is crucial, as NSAIDs, bisphosphonates, potassium supplements, or iron can cause medication-induced esophagitis or gastritis in patients with epigastric pain 5
If symptoms persist despite 8 weeks of optimized PPI therapy, the American College of Cardiology recommends referring for upper endoscopy, and if endoscopy is normal and symptoms persist, considering esophageal function testing and pH monitoring to exclude esophageal motility disorders 5
For recurrent presentations with negative cardiac and GI workup, the American College of Cardiology suggests considering referral to cognitive-behavioral therapy for possible psychosomatic etiology 5