Diagnostic Approach to Epigastric Pain

Initial Evaluation

• The American College of Radiology recommends H. pylori testing as the initial step for patients with uncomplicated epigastric pain, as it is non-invasive, cost-effective, and guides targeted therapy 1, 3
• Endoscopy is reserved for patients with alarm features, such as hematemesis, significant weight loss, or dysphagia, or for those who fail empiric therapy 1, 2

Imaging Modalities

• CT abdomen/pelvis with IV contrast is appropriate when there is concern for serious complications or malignancy, such as suspected perforated peptic ulcer, gastric outlet obstruction, or constitutional symptoms suggesting malignancy 2, 4
• Barium esophagram and upper GI series are most appropriate for suspected hiatal hernia, GERD with reflux symptoms, preoperative evaluation for antireflux surgery, or suspected esophageal stricture or dysphagia 2, 3, 5

Treatment and Follow-up

• Positive H. pylori results warrant eradication therapy, which can resolve symptoms without need for endoscopy in uncomplicated cases 1
• Proceed to endoscopy if H. pylori eradication fails to resolve symptoms, alarm features develop, or symptoms persist despite appropriate PPI therapy 1