Epigastric abdominal pain - Revision history

Danbot: Strip excess bold

2026-03-22T09:29:39Z

Strip excess bold

← Older revision		Revision as of 09:29, 22 March 2026
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	*This page outlines the general approach to adult epigastric pain		*This page outlines the general approach to adult epigastric pain
	*The epigastric region contains: stomach, duodenum, pancreas, hepatic flexure, transverse colon, and the abdominal aorta		*The epigastric region contains: stomach, duodenum, pancreas, hepatic flexure, transverse colon, and the abdominal aorta
	*Key EM considerations: ~~'''~~[[acute coronary syndrome]]~~'''~~ can present as epigastric pain (always consider in patients >40 or with cardiac risk factors), [[pancreatitis]], [[peptic ulcer disease]], [[AAA]]		*Key EM considerations: [[acute coronary syndrome]] can present as epigastric pain (always consider in patients >40 or with cardiac risk factors), [[pancreatitis]], [[peptic ulcer disease]], [[AAA]]
	*Epigastric pain is one of the most common presentations for atypical MI, especially in women, elderly, and diabetic patients		*Epigastric pain is one of the most common presentations for atypical MI, especially in women, elderly, and diabetic patients
	{{Abdominal pain location}}		{{Abdominal pain location}}
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	===Must Not Miss===		===Must Not Miss===
	*~~'''~~[[Acute coronary syndrome]]~~'''~~: atypical MI presentation — get ECG early		*[[Acute coronary syndrome]]: atypical MI presentation — get ECG early
	*~~'''~~Perforated [[peptic ulcer disease\|peptic ulcer]]~~'''~~: free air, peritonitis		*Perforated [[peptic ulcer disease\|peptic ulcer]]: free air, peritonitis
	*~~'''~~[[Ruptured AAA]]~~'''~~: hypotension, pulsatile mass, elderly		*[[Ruptured AAA]]: hypotension, pulsatile mass, elderly
	*~~'''~~Severe [[pancreatitis]]~~'''~~: especially necrotizing		*Severe [[pancreatitis]]: especially necrotizing
	*~~'''~~[[Boerhaave syndrome]]~~'''~~: esophageal perforation after forceful vomiting		*[[Boerhaave syndrome]]: esophageal perforation after forceful vomiting

	==Evaluation==		==Evaluation==
	===Immediate===		===Immediate===
	*~~'''~~[[ECG]]~~'''~~: obtain early in all patients with epigastric pain, especially age >40 or any cardiac risk factors — inferior MI commonly presents as epigastric pain		*[[ECG]]: obtain early in all patients with epigastric pain, especially age >40 or any cardiac risk factors — inferior MI commonly presents as epigastric pain
	*Bedside glucose		*Bedside glucose

	===Laboratory===		===Laboratory===
	*[[CBC]], [[BMP]]		*[[CBC]], [[BMP]]
	*[[LFTs]], ~~'''~~lipase~~'''~~ (>3x upper limit of normal diagnostic for pancreatitis)		*[[LFTs]], lipase (>3x upper limit of normal diagnostic for pancreatitis)
	*[[Troponin]] (ACS screening)		*[[Troponin]] (ACS screening)
	*[[Urinalysis]]		*[[Urinalysis]]
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	===Imaging===		===Imaging===
	*~~'''~~[[CXR]]~~'''~~: free air under diaphragm (perforation), mediastinal air (Boerhaave)		*[[CXR]]: free air under diaphragm (perforation), mediastinal air (Boerhaave)
	*~~'''~~[[RUQ US]]~~'''~~: gallstones, biliary pathology		*[[RUQ US]]: gallstones, biliary pathology
	*~~'''~~[[CT abdomen pelvis]]~~'''~~ with IV contrast: pancreatitis complications, perforation, AAA, mass		*[[CT abdomen pelvis]] with IV contrast: pancreatitis complications, perforation, AAA, mass
	*~~'''~~[[POCUS]]~~'''~~: free fluid, gallbladder, aorta (AAA screening)		*[[POCUS]]: free fluid, gallbladder, aorta (AAA screening)
	*CT angiography if AAA or aortic pathology suspected		*CT angiography if AAA or aortic pathology suspected

	==Management==		==Management==
	*~~'''~~ECG first~~'''~~ in older patients or those with risk factors — if ACS, activate cardiac protocol		*ECG first in older patients or those with risk factors — if ACS, activate cardiac protocol
	*IV fluids, analgesia		*IV fluids, analgesia
	*~~'''~~GI cocktail~~'''~~ (antacid + viscous lidocaine +/- anticholinergic): may provide symptomatic relief for GERD/gastritis, but does NOT rule out cardiac cause even if effective		*GI cocktail (antacid + viscous lidocaine +/- anticholinergic): may provide symptomatic relief for GERD/gastritis, but does NOT rule out cardiac cause even if effective
	*~~'''~~PPI~~'''~~ ([[pantoprazole]]) for suspected peptic ulcer or GERD		*PPI ([[pantoprazole]]) for suspected peptic ulcer or GERD
	*~~'''~~[[Pancreatitis]]~~'''~~: aggressive IV fluid resuscitation, pain control, NPO initially, monitor for complications		*[[Pancreatitis]]: aggressive IV fluid resuscitation, pain control, NPO initially, monitor for complications
	*~~'''~~GI bleeding~~'''~~: resuscitation, PPI infusion, GI consultation for endoscopy		*GI bleeding: resuscitation, PPI infusion, GI consultation for endoscopy
	*~~'''~~Perforated ulcer~~'''~~: emergent surgical consultation, broad-spectrum IV antibiotics		*Perforated ulcer: emergent surgical consultation, broad-spectrum IV antibiotics
	*~~'''~~Ruptured AAA~~'''~~: emergent vascular surgery, permissive hypotension		*Ruptured AAA: emergent vascular surgery, permissive hypotension

	==Disposition==		==Disposition==

Danbot: Expanded with EM-focused content: ACS mimicry warning, must-not-miss diagnoses, red flags, ECG-first approach, management

2026-03-20T23:44:05Z

Expanded with EM-focused content: ACS mimicry warning, must-not-miss diagnoses, red flags, ECG-first approach, management

← Older revision		Revision as of 23:44, 20 March 2026
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	~~<languages/>~~
	~~<translate>~~

	==Background==		==Background==

	*This page outlines the general approach to adult epigastric pain		*This page outlines the general approach to adult epigastric pain
			*The epigastric region contains: stomach, duodenum, pancreas, hepatic flexure, transverse colon, and the abdominal aorta
	~~</translate~~>		*Key EM considerations: '''[[acute coronary syndrome]]''' can present as epigastric pain (always consider in patients >40 or with cardiac risk factors), [[pancreatitis]], [[peptic ulcer disease]], [[AAA]]
			*Epigastric pain is one of the most common presentations for atypical MI, especially in women, elderly, and diabetic patients
	{{Abdominal pain location}}		{{Abdominal pain location}}
	~~<translate>~~


	==Clinical Features==		==Clinical Features==
			===History===
			*Onset, character, radiation (back = pancreatitis, AAA; chest = ACS, GERD; right shoulder = biliary)
			*Relationship to meals: postprandial (biliary, peptic ulcer), relief with eating (duodenal ulcer), worse with eating (gastric ulcer)
			*Alcohol use, gallstone history (pancreatitis)
			*NSAID/aspirin use (peptic ulcer disease)
			*Cardiac risk factors (ACS presenting as epigastric pain)
			*Melena or hematemesis (GI bleeding from ulcer or varices)
			*Prior episodes

	*~~Pain in the epigastrum~~		===Physical Exam===
			*Epigastric tenderness, guarding
			*Murphy sign (biliary — though usually more RUQ)
			*Cullen sign (periumbilical ecchymosis) or Grey Turner sign (flank ecchymosis) — late signs of hemorrhagic pancreatitis
			*Pulsatile abdominal mass (AAA)
			*Absent/decreased bowel sounds

			===Red Flags===
			*Epigastric pain with diaphoresis, dyspnea, or radiation to jaw/arm (ACS)
			*Hematemesis or melena (GI bleeding)
			*Rigid abdomen with free air (perforated ulcer)
			*Pulsatile mass (ruptured AAA)
			*Severe pain radiating to back with hemodynamic instability (pancreatitis with hemorrhage or ruptured AAA)

	==Differential Diagnosis==		==Differential Diagnosis==

	~~</translate>~~
	{{Template:Abdominal Pain DDX Epigastric}}		{{Template:Abdominal Pain DDX Epigastric}}
	~~<translate>~~

			===Must Not Miss===
			*'''[[Acute coronary syndrome]]''': atypical MI presentation — get ECG early
			*'''Perforated [[peptic ulcer disease\|peptic ulcer]]''': free air, peritonitis
			*'''[[Ruptured AAA]]''': hypotension, pulsatile mass, elderly
			*'''Severe [[pancreatitis]]''': especially necrotizing
			*'''[[Boerhaave syndrome]]''': esophageal perforation after forceful vomiting

	==Evaluation==		==Evaluation==
			===Immediate===
			*'''[[ECG]]''': obtain early in all patients with epigastric pain, especially age >40 or any cardiac risk factors — inferior MI commonly presents as epigastric pain
			*Bedside glucose

			===Laboratory===
			*[[CBC]], [[BMP]]
			*[[LFTs]], '''lipase''' (>3x upper limit of normal diagnostic for pancreatitis)
			*[[Troponin]] (ACS screening)
			*[[Urinalysis]]
			*Urine pregnancy test (females of reproductive age)
			*Coagulation studies if bleeding
			*[[Lactate]] if concern for ischemia or sepsis
			*Type and screen if active GI bleeding

	===~~Workup~~===		===Imaging===
			*'''[[CXR]]''': free air under diaphragm (perforation), mediastinal air (Boerhaave)
	*CBC		*'''[[RUQ US]]''': gallstones, biliary pathology
	*Chem		*'''[[CT abdomen pelvis]]''' with IV contrast: pancreatitis complications, perforation, AAA, mass
	*[[~~Special:MyLanguage/LFTs\|LFTs~~]]		*'''[[POCUS]]''': free fluid, gallbladder, aorta (AAA screening)
	*Lipase		*CT angiography if AAA or aortic pathology suspected
	*Coags
	*[[Special:~~MyLanguage/Urinalysis\|Urinalysis]]~~
	*Urine pregnancy (~~females~~)
	*?[[~~Special:MyLanguage/ECG\|ECG~~]] ~~(if >50 or at risk for cardiac disease)~~
	*?[[~~Special:MyLanguage/RUQ US\|RUQ US~~]]
	*?[[~~Special:MyLanguage/CXR\|CXR~~]]
	**Consider if ~~at risk for perforated ulcer~~


	~~===Diagnosis===~~


	==Management==		==Management==
			*'''ECG first''' in older patients or those with risk factors — if ACS, activate cardiac protocol
	*~~Treat underlying disease process~~		*IV fluids, analgesia
	*~~Consider PO~~ antacid (~~e.g.~~ [[~~Special:MyLanguage/Bismuth subsalicylate\|Maalox~~]] ~~Plus~~)		*'''GI cocktail''' (antacid + viscous lidocaine +/- anticholinergic): may provide symptomatic relief for GERD/gastritis, but does NOT rule out cardiac cause even if effective
	**The addition of viscous [[~~Special:MyLanguage/lidocaine\|lidocaine~~]] ~~2% and/or Donnatol (i.e. "~~GI ~~Cocktail") is no more effective than plain liquid antacid<ref>Berman DA~~, ~~Porter RS~~, ~~Graber M. "The~~ GI ~~Cocktail is no more effective than plain liquid antacid~~: ~~a randomized~~, ~~double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239~~-~~44.</ref>~~		*'''PPI''' ([[pantoprazole]]) for suspected peptic ulcer or GERD
			*'''[[Pancreatitis]]''': aggressive IV fluid resuscitation, pain control, NPO initially, monitor for complications
			*'''GI bleeding''': resuscitation, PPI infusion, GI consultation for endoscopy
			*'''Perforated ulcer''': emergent surgical consultation, broad-spectrum IV antibiotics
			*'''Ruptured AAA''': emergent vascular surgery, permissive hypotension

	==Disposition==		==Disposition==
			*Admit: pancreatitis requiring IV management, ACS, GI bleeding, perforation, biliary obstruction
	*~~Disposition per underlying disease process~~		*Discharge: mild gastritis/GERD with resolved symptoms, negative cardiac workup, ability to tolerate oral intake
			*Follow-up: PCP in 1-2 weeks for new PPI starts; GI referral for suspected ulcer (H. pylori testing, EGD)
			*Return precautions: worsening pain, vomiting blood, black stools, chest pain, lightheadedness

	==See Also==		==See Also==
			*[[Abdominal Pain]]
	*[[~~Special:MyLanguage/Abdominal Pain\|~~Abdominal Pain]]		*[[Pancreatitis]]
	*[[~~Special:MyLanguage/Abdominal Pain (Peds)\|Abdominal Pain (Peds)~~]]		*[[Peptic ulcer disease]]
			*[[GERD]]

	==External Links==		==External Links==


	==References==		==References==

	<references/>		<references/>

	[[Category:GI]]		[[Category:GI]]
	[[Category:Symptoms]]		[[Category:Symptoms]]
	~~</translate>~~

Ostermayer: Prepared the page for translation

2026-01-04T22:51:20Z

Prepared the page for translation

← Older revision		Revision as of 22:51, 4 January 2026
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			<languages/>
			<translate>

	==Background==		==Background==

	*This page outlines the general approach to adult epigastric pain		*This page outlines the general approach to adult epigastric pain

			</translate>
	{{Abdominal pain location}}		{{Abdominal pain location}}
			<translate>


	==Clinical Features==		==Clinical Features==

	*Pain in the epigastrum		*Pain in the epigastrum


	==Differential Diagnosis==		==Differential Diagnosis==

			</translate>
	{{Template:Abdominal Pain DDX Epigastric}}		{{Template:Abdominal Pain DDX Epigastric}}
			<translate>


	==Evaluation==		==Evaluation==


	===Workup===		===Workup===

	*CBC		*CBC
	*Chem		*Chem
	*[[LFTs]]		*[[Special:MyLanguage/LFTs\|LFTs]]
	*Lipase		*Lipase
	*Coags		*Coags
	*[[Urinalysis]]		*[[Special:MyLanguage/Urinalysis\|Urinalysis]]
	*Urine pregnancy (females)		*Urine pregnancy (females)
	*?[[ECG]] (if >50 or at risk for cardiac disease)		*?[[Special:MyLanguage/ECG\|ECG]] (if >50 or at risk for cardiac disease)
	*?[[RUQ US]]		*?[[Special:MyLanguage/RUQ US\|RUQ US]]
	*?[[CXR]]		*?[[Special:MyLanguage/CXR\|CXR]]
	**Consider if at risk for perforated ulcer		**Consider if at risk for perforated ulcer


	===Diagnosis===		===Diagnosis===


	==Management==		==Management==

	*Treat underlying disease process		*Treat underlying disease process
	*Consider PO antacid (e.g. [[Bismuth subsalicylate\|Maalox]] Plus)		*Consider PO antacid (e.g. [[Special:MyLanguage/Bismuth subsalicylate\|Maalox]] Plus)
	**The addition of viscous [[lidocaine]] 2% and/or Donnatol (i.e. "GI Cocktail") is no more effective than plain liquid antacid<ref>Berman DA, Porter RS, Graber M. "The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239-44.</ref>		**The addition of viscous [[Special:MyLanguage/lidocaine\|lidocaine]] 2% and/or Donnatol (i.e. "GI Cocktail") is no more effective than plain liquid antacid<ref>Berman DA, Porter RS, Graber M. "The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239-44.</ref>


	==Disposition==		==Disposition==

	*Disposition per underlying disease process		*Disposition per underlying disease process


	==See Also==		==See Also==
	*[[Abdominal Pain]]
	*[[Abdominal Pain (Peds)]]		*[[Special:MyLanguage/Abdominal Pain\|Abdominal Pain]]
			*[[Special:MyLanguage/Abdominal Pain (Peds)\|Abdominal Pain (Peds)]]


	==External Links==		==External Links==


	==References==		==References==

	<references/>		<references/>

	[[Category:GI]]		[[Category:GI]]
	[[Category:Symptoms]]		[[Category:Symptoms]]
			</translate>

Rossdonaldson1: /* Background */

2024-01-31T22:37:59Z

Background

← Older revision		Revision as of 22:37, 31 January 2024
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	==Background==		==Background==
	*This page outlines the general approach to adult epigastric pain		*This page outlines the general approach to adult epigastric pain

			{{Abdominal pain location}}

	==Clinical Features==		==Clinical Features==

Rossdonaldson1: /* Workup */

2024-01-31T22:01:20Z

Workup

← Older revision		Revision as of 22:01, 31 January 2024
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	{{Template:Abdominal Pain DDX Epigastric}}		{{Template:Abdominal Pain DDX Epigastric}}

	==Workup==		==Evaluation==
			===Workup===
	*CBC		*CBC
	*Chem		*Chem
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	*?[[CXR]]		*?[[CXR]]
	**Consider if at risk for perforated ulcer		**Consider if at risk for perforated ulcer

			===Diagnosis===

	==Management==		==Management==

Rossdonaldson1: /* Clinical Features */

2024-01-31T22:00:57Z

Clinical Features

← Older revision		Revision as of 22:00, 31 January 2024
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	==Clinical Features==		==Clinical Features==
			*Pain in the epigastrum

	==Differential Diagnosis==		==Differential Diagnosis==

ClaireLewis: /* Workup */

2019-09-14T15:22:04Z

Workup

← Older revision		Revision as of 15:22, 14 September 2019
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	*CBC		*CBC
	*Chem		*Chem
	*LFTs		*[[LFTs]]
	*Lipase		*Lipase
	*Coags		*Coags
	*[[Urinalysis]]		*[[Urinalysis]]
	*Urine pregnancy (females)		*Urine pregnancy (females)
	*?ECG (if >50 or at risk for cardiac disease)		*?[[ECG]] (if >50 or at risk for cardiac disease)
	*?[[RUQ US]]		*?[[RUQ US]]
	*?CXR		*?[[CXR]]
	**Consider if at risk for perforated ulcer		**Consider if at risk for perforated ulcer

ClaireLewis: /* Management */

2019-09-14T15:21:36Z

Management

← Older revision		Revision as of 15:21, 14 September 2019
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	==Management==		==Management==
	*Treat underlying disease process		*Treat underlying disease process
	*Consider PO antacid (e.g. Maalox Plus)		*Consider PO antacid (e.g. [[Bismuth subsalicylate\|Maalox]] Plus)
	**The addition of viscous lidocaine 2% and/or Donnatol (i.e. "GI Cocktail") is no more effective than plain liquid antacid<ref>Berman DA, Porter RS, Graber M. "The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239-44.</ref>		**The addition of viscous [[lidocaine]] 2% and/or Donnatol (i.e. "GI Cocktail") is no more effective than plain liquid antacid<ref>Berman DA, Porter RS, Graber M. "The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239-44.</ref>

	==Disposition==		==Disposition==

Rossdonaldson1: /* Management */

2017-10-18T06:10:53Z

Management

← Older revision		Revision as of 06:10, 18 October 2017
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	==Management==		==Management==
	*Treat underlying disease process		*Treat underlying disease process
	*Consider ~~GI cocktail~~ (Maalox Plus~~/Lidocaine Viscous~~ 2%/Donnatol)		*Consider PO antacid (e.g. Maalox Plus)
			**The addition of viscous lidocaine 2% and/or Donnatol (i.e. "GI Cocktail") is no more effective than plain liquid antacid<ref>Berman DA, Porter RS, Graber M. "The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial." J Emerg Med. 2003 Oct;25(3):239-44.</ref>

	==Disposition==		==Disposition==

Ktanner777: /* Management */

2017-10-09T06:05:52Z

Management

← Older revision		Revision as of 06:05, 9 October 2017
Line 22:		Line 22:
	==Management==		==Management==
	*Treat underlying disease process		*Treat underlying disease process
	*Consider GI cocktail		*Consider GI cocktail (Maalox Plus/Lidocaine Viscous 2%/Donnatol)

	==Disposition==		==Disposition==