Epigastric PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

442 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Abdominal Distension Abdominal Pain, Undifferentiated Acute Abdominal Pain (general)Suspected Incarcerated Or Strangulated Hernia Pancreatitis Concern Biliary Colic And Cholecystitis Concern Appendicitis Concern Diverticulitis Concern Rectal Pain And Anorectal Complaints Dysphagia And Food Bolus Impaction Foreign Body Ingestion Refractory Vomiting And Recurrent Vomiting Syndromes Cannabis Associated Hyperemesis Upper Gastrointestinal Bleeding Symptoms (melena)Lower Gastrointestinal Bleeding And Hematochezia Constipation And Obstipation Diarrhea Acute Hepatitis And Jaundice Concern Right Upper Quadrant Pain Epigastric Pain Left Upper Quadrant Pain Right Lower Quadrant Pain Left Lower Quadrant Pain Suprapubic Pain

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx60

HPI overview

›Symptom characterization

›Primary location epigastric

›Pain versus burning versus pressure versus fullness

›First episode versus recurrent pattern

›Prior evaluations and prior diagnoses

Onset

›Onset details

›Sudden onset minutes to hours

›Gradual onset hours to days

›Postprandial onset minutes to hours

›Nocturnal onset

Provocation/Palliation

›Provocation and palliation

›Exertion trigger

›Food trigger

›Alcohol trigger

›NSAID exposure trigger

›Relief with antacids

›Relief with leaning forward

›Worse supine

Quality

›Quality descriptors

›Burning

›Gnawing

›Pressure

›Tearing

›Sharp pleuritic component

Region/Radiation

›Location and radiation

›Radiation to chest

›Radiation to back

›Radiation to right shoulder

›Migration pattern

Severity

›Severity and impact

›Pain score trajectory

›Limitation of oral intake

›Sleep disruption

Timing

›Time course

›Constant

›Intermittent colicky

›Progressive worsening

›Episodic with meals

Associated symptoms

›Associated symptoms cluster

›Nausea

›Vomiting

›Hematemesis

›Melena

›Dyspnea

›Diaphoresis

›Syncope

›Fever

›Jaundice

›Weight loss

Context and triggers

›Symptom context

›Recent heavy meal

›Recent binge alcohol

›Recent viral illness

›Recent procedure endoscopy ERCP

›Trauma

Prior episodes and baseline

›Prior episodes

›Similar pain responsive to antacids

›Prior pancreatitis episodes

›Prior gallstones or cholecystitis

›Baseline dyspepsia or GERD symptoms

02Alarm Features/alarm30

Immediate escalation triggers

›Time critical features

›Hypotension or shock

›Altered mental status

›Persistent severe pain out of proportion

›Ongoing hematemesis or large volume melena

›Respiratory distress

Vital sign danger thresholds

›High risk vitals

›SBP less than 90 mmHg

›HR greater than 120 per minute

›RR greater than 24 per minute

›SpO2 less than 90 percent on room air

›Temperature 38.5 C or higher with abdominal pain

High risk historical features

›High risk history

›Known coronary artery disease

›Known aortic aneurysm

›Anticoagulation use

›Immunocompromised state

›Pregnancy or postpartum state

›Recent instrumentation ERCP endoscopy

High risk exam findings

›High risk exam

›Peritonitis rigidity rebound guarding

›Pulsatile abdominal mass

›New focal neurologic deficit

›Severe epigastric tenderness with guarding

›Jaundice with fever

Do not miss patterns

›High risk symptom patterns

›Epigastric pain with diaphoresis or exertional component

›Epigastric pain with syncope

›Epigastric pain radiating to back with hypotension

›Sudden tearing pain with neurologic symptoms

03Medications/meds21

Current medications and recent changes

›Medication exposure

›New medication within 30 days

›Recent dose increase

›Recent discontinuation of PPI or H2 blocker

High risk medication classes

›Medication risks

›NSAIDs

›Aspirin

›Anticoagulants

›Antiplatelets

›Glucocorticoids

›GLP1 receptor agonists

›Opioids

OTC and supplements

›Nonprescription exposures

›Bismuth

›Antacids

›Herbal supplements

›Iron

Therapy constraints

›Contraindication screen

›QT prolonging medications

›Renal impairment affecting contrast decisions

›Allergy to iodinated contrast

04Diet/diet11

Recent intake and triggers

›Intake pattern

›Recent fatty meal

›Recent spicy or acidic foods

›Fasting or poor intake

Hydration and vomiting risk

›Hydration markers

›Reduced urine output

›Inability to tolerate oral fluids

Alcohol and caffeine

›Exposures

›Recent alcohol binge

›Daily heavy alcohol use

›High caffeine or energy drink use

05Review of Systems/ros29

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain or pressure

›Dyspnea

›Palpitations

›Orthopnea

›Leg swelling

Gastrointestinal

›GI symptoms

›Dysphagia

›Odynophagia

›Early satiety

›Hematemesis

›Melena

›Hematochezia

›Diarrhea

›Constipation

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Myalgias

Genitourinary and pregnancy

›GU and reproductive symptoms

›Dysuria

›Flank pain

›Missed period

›Vaginal bleeding

Neurologic

›Neuro symptoms

›Syncope

›Focal weakness

›Severe headache

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral information

›Source partner family EMS facility

›Reliability concerns intoxication cognitive impairment language barrier

Family history

›Family risk

›Premature coronary artery disease

›Aortic aneurysm or dissection

›Peptic ulcer disease complications

›Familial hypertriglyceridemia

Exposure history

›Household and contact risks

›Sick contacts gastroenteritis

›Recent travel or foodborne exposure

07Risk Factors/rf26

Cardiovascular and thrombotic risk

›ACS risk factors

›Age risk

›Diabetes

›Hypertension

›Smoking

›Dyslipidemia

›Known CAD prior MI PCI CABG

Aortic and vascular risk

›Aortic risk factors

›Known aneurysm

›Connective tissue disorder

›Uncontrolled hypertension

›Cocaine or stimulant use

GI mucosal injury risk

›Peptic ulcer risk factors

›NSAID or aspirin use

›H pylori history

›Prior ulcer or GI bleed

Pancreatitis risk

›Pancreatitis risks

›Alcohol use disorder

›Gallstones history

›Hypertriglyceridemia

›New medication associated pancreatitis

Special populations

›Population modifiers

›Pregnancy

›Older adult frailty

›Immunocompromised state

›Anticoagulated state

08Differential Diagnosis/ddx64

Life threatening

›Life threatening causes

›Acute coronary syndrome NSTEMI STEMI (I21.4 I21.3)

›Epigastric pain as anginal equivalent

›Higher risk with diaphoresis dyspnea exertional trigger

›Aortic dissection (I71.0)

›Sudden severe pain

›Pulse deficit neurologic symptoms hypotension

›Ruptured abdominal aortic aneurysm (I71.3)

›Hypotension syncope back pain pulsatile mass

›Anticoagulation increases hemorrhage risk

›Perforated peptic ulcer (K25.1 K26.1)

›Sudden severe pain

›Peritonitis free air risk

›Esophageal rupture (K22.3)

›Severe pain after forceful vomiting

›Subcutaneous emphysema sepsis risk

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›AF or vascular disease risk

›Severe acute pancreatitis with organ failure (K85.9)

›Persistent vomiting systemic inflammatory response

›Hypotension hypoxemia

Common

›Common causes

›Dyspepsia functional dyspepsia (K30)

›Postprandial fullness early satiety epigastric pain

›Normal vitals and benign exam

›GERD or esophagitis (K21.9 K20.9)

›Burning regurgitation worse supine

›Response to acid suppression

›Peptic ulcer disease (K27.9)

›Gnawing epigastric pain

›NSAID exposure or prior ulcer

›Gastritis (K29.70)

›Epigastric discomfort nausea

›NSAID alcohol association

›Acute pancreatitis (K85.9)

›Epigastric pain radiating to back

›Relief leaning forward

›Biliary colic atypical epigastric (K80.20)

›Postprandial pain

›Associated nausea

Less common

›Less common causes

›Gastroparesis (K31.84)

›Early satiety vomiting undigested food

›Diabetes or GLP1 exposure

›Hepatitis (K75.9)

›Malaise jaundice

›Transaminitis

›Lower lobe pneumonia (J18.9)

›Fever cough pleuritic pain

›Abdominal pain referred

›DKA or HHS (E10.10 E11.10 E11.00)

›Polyuria polydipsia

›Kussmaul breathing altered mentation

›Herpes zoster prodrome (B02.9)

›Dermatomal pain before rash

›Hyperesthesia

Key mimics and pitfalls

›Mimics and pitfalls

›ACS misattributed to reflux

›Older adult diabetes female presentation

›Epigastric discomfort without chest pain

›Normal lipase early pancreatitis

›Early presentation within hours

›Hypertriglyceridemia interference possible

09Past Medical History/pmh21

Relevant conditions

›Chronic disease context

›Coronary artery disease

›Heart failure

›Atrial fibrillation

›Chronic kidney disease

›Cirrhosis

›Diabetes

Prior GI history

›Prior GI diagnoses

›GERD esophagitis

›Peptic ulcer disease

›Prior upper GI bleed

›Prior pancreatitis

›Gallstones or cholecystectomy

Surgeries and procedures

›Prior procedures

›Bariatric surgery

›ERCP

›Endoscopy findings and date

Baseline function

›Baseline status

›Baseline oral intake

›Baseline pain disorders

›Baseline mobility and frailty

10Physical Exam/exam27

General and vitals interpretation

›Initial impression

›Toxic appearance versus well appearing

›Hydration status mucous membranes capillary refill

›Respiratory effort and work of breathing

Cardiovascular

›Cardiac and perfusion

›Heart sounds new murmur

›Peripheral pulses symmetry

›Signs of heart failure

Pulmonary

›Lung exam

›Focal crackles or consolidation signs

›Pleural rub

Abdominal exam

›Abdomen

›Epigastric tenderness location and severity

›Guarding rebound rigidity

›Distension

›Hepatomegaly

›Murphy sign

›Pulsatile mass

Skin and zoster screen

›Skin

›Dermatomal hyperesthesia

›Vesicular rash

Rectal and bleeding screen

›Bleeding assessment

›Melena on exam when performed

›Signs of anemia pallor

Neurologic

›Neuro screen

›Mental status

›Focal deficits

11Lab Studies/labs21

Core labs

›Initial lab panel

›CBC anemia leukocytosis

›Electrolytes including glucose and bicarbonate

›Creatinine for dehydration and contrast planning

›AST ALT ALP bilirubin

Pancreatitis labs

›Pancreatitis evaluation

›Lipase

›Triglycerides mmol/L

›Calcium mmol/L

Cardiac labs

›ACS evaluation

›High sensitivity troponin with serial timing per local protocol dependent

›BNP when heart failure alternative suspected

Bleeding and liver synthetic function

›Hemorrhage risk labs

›INR

›Type and screen when GI bleed concern

Infection and ischemia adjuncts

›Adjunct labs when indicated

›Lactate mmol/L for shock or ischemia concern

›Blood cultures when sepsis concern

Pregnancy testing

›Pregnancy related testing

›Urine or serum hCG for pregnancy potential

›Rh type when pregnancy bleeding concern

12Imaging/img16

Scoring Systems

›Risk tools aligned to suspected diagnosis

›HEART score for possible ACS

›Glasgow Blatchford score for upper GI bleed

›AIMS65 for upper GI bleed severity

›BISAP for acute pancreatitis severity

MRI

›MRI and MRCP

›MRCP for biliary obstruction or choledocholithiasis when ultrasound nondiagnostic

›MRI abdomen when radiation avoidance important and patient stable

›CT based strategies

›CT abdomen pelvis with IV contrast for perforation complication concern and alternative diagnosis search

›CTA chest abdomen pelvis for dissection or aneurysm concern

›CTA abdomen for mesenteric ischemia concern

Ultrasound

›Ultrasound and POCUS

›RUQ ultrasound for gallstones biliary dilation

›POCUS aorta for AAA screening

›Focused cardiac ultrasound for pericardial effusion severe LV dysfunction when indicated

13Special Tests/spec10

Bedside and procedural diagnostics

›Bedside tests

›Point of care glucose

›Point of care ketones when DKA concern

›Stool occult blood testing when GI bleed uncertainty

Gastroenterology diagnostics

›Endoscopic and specialty tests

›Upper endoscopy timing based on GI bleed risk and stability

›H pylori testing strategy after acute bleeding stabilized or outpatient dyspepsia pathway

Pulmonary and infectious diagnostics

›Respiratory tests when indicated

›Chest radiograph for pneumonia or free air screen adjunct

›Viral testing when systemic viral syndrome plausible

14ECG/ecg10

ECG indications and high risk patterns

›ECG pathway

›ECG for epigastric pain with any cardiopulmonary symptom or risk factors

›Repeat ECG for persistent symptoms or dynamic troponin change

Ischemia patterns

›Ischemia recognition

›Inferior ischemia can present with epigastric pain

›ST elevation or depression dynamic change

›New T wave inversion in contiguous leads

Conduction and electrolyte clues

›Nonischemic high risk findings

›QT prolongation with emesis and electrolyte loss

›Hyperkalemia patterns when renal failure or DKA concern

15Assessment/ax12

Problem representation and severity

›Problem framing

›Epigastric pain with stability assessment stable versus unstable

›Highest risk diagnosis first rule out sequence

Working diagnoses

›Leading diagnosis options

›Dyspepsia or GERD without alarm features (K30 K21.9)

›Peptic ulcer disease concern (K27.9)

›Acute pancreatitis concern (K85.9)

›Possible ACS anginal equivalent (I20.9 I21.4)

Risk stratification logic

›Risk stratification

›ACS risk using ECG and troponin serial pathway

›GI bleed risk using bedside stability and bleeding scores when applicable

›Pancreatitis severity using BISAP and organ failure features

16Plan/plan27

Approach to the critical patient

›First 5 minutes

›Monitor cardiac pulse oximetry blood pressure

›Two large bore IV if hypotension bleeding severe vomiting

›Oxygen if SpO2 less than 90 percent

›Immediate ECG if any ACS concern

›Early bedside ultrasound if shock or AAA concern

Analgesia and symptom control

›Symptom treatment

›Acetaminophen PO or IV dosing per weight and liver risk

›Opioid analgesia for severe pain with reassessment

›Antiemetic selection with QT risk awareness

GI targeted therapy

›Acid suppression strategy when appropriate

›PPI therapy for suspected ulcer or gastritis pathway

›Avoid NSAIDs when ulcer concern

Fluids and electrolytes

›Resuscitation and correction

›Isotonic crystalloid for dehydration or pancreatitis

›Potassium replacement guided by ECG and labs

Diagnostic sequencing

›Test sequencing

›ECG and troponin pathway early for anginal equivalent

›Lipase and LFTs early for pancreatobiliary differential

›CTA if dissection AAA mesenteric ischemia concern

Consultation plan

›Consultation triggers

›Cardiology for ischemic ECG or dynamic troponin

›Surgery for perforation peritonitis bowel ischemia concern

›Gastroenterology for significant GI bleed or refractory symptoms

Reassessment loop

›Reassessment cadence

›Repeat vitals and pain score within 30 to 60 minutes after interventions

›Escalate if rising lactate worsening vitals new peritonitis or new ECG change

17Disposition/dispo19

ICU and high acuity criteria

›ICU criteria

›Vasopressor requirement

›Persistent hypoxemia or respiratory failure

›Severe pancreatitis with organ failure

›Massive GI bleed with instability

Inpatient admission criteria

›Admission criteria

›Suspected ACS or abnormal serial troponin or ischemic ECG

›Pancreatitis requiring IV fluids and ongoing pain control

›Inability to tolerate oral intake with dehydration

›Suspected perforation or peritonitis

Observation pathway criteria

›Observation considerations

›Low risk ACS pathway completion needed

›Symptom control and oral challenge after fluids and antiemetics

Discharge criteria

›Discharge requirements

›Hemodynamic stability

›Pain controlled with oral regimen

›Tolerating oral fluids

›No alarm features and reassuring evaluation for life threats

›Follow up plan reliable

18Discharge Instructions/di21

Copy discharge instructions

›Summary

›Seen for epigastric pain evaluation

›Testing today did not show an emergency cause requiring admission

›Medications

›Take prescribed acid suppression as directed if provided

›Avoid NSAIDs such as ibuprofen or naproxen unless instructed otherwise

›Avoid alcohol until symptoms resolved

›Diet and activity

›Start with clear fluids then advance to bland foods as tolerated

›Avoid large fatty meals for 24 to 48 hours

›Follow up

›Follow up with primary care within 2 to 7 days

›Earlier follow up within 24 to 72 hours if symptoms persist

›Return to ED now for

›Chest pain pressure or shortness of breath

›Fainting or severe weakness

›Vomiting blood or black stools

›Fever or shaking chills

›Worsening abdominal pain or new severe pain

›Inability to keep down fluids

›Yellow skin or eyes

19References/r6

Guidelines and key sources

›Evidence based sources

›ACC AHA guideline for the evaluation and diagnosis of chest pain 2021

›ACC AHA guideline for the diagnosis and management of aortic disease 2022

›ACG and CAG clinical guideline management of dyspepsia 2017

›ACG clinical guideline management of acute pancreatitis 2013

›ACG clinical guideline upper gastrointestinal and ulcer bleeding 2021

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Epigastric PainAPPROACH

ABDOMINAL AND GASTROINTESTINAL · 19 SECTIONS

⚲

442 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx60

HPI overview

›Symptom characterization

›Primary location epigastric

›Pain versus burning versus pressure versus fullness

›First episode versus recurrent pattern

›Prior evaluations and prior diagnoses

Onset

›Onset details

›Sudden onset minutes to hours

›Gradual onset hours to days

›Postprandial onset minutes to hours

›Nocturnal onset

Provocation/Palliation

›Provocation and palliation

›Exertion trigger

›Food trigger

›Alcohol trigger

›NSAID exposure trigger

›Relief with antacids

›Relief with leaning forward

›Worse supine

Quality

›Quality descriptors

›Burning

›Gnawing

›Pressure

›Tearing

›Sharp pleuritic component

Region/Radiation

›Location and radiation

›Radiation to chest

›Radiation to back

›Radiation to right shoulder

›Migration pattern

Severity

›Severity and impact

›Pain score trajectory

›Limitation of oral intake

›Sleep disruption

Timing

›Time course

›Constant

›Intermittent colicky

›Progressive worsening

›Episodic with meals

Associated symptoms

›Associated symptoms cluster

›Nausea

›Vomiting

›Hematemesis

›Melena

›Dyspnea

›Diaphoresis

›Syncope

›Fever

›Jaundice

›Weight loss

Context and triggers

›Symptom context

›Recent heavy meal

›Recent binge alcohol

›Recent viral illness

›Recent procedure endoscopy ERCP

›Trauma

Prior episodes and baseline

›Prior episodes

›Similar pain responsive to antacids

›Prior pancreatitis episodes

›Prior gallstones or cholecystitis

›Baseline dyspepsia or GERD symptoms

02Alarm Features/alarm30

Immediate escalation triggers

›Time critical features

›Hypotension or shock

›Altered mental status

›Persistent severe pain out of proportion

›Ongoing hematemesis or large volume melena

›Respiratory distress

Vital sign danger thresholds

›High risk vitals

›SBP less than 90 mmHg

›HR greater than 120 per minute

›RR greater than 24 per minute

›SpO2 less than 90 percent on room air

›Temperature 38.5 C or higher with abdominal pain

High risk historical features

›High risk history

›Known coronary artery disease

›Known aortic aneurysm

›Anticoagulation use

›Immunocompromised state

›Pregnancy or postpartum state

›Recent instrumentation ERCP endoscopy

High risk exam findings

›High risk exam

›Peritonitis rigidity rebound guarding

›Pulsatile abdominal mass

›New focal neurologic deficit

›Severe epigastric tenderness with guarding

›Jaundice with fever

Do not miss patterns

›High risk symptom patterns

›Epigastric pain with diaphoresis or exertional component

›Epigastric pain with syncope

›Epigastric pain radiating to back with hypotension

›Sudden tearing pain with neurologic symptoms

03Medications/meds21

Current medications and recent changes

›Medication exposure

›New medication within 30 days

›Recent dose increase

›Recent discontinuation of PPI or H2 blocker

High risk medication classes

›Medication risks

›NSAIDs

›Aspirin

›Anticoagulants

›Antiplatelets

›Glucocorticoids

›GLP1 receptor agonists

›Opioids

OTC and supplements

›Nonprescription exposures

›Bismuth

›Antacids

›Herbal supplements

›Iron

Therapy constraints

›Contraindication screen

›QT prolonging medications

›Renal impairment affecting contrast decisions

›Allergy to iodinated contrast

04Diet/diet11

Recent intake and triggers

›Intake pattern

›Recent fatty meal

›Recent spicy or acidic foods

›Fasting or poor intake

Hydration and vomiting risk

›Hydration markers

›Reduced urine output

›Inability to tolerate oral fluids

Alcohol and caffeine

›Exposures

›Recent alcohol binge

›Daily heavy alcohol use

›High caffeine or energy drink use

05Review of Systems/ros29

Cardiopulmonary

›Cardiopulmonary symptoms

›Chest pain or pressure

›Dyspnea

›Palpitations

›Orthopnea

›Leg swelling

Gastrointestinal

›GI symptoms

›Dysphagia

›Odynophagia

›Early satiety

›Hematemesis

›Melena

›Hematochezia

›Diarrhea

›Constipation

Infectious and inflammatory

›Systemic symptoms

›Fever

›Chills

›Night sweats

›Myalgias

Genitourinary and pregnancy

›GU and reproductive symptoms

›Dysuria

›Flank pain

›Missed period

›Vaginal bleeding

Neurologic

›Neuro symptoms

›Syncope

›Focal weakness

›Severe headache

06Collateral History and Family History/chafh11

Collateral and reliability

›Collateral information

›Source partner family EMS facility

›Reliability concerns intoxication cognitive impairment language barrier

Family history

›Family risk

›Premature coronary artery disease

›Aortic aneurysm or dissection

›Peptic ulcer disease complications

›Familial hypertriglyceridemia

Exposure history

›Household and contact risks

›Sick contacts gastroenteritis

›Recent travel or foodborne exposure

07Risk Factors/rf26

Cardiovascular and thrombotic risk

›ACS risk factors

›Age risk

›Diabetes

›Hypertension

›Smoking

›Dyslipidemia

›Known CAD prior MI PCI CABG

Aortic and vascular risk

›Aortic risk factors

›Known aneurysm

›Connective tissue disorder

›Uncontrolled hypertension

›Cocaine or stimulant use

GI mucosal injury risk

›Peptic ulcer risk factors

›NSAID or aspirin use

›H pylori history

›Prior ulcer or GI bleed

Pancreatitis risk

›Pancreatitis risks

›Alcohol use disorder

›Gallstones history

›Hypertriglyceridemia

›New medication associated pancreatitis

Special populations

›Population modifiers

›Pregnancy

›Older adult frailty

›Immunocompromised state

›Anticoagulated state

08Differential Diagnosis/ddx64

Life threatening

›Life threatening causes

›Acute coronary syndrome NSTEMI STEMI (I21.4 I21.3)

›Epigastric pain as anginal equivalent

›Higher risk with diaphoresis dyspnea exertional trigger

›Aortic dissection (I71.0)

›Sudden severe pain

›Pulse deficit neurologic symptoms hypotension

›Ruptured abdominal aortic aneurysm (I71.3)

›Hypotension syncope back pain pulsatile mass

›Anticoagulation increases hemorrhage risk

›Perforated peptic ulcer (K25.1 K26.1)

›Sudden severe pain

›Peritonitis free air risk

›Esophageal rupture (K22.3)

›Severe pain after forceful vomiting

›Subcutaneous emphysema sepsis risk

›Mesenteric ischemia (K55.9)

›Pain out of proportion

›AF or vascular disease risk

›Severe acute pancreatitis with organ failure (K85.9)

›Persistent vomiting systemic inflammatory response

›Hypotension hypoxemia

Common

›Common causes

›Dyspepsia functional dyspepsia (K30)

›Postprandial fullness early satiety epigastric pain

›Normal vitals and benign exam

›GERD or esophagitis (K21.9 K20.9)

›Burning regurgitation worse supine

›Response to acid suppression

›Peptic ulcer disease (K27.9)

›Gnawing epigastric pain

›NSAID exposure or prior ulcer

›Gastritis (K29.70)

›Epigastric discomfort nausea

›NSAID alcohol association

›Acute pancreatitis (K85.9)

›Epigastric pain radiating to back

›Relief leaning forward

›Biliary colic atypical epigastric (K80.20)

›Postprandial pain

›Associated nausea

Less common

›Less common causes

›Gastroparesis (K31.84)

›Early satiety vomiting undigested food

›Diabetes or GLP1 exposure

›Hepatitis (K75.9)

›Malaise jaundice

›Transaminitis

›Lower lobe pneumonia (J18.9)

›Fever cough pleuritic pain

›Abdominal pain referred

›DKA or HHS (E10.10 E11.10 E11.00)

›Polyuria polydipsia

›Kussmaul breathing altered mentation

›Herpes zoster prodrome (B02.9)

›Dermatomal pain before rash

›Hyperesthesia

Key mimics and pitfalls

›Mimics and pitfalls

›ACS misattributed to reflux

›Older adult diabetes female presentation

›Epigastric discomfort without chest pain

›Normal lipase early pancreatitis

›Early presentation within hours

›Hypertriglyceridemia interference possible

09Past Medical History/pmh21

Relevant conditions

›Chronic disease context

›Coronary artery disease

›Heart failure

›Atrial fibrillation

›Chronic kidney disease

›Cirrhosis

›Diabetes

Prior GI history

›Prior GI diagnoses

›GERD esophagitis

›Peptic ulcer disease

›Prior upper GI bleed

›Prior pancreatitis

›Gallstones or cholecystectomy

Surgeries and procedures

›Prior procedures

›Bariatric surgery

›ERCP

›Endoscopy findings and date

Baseline function

›Baseline status

›Baseline oral intake

›Baseline pain disorders

›Baseline mobility and frailty

10Physical Exam/exam27

General and vitals interpretation

›Initial impression

›Toxic appearance versus well appearing

›Hydration status mucous membranes capillary refill

›Respiratory effort and work of breathing

Cardiovascular

›Cardiac and perfusion

›Heart sounds new murmur

›Peripheral pulses symmetry

›Signs of heart failure

Pulmonary

›Lung exam

›Focal crackles or consolidation signs

›Pleural rub

Abdominal exam

›Abdomen

›Epigastric tenderness location and severity

›Guarding rebound rigidity

›Distension

›Hepatomegaly

›Murphy sign

›Pulsatile mass

Skin and zoster screen

›Skin

›Dermatomal hyperesthesia

›Vesicular rash

Rectal and bleeding screen

›Bleeding assessment

›Melena on exam when performed

›Signs of anemia pallor

Neurologic

›Neuro screen

›Mental status

›Focal deficits

11Lab Studies/labs21

Core labs

›Initial lab panel

›CBC anemia leukocytosis

›Electrolytes including glucose and bicarbonate

›Creatinine for dehydration and contrast planning

›AST ALT ALP bilirubin

Pancreatitis labs

›Pancreatitis evaluation

›Lipase

›Triglycerides mmol/L

›Calcium mmol/L

Cardiac labs

›ACS evaluation

›High sensitivity troponin with serial timing per local protocol dependent

›BNP when heart failure alternative suspected

Bleeding and liver synthetic function

›Hemorrhage risk labs

›INR

›Type and screen when GI bleed concern

Infection and ischemia adjuncts

›Adjunct labs when indicated

›Lactate mmol/L for shock or ischemia concern

›Blood cultures when sepsis concern

Pregnancy testing

›Pregnancy related testing

›Urine or serum hCG for pregnancy potential

›Rh type when pregnancy bleeding concern

12Imaging/img16

Scoring Systems

›Risk tools aligned to suspected diagnosis

›HEART score for possible ACS

›Glasgow Blatchford score for upper GI bleed

›AIMS65 for upper GI bleed severity

›BISAP for acute pancreatitis severity

MRI

›MRI and MRCP

›MRCP for biliary obstruction or choledocholithiasis when ultrasound nondiagnostic

›MRI abdomen when radiation avoidance important and patient stable

›CT based strategies

›CT abdomen pelvis with IV contrast for perforation complication concern and alternative diagnosis search

›CTA chest abdomen pelvis for dissection or aneurysm concern

›CTA abdomen for mesenteric ischemia concern

Ultrasound

›Ultrasound and POCUS

›RUQ ultrasound for gallstones biliary dilation

›POCUS aorta for AAA screening

›Focused cardiac ultrasound for pericardial effusion severe LV dysfunction when indicated

13Special Tests/spec10

Bedside and procedural diagnostics

›Bedside tests

›Point of care glucose

›Point of care ketones when DKA concern

›Stool occult blood testing when GI bleed uncertainty

Gastroenterology diagnostics

›Endoscopic and specialty tests

›Upper endoscopy timing based on GI bleed risk and stability

›H pylori testing strategy after acute bleeding stabilized or outpatient dyspepsia pathway

Pulmonary and infectious diagnostics

›Respiratory tests when indicated

›Chest radiograph for pneumonia or free air screen adjunct

›Viral testing when systemic viral syndrome plausible

14ECG/ecg10

ECG indications and high risk patterns

›ECG pathway

›ECG for epigastric pain with any cardiopulmonary symptom or risk factors

›Repeat ECG for persistent symptoms or dynamic troponin change

Ischemia patterns

›Ischemia recognition

›Inferior ischemia can present with epigastric pain

›ST elevation or depression dynamic change

›New T wave inversion in contiguous leads

Conduction and electrolyte clues

›Nonischemic high risk findings

›QT prolongation with emesis and electrolyte loss

›Hyperkalemia patterns when renal failure or DKA concern

15Assessment/ax12

Problem representation and severity

›Problem framing

›Epigastric pain with stability assessment stable versus unstable

›Highest risk diagnosis first rule out sequence

Working diagnoses

›Leading diagnosis options

›Dyspepsia or GERD without alarm features (K30 K21.9)

›Peptic ulcer disease concern (K27.9)

›Acute pancreatitis concern (K85.9)

›Possible ACS anginal equivalent (I20.9 I21.4)

Risk stratification logic

›Risk stratification

›ACS risk using ECG and troponin serial pathway

›GI bleed risk using bedside stability and bleeding scores when applicable

›Pancreatitis severity using BISAP and organ failure features

16Plan/plan27

Approach to the critical patient

›First 5 minutes

›Monitor cardiac pulse oximetry blood pressure

›Two large bore IV if hypotension bleeding severe vomiting

›Oxygen if SpO2 less than 90 percent

›Immediate ECG if any ACS concern

›Early bedside ultrasound if shock or AAA concern

Analgesia and symptom control

›Symptom treatment

›Acetaminophen PO or IV dosing per weight and liver risk

›Opioid analgesia for severe pain with reassessment

›Antiemetic selection with QT risk awareness

GI targeted therapy

›Acid suppression strategy when appropriate

›PPI therapy for suspected ulcer or gastritis pathway

›Avoid NSAIDs when ulcer concern

Fluids and electrolytes

›Resuscitation and correction

›Isotonic crystalloid for dehydration or pancreatitis

›Potassium replacement guided by ECG and labs

Diagnostic sequencing

›Test sequencing

›ECG and troponin pathway early for anginal equivalent

›Lipase and LFTs early for pancreatobiliary differential

›CTA if dissection AAA mesenteric ischemia concern

Consultation plan

›Consultation triggers

›Cardiology for ischemic ECG or dynamic troponin

›Surgery for perforation peritonitis bowel ischemia concern

›Gastroenterology for significant GI bleed or refractory symptoms

Reassessment loop

›Reassessment cadence

›Repeat vitals and pain score within 30 to 60 minutes after interventions

›Escalate if rising lactate worsening vitals new peritonitis or new ECG change

17Disposition/dispo19

ICU and high acuity criteria

›ICU criteria

›Vasopressor requirement

›Persistent hypoxemia or respiratory failure

›Severe pancreatitis with organ failure

›Massive GI bleed with instability

Inpatient admission criteria

›Admission criteria

›Suspected ACS or abnormal serial troponin or ischemic ECG

›Pancreatitis requiring IV fluids and ongoing pain control

›Inability to tolerate oral intake with dehydration

›Suspected perforation or peritonitis

Observation pathway criteria

›Observation considerations

›Low risk ACS pathway completion needed

›Symptom control and oral challenge after fluids and antiemetics

Discharge criteria

›Discharge requirements

›Hemodynamic stability

›Pain controlled with oral regimen

›Tolerating oral fluids

›No alarm features and reassuring evaluation for life threats

›Follow up plan reliable

18Discharge Instructions/di21

Copy discharge instructions

›Summary

›Seen for epigastric pain evaluation

›Testing today did not show an emergency cause requiring admission

›Medications

›Take prescribed acid suppression as directed if provided

›Avoid NSAIDs such as ibuprofen or naproxen unless instructed otherwise

›Avoid alcohol until symptoms resolved

›Diet and activity

›Start with clear fluids then advance to bland foods as tolerated

›Avoid large fatty meals for 24 to 48 hours

›Follow up

›Follow up with primary care within 2 to 7 days

›Earlier follow up within 24 to 72 hours if symptoms persist

›Return to ED now for

›Chest pain pressure or shortness of breath

›Fainting or severe weakness

›Vomiting blood or black stools

›Fever or shaking chills

›Worsening abdominal pain or new severe pain

›Inability to keep down fluids

›Yellow skin or eyes

19References/r6

Guidelines and key sources

›Evidence based sources

›ACC AHA guideline for the evaluation and diagnosis of chest pain 2021

›ACC AHA guideline for the diagnosis and management of aortic disease 2022

›ACG and CAG clinical guideline management of dyspepsia 2017

›ACG clinical guideline management of acute pancreatitis 2013

›ACG clinical guideline upper gastrointestinal and ulcer bleeding 2021

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.