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
Past Medical History
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
Physical Exam
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
Lab Studies
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
Imaging
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
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
Special Tests
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
ECG
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
Assessment
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
Plan
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
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.