epigastric pain in the ED

read this first: abdominal pain in ED

• abdominal aortic aneurysm
• pancreatitis
• peptic ulcer disease
• gastritis
• gastro-oesophageal reflux
• acute myocardial infarction - esp. inferior AMI or diabetic patients, thus ECG in the elderly or diabetic
• early appendicitis
• diabetic ketoacidosis
• biliary causes such as ascending cholangitis even in the cholecystectomy patient
• other causes of Dyspepsia
• aortic dissection - late presentations often have vomiting with raised inflammatory markers +/- fever and hypotension and may progress to back pain
• acute intermittent porphyria (AIP) (rare)

• NB. pain radiating through to back suggests abdominal aortic aneurysm (AAA), penetrating PU, pancreatitis or biliary colic
• if over 50yrs age, then urgent:
  • bedside US to exclude AAA
  • ECG to help exclude AMI, esp. if diabetic
• FBE, U&E, LFT, lipase, (CRP,) RBG
• PR exam to exclude melaena
• erect CXR if pain is severe and suggests possible perforated viscus
• FWT urine - ketones for diabetic ketoacidosis (DKA); sometimes urinary tract infections (UTIs) / cystitis will present as vague abdo. pain.