Which is the next step in evaluation for a patient with epigastric pain and alarm features?

• A. Upper endoscopy
• B. Abdominal ultrasound
• C. CT scan of the abdomen
• D. Barium swallow

Answer: (A)

When there are alarm features with epigastric pain, the priority is to evaluate for serious upper GI pathology such as ulcers or cancer. Upper endoscopy provides direct visualization of the esophagus, stomach, and duodenum and, crucially, allows biopsies to confirm inflammation, infection (like H. pylori), dysplasia, or malignancy. It also enables potential therapeutic interventions if a lesion is found. Because of these advantages, it is the most informative first test in this scenario. Other tests don’t offer the same level of mucosal assessment with tissue sampling: ultrasound is best for biliary or pancreatic issues but not for mucosal lesions; CT scans can detect some complications or extraluminal disease but don’t replace endoscopy for diagnosing mucosal pathology; a barium swallow mainly assesses esophageal structure and motility and doesn’t provide comprehensive evaluation or biopsies of the stomach and duodenum.