Epigastric pain

Probability diagnosis

GORD/gastritis

Gastric ulcer

Duodenal ulcer/duodenitis

Non-ulcer heartburn

Gallstones/biliary colic

Abdominal muscular strain

Irritable upper GIT

Serious disorders not to be missed

Vascular:

• Acute coronary syndromes esp. AMI

• Ruptured abdominal aortic aneurysm (AAA)

• Mesenteric artery ischaemia

Infection:

• Cholecystitis

• Hepatitis

• Lower lobe pneumonia

• Ascending cholangitis

Cancer/tumour:

• Cancer of stomach or pancreas

• Metastatic cancer

Other:

• Pancreatitis

• Perforated ulcer/viscus

Pitfalls (often missed)

Oesophageal spasm

Biliary motility disorder

Aerophagy

Rarities:

• Porphyria

• Addison disease

• Sickle cell disease

• Epigastric hernia

Masquerades checklist

Depression

Drugs e.g. NSAIDs, antibiotics, bisphosphonates, alcohol

Spinal dysfunction—referred

Is the patient trying to tell me something?

A consideration if nil findings.

Key history

Clarify the exact nature of the presenting complaint: the nature of the pain/discomfort, indigestion or heartburn. Analyse any pain according to the SOCRATES formulation. Include associated general symptoms such as weight loss, fever or vomiting. Examine past medical history incl. peptic ulcer, diabetes, hypertension and cerebrovascular disease, as well as drug history, esp. alcohol and NSAID use.

Key examination

• General features: appearance of patient and vital signs

• Abdominal examination, particularly inspection, palpation and auscultation

• Palpate for nodes in the neck (ca. stomach)

Key investigations

Nil for most cases.

First line:

• urinalysis

• FBE

• ESR/CRP

• Helicobacter pylori test

• upper GIT endoscopy

• ultrasound (?gallstones)

Consider:

• cardiac enzymes

• s lipase/amylase

• ECG

• CXR

• oesophageal manometry

• other imaging if indicated e.g. CT or MRI esp. if epigastric mass

Diagnostic tips

Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric ulcer. Pain before meals relieved by food indicates chronic duodenal ulcer.

Epigastric pain waking the person soon after falling asleep (e.g. 3am) indicates gastric ulcer or biliary colic. Pain can be referred from disorders of the heart, lungs, pancreas, biliary tract and spine.