Epigastric Pain

Differential Diagnosis

Occasional Diagnoses

  • Drug Related, e.g. Antibiotics, Nsaids, Bisphosphonates
  • Pancreatitis (Acute or Chronic)
  • Muscular
  • Peritonitis (Perforated Du or Carcinoma)
  • Carcinoma of the Stomach
  • Gastric Ulcer
  • Oesophageal Spasm
  • Aerophagy

Rare Diagnoses

  • Angina or Myocardial Infarct
  • Pneumonia
  • Carcinoma of the Pancreas
  • Ruptured Abdominal Aortic Aneurysm
  • Gastrointestinal Obstruction
  • Referred from Spine
  • Epigastric Hernia

Ready Reckoner

Key distinguishing features of the most common diagnoses

NUDGORD/GastritisIBSGallstonesDU/Duodenitis
Nocturnal PainPossiblePossibleNoPossibleYes
Relief with AntacidsPossibleYesNoNoPossible
Stress RelatedPossiblePossibleYesNoPossible
Radiates to BackNoNoNoPossiblePossible
VomitingNoNoNoPossiblePossible

Possible Investigations

Likely:FBC, H. pylori testing.

Possible:LFT, upper GI endoscopy, ultrasound.

Small Print:Serum amylase, barium swallow or meal, oesophageal manometry/pH studies, cardiac biomarkers, ECG, CXR, erect and supine abdominal X-rays, further hospital-based upper GI investigations.

  • FBC: Anaemia in underlying malignancy or bleeding from peptic ulcer; WCC raised in cholecystitis and pancreatitis. Raised platelets associated with oesophageal or stomach cancer.
  • H. pylori testing: Strong association with peptic ulcer disease; possibly also with other gastrointestinal pathologies.
  • LFT: May be abnormal in gallstones or malignancy.
  • Upper GI endoscopy: To visualise/biopsy the upper GI tract (in particular, to exclude carcinoma of the stomach).
  • Ultrasound: For gallstones; may reveal other pathology such as pancreatic disease.
  • Barium swallow or meal: For investigation of the oesophagus, stomach and duodenum in those unwilling to have, or unfit for, endoscopy.
  • Serum amylase: Elevated in acute pancreatitis.
  • Other tests: Most of these are likely to be initiated in secondary care after referral. They include oesophageal manometry/pH studies (if likely oesophageal problem but a normal endoscopy), cardiac biomarkers and ECG (possible acute cardiac event), CXR (pneumonia), erect and supine abdominal X-rays (obstruction), CT or MRI scan if a mass is suspected or symptoms remain unexplained.

Top Tips

  • It’s important to address underlying concerns. Most patients with epigastric pain do not seek medical help. Those that do usually fear significant disease such as cancer.
  • A diagnosis of peptic ulcer still frightens many patients, especially older age groups, as they may be unaware of recent therapeutic advances. Provide adequate explanation and reassurance.
  • Don’t overlook the medication history, as this may provide a simple solution to the problem.
  • A normal endoscopy does not rule out oesophageal problems such as GORD or spasm.
  • Cardiac pain can sometimes be epigastric. If suspecting angina, beware that a trial of GTN can help or confuse – as it also eases oesophageal spasm.

Red Flags

  • Guidance on who to refer urgently to exclude carcinoma, and for what, can be complex and confusing. Some degree of judgement is required, but certainly patients aged 55 or more with unexplained dyspepsia and weight loss need urgent referral, as do patients with dysphagia.
  • In an obviously unwell patient with weight loss and epigastric pain, do not be ‘reassured’ by a normal endoscopy. There may well still be significant pathology such as carcinoma of the pancreas.
  • In at least 50% of cases, carcinoma of the pancreas presents with epigastric pain rather than the classical painless, progressive jaundice.
  • In acute cases, do not overlook referred pain – from heart, lungs or spine.
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