Epigastric pain various causes differentiation

1. Differential Diagnosis of
Abdominal Pain Localized in
Epigastric Region

2. Epigastric pain
- Pain localized in the upper abdominal area just under the ribs
- History is crucial for differential diagnosis:
• Onset (Gradual or sudden),
• Duration (intermittent/constant)
• Character of pain (dull, achy, throbbing, sharp, piercing)
• Frequency, radiation
• Associated symptoms: nausea, vomiting, fevers, chills,
diarrhea, constipation, weight loss, hematochezia, melena,
jaundice, changes in urine or stool,
• Exacerbating or relieving factors
• Alcohol intake
• Medications intake (Aspirin, NSAIDS)
• Family history of bowel disorders
• Menstrual and contraceptive history in women

3. Etiology
 Biliary causes:
 Cholelithiasis, cholecystitis, and cholangitis
Cardiac causes:
 Myocardial infarction, or pericarditis
GI causes:
 Esophagitis, functional dyspepsia, GERD, peptic ulcer, gastritis
 Gastric outlet obstruction, or malignancy
 Early appendicitis could be a colonic cause
 Pancreatic causes – mass or pancreatitis
Vascular causes:
 Aortic aneurysm, or mesenteric ischemia
Other: herpes zoster, muscle strain, hernia, pneumonia

4. Evaluation of Epigastric Pain
-Initially, the following:
• History of GI, pulmonary, and cardiac systems
• Physical exam
• Chest x-ray
• EKG
• CBC
• Serum amylase
• LFT
-Ultrasonography
• Hepatobiliary tree/pancreatic pathologies must be excluded
at first
• Liver, gallbladder, bile ducts, and pancreatic pathologies
• Increased amylase or lipase, or LFT – further evaluation with
contrast CT may be used
• In case no abnormalities are detected, recurrent epigastric
pain, and other symptoms – evaluate w/ GI endoscopy
• In case first episode of pain – start symptomatic treatment of
dyspepsia

5. Biliary causes
Cholelithiasis
• gallstones in gallbladder
• Biliary colic is the common symptom, a right upper quadrant pain which
may radiate to epigastric area and right shoulder
• Often postprandial and lasts from 30-90 minutes
• Vomiting and nausea may be present
• Diagnosis: RUQ ultrasonography
• Findings on ultrasound: echogenic foci which show acoustic shadowing
Cholecystitis and cholangitis are usually complications of cholelithiasis
Cholecystitis
• Inflammation of gallbladder and cystic duct
• Biliary colic, plus:
• Murphy’s sign
• Fever and chills may be present
• Palpable gallbladder, tenderness,
• Leucocytosis, abnormal LFT
• Diagnosis through RUQ ultrasonography
• Findings: cholelithiasis combined with sonographic murphy sign,
gallbladder wall thickening (>3 mm), and pericholecystic fluid

6. Cholangitis
• Bacterial infection and inflammation of biliary tract
• Abdominal pain, fever, altered mental status
• Right upper quadrant tenderness
• Jaundice
• Murphy’s sign negative
• Sepsis (hypotension, tachycardia)
• Elevated bilirubin and elevated LFT
• Leucocytosis
• Cholestasis
• Diagnosis: RUQ US, ERCP
• On ultrasound: thickening of the walls of the bile ducts, biliary
dilation with calculi with/without pus
• ERCP allows for small ducts visualization, complete
assessment of biliary tree showing the obstructive lesions and
stenosis

7. Pancreatitis
• Epigastric pain relatively sudden in onset
• Radiates to the back
• Associated with nausea, vomiting, anorexia, steatorrhea
Risk factors
• Gallstones
• Recent ERCP
• Alcohol use
• Trauma
Lab tests
• Complete blood count
• Electrolytes, BUN, creatinine, and glucose
• Aminotransferases, alkaline phosphatase, and bilirubin
• Lipase (amylase is a less specific alternative, where lipase
is not available)
• Elevation of serum lipase in the presence of epigastric pain
is very suggestive of pancreatitis.

8. Workup
• Abdominal ultrasound to exclude gallstones
• CT scan is sensitive for pancreatitis
• US and CT are crucial for diagnosis in chronic
pancreatitis where amylase and lipase may be normal
• Biliary etiology (gallstone-related) is suspected in the
absence of US findings with elevated transaminases
and pancreatitis
• Gallstones should be investigated with ERCP

9. Dyspepsia
• Pain limited to the epigastrium can be classified as
dyspepsia once pancreatic and hepatobiliary pain are
excluded
• Associated with bloating, abdominal fullness,
heartburn, or nausea
• Evaluate which patients require further investigation
and which can safely undergo a therapeutic trial of
antisecretory therapy or watchful waiting
• Alarm features requiring further investigations include:
 Weight loss, age >50, persistent vomiting, dysphagia,
anemia, hematemesis
 Palpable abdominal mass
 Family history of GI carcinoma
 Acuity and severity dictate the urgency of referral for
endoscopy

10. Dyspepsia Diagnostic Testing
Age <60
1. Perform upper gastroscopy in
patients with >1 alarm feature
to evaluate for organic disease
• Evaluate for functional
dyspepsia and active H.pylori
infection on gastric biopsy in
case organic disease is absent
2. Or test for H.pylori infection
with stool antigen or urea breath
test
Age >60
• Upper gastroscopy is performed
in all patients
• Evaluate for functional
dyspepsia and active H.pylori
infection in case organic
disease is absent

11. Routine Laboratory Tests
• Routine blood counts and blood chemistry
• including liver function tests, serum lipase, and
amylase
• to identify patients with alarm features (e.g, iron
deficiency anemia) and underlying metabolic
diseases that can cause dyspepsia (e.g,
diabetes, hypercalcemia)

12. Organic disorders
1. GERD
• Heartburn and acid regurgitation are typical symptoms
• Burning sensation rises from stomach towards the neck
• Symptoms are exacerbated by fatty foods, caffeine, and recumbent
position
• 10% of the US population has daily heartburn
• Diagnostic testing includes empirical trial of a PPI (40mg 2 times
daily for 1 week) as a first step
• Barium radiography
• Upper GI endoscopy in severe disease: macroscopic or
microscopic changes on biopsy (esophagitis)
• Barrett's esophagus - replacement of the squamous epithelium of
the esophagus by columnar epithelium—develops in 10% to 15%
of patients who have chronic gastroesophageal reflux disease
(GERD). Barrett's esophagus is associated with an increased risk
of esophageal adenocarcinoma.

13. 2. Peptic Ulcer Disease
• A total of 400,000 new cases of PUD are diagnosed each year
• H.pylori is the major cause of peptic ulcer disease
• Risk factors for PUD beyond H pylori infection include use of
aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), male
sex, family history, stress, smoking, chronic renal failure, chronic
obstructive pulmonary disease, and alcoholism
• H.pylori is a gram-negative, urease-producing bacterium that
colonizes gastric mucosa and produces chronic, superficial antral
gastritis
• peptic ulcer disease is often improved when a patient either has an
empty stomach or consumes food to satiety
• Diagnosis: double contrast Upper GI (barium swallow) and
esophagogastroduodenoscopy (higher sensitivity)
• H.pylori testing: urea breath test or rapid urea test (invasive,
requires EGD)

14. 3. Functional Dyspepsia
• Defined as chronic dyspeptic symptoms (episodic or persistent
pain or discomfort localized to the epigastrium or upper abdomen),
for which clinical evaluation and studies have failed to reveal a
pathologic cause.
• It is, therefore, a diagnosis of exclusion
• Patients can be grouped by symptom pattern as ulcerlike,
dysmotility-like, and refluxlike, but there is much overlap

15. 4. Gastroesophageal malignancy
• Significant weight loss, anorexia, vomiting, dysphagia, odynophagia, and
a family history of gastrointestinal cancers suggest the presence of an
underlying gastroesophageal malignancy.
• Imaging tests: double-contrast barium upper GI examination, CT scan
• Diagnosis is confirmed with a biopsy and laboratory analysis

16. Myocardial Infarction
• Epigastric pain could possibly be an extension of cardiac pain, or
referred pain
• Patient should be asked about exertional dyspnea
• In suspected acute coronary syndrome urgent evaluation and
management is required
• Diagnostic criteria:
 Elevated cardiac troponins (T and I) is mandatory to establish
diagnosis
 In addition to elevated troponins patient must display either
symptoms or ECG changes consistent with myocardial ischemia /
infarction
 ECG – ST elevations, ST depressions, T-wave inversions or
hyperacute T-waves, and pathological Q-waves
 Symptoms – ischemic chest pain, dyspnea, nausea, fatigue

17.  Pericarditis
• Acute pericarditis presents with acute retrosternal sharp, pleuritic,
chest pain that radiates to neck, jaw, or arms, similar to MI.
• In contrast to MI, chest pain is exacerbated in the supine position,
by coughing, and with inspiration.
• Pain improves in the sitting position or by leaning forward
• Not relieved with nitrates
• Diagnostic criteria: at least two of the following
 Non-ischemic chest pain
 ECG evidence of PR depression or ST segment deviation
 Detection of pericardial rub on auscultation
 Pericardial effusion on echocardiography
• MRI can detect small pericardial effusions that aren’t detected on
echocardiography

18. Abdominal Aortic Aneurysm
• Is defined as focal dilatation with enlargement of the diameter of
abdominal aorta to 3 cm or more
• Caused by atherosclerosis
• Symptoms include back, flank, abdominal, or groin pain
• Pain may radiate to lower extremities
• Local compression: early satiety, nausea, vomiting,
• An expanding aortic aneurysm causes sudden, severe, and constant
low back, flank, and abdominal pain.
• Syncope may be the main complaint, with pain less prominent
• Diagnosis is made with US
• A CT scan may be needed to determine exact location, size, and
involvement of other vessels.

19. Mesensteric Artery Ischemia
• Refers to ischemia that affects the blood vessels of small intestine
• Secondary to occlusive (thrombosis) or nonocclusive (spasms)
obstruction of the arteries
• Or can be caused by obstruction of venous outflow (venous
thrombosis)
• Acute or chronic
• Acute mesensteric ischemia is sudden in onset with sudden
abdominal pain associated with nausea, vomiting, or diarrhea
• Chronic mesensteric ischemia is seen in atherosclerosis, it causes
intermittent ischemia that usually worsens with eating
• History of a prior embolic event or family history of DVT or
pulmonary emboli is important
• Diagnosis: mesenteric angiography or CT angiography
• Lab tests findings: leukocytosis, elevated d-dimer and lactate

20. Herpes zoster
• Pain rising from abdominal wall rather than due to inflammation of
the underlying viscera
• Positive Carnett’s sign
• Burning/stinging pain, may be associated with itching
• Other symptoms, such as malaise, myalgia, headache,
photophobia, and, uncommonly, fever
Pneumonia
• Fever
• Respiratory symptoms: dyspnea, cough, sputum, chest pain
• CXR findings of a new pulmonary infiltrate.

21. Sources
•Uptodate.com
•Medscape.com
•Ncbi.nlm.nih.gov