Epigastric abdominal pain

Background

• This page outlines the general approach to adult epigastric pain
• The epigastric region contains: stomach, duodenum, pancreas, hepatic flexure, transverse colon, and the abdominal aorta
• Key EM considerations: acute coronary syndrome can present as epigastric pain (always consider in patients >40 or with cardiac risk factors), pancreatitis, peptic ulcer disease, AAA
• Epigastric pain is one of the most common presentations for atypical MI, especially in women, elderly, and diabetic patients

Classification by Abdominal pain location

Side-by-side comparison of quadrants and regions.

Chart of commonly reported referred pain sites.

RUQ pain	Epigastric pain	LUQ pain
Flank pain	Diffuse abdominal pain	Flank pain
RLQ pain	Pelvic pain	LLQ pain

Clinical Features

History

• Onset, character, radiation (back = pancreatitis, AAA; chest = ACS, GERD; right shoulder = biliary)
• Relationship to meals: postprandial (biliary, peptic ulcer), relief with eating (duodenal ulcer), worse with eating (gastric ulcer)
• Alcohol use, gallstone history (pancreatitis)
• NSAID/aspirin use (peptic ulcer disease)
• Cardiac risk factors (ACS presenting as epigastric pain)
• Melena or hematemesis (GI bleeding from ulcer or varices)
• Prior episodes

Physical Exam

• Epigastric tenderness, guarding
• Murphy sign (biliary — though usually more RUQ)
• Cullen sign (periumbilical ecchymosis) or Grey Turner sign (flank ecchymosis) — late signs of hemorrhagic pancreatitis
• Pulsatile abdominal mass (AAA)
• Absent/decreased bowel sounds

Red Flags

• Epigastric pain with diaphoresis, dyspnea, or radiation to jaw/arm (ACS)
• Hematemesis or melena (GI bleeding)
• Rigid abdomen with free air (perforated ulcer)
• Pulsatile mass (ruptured AAA)
• Severe pain radiating to back with hemodynamic instability (pancreatitis with hemorrhage or ruptured AAA)

Differential Diagnosis

Epigastric Pain

• Gastroesophageal reflux disease (GERD)
• Peptic ulcer disease with or without perforation
  • Zollinger-Ellison syndrome
• Gastritis
• Pancreatitis
• Gallbladder disease
  • Acute cholecystitis
  • Cholangitis
  • Symptomatic cholelithiasis
  • Acalculous cholecystitis
• Myocardial Ischemia
• Splenic Infarctionenlargement/rupture/aneurysm
• Pericarditis/Myocarditis
• Aortic dissection
• Hepatitis
• Pyelonephritis
• Pneumonia
• Pyogenic liver abscess
• Fitz-Hugh-Curtis Syndrome
• Hepatomegaly due to CHF
• Bowel obstruction
• SMA syndrome
• Pulmonary embolism
• Bezoar
• Ingested foreign body

Must Not Miss

• Acute coronary syndrome: atypical MI presentation — get ECG early
• Perforated peptic ulcer: free air, peritonitis
• Ruptured AAA: hypotension, pulsatile mass, elderly
• Severe pancreatitis: especially necrotizing
• Boerhaave syndrome: esophageal perforation after forceful vomiting

Evaluation

Immediate

• ECG: obtain early in all patients with epigastric pain, especially age >40 or any cardiac risk factors — inferior MI commonly presents as epigastric pain
• Bedside glucose

Laboratory

• CBC, BMP
• LFTs, lipase (>3x upper limit of normal diagnostic for pancreatitis)
• Troponin (ACS screening)
• Urinalysis
• Urine pregnancy test (females of reproductive age)
• Coagulation studies if bleeding
• Lactate if concern for ischemia or sepsis
• Type and screen if active GI bleeding

Imaging

• CXR: free air under diaphragm (perforation), mediastinal air (Boerhaave)
• RUQ US: gallstones, biliary pathology
• CT abdomen pelvis with IV contrast: pancreatitis complications, perforation, AAA, mass
• POCUS: free fluid, gallbladder, aorta (AAA screening)
• CT angiography if AAA or aortic pathology suspected

Management

• ECG first in older patients or those with risk factors — if ACS, activate cardiac protocol
• IV fluids, analgesia
• GI cocktail (antacid + viscous lidocaine +/- anticholinergic): may provide symptomatic relief for GERD/gastritis, but does NOT rule out cardiac cause even if effective
• PPI (pantoprazole) for suspected peptic ulcer or GERD
• Pancreatitis: aggressive IV fluid resuscitation, pain control, NPO initially, monitor for complications
• GI bleeding: resuscitation, PPI infusion, GI consultation for endoscopy
• Perforated ulcer: emergent surgical consultation, broad-spectrum IV antibiotics
• Ruptured AAA: emergent vascular surgery, permissive hypotension

Disposition

• Admit: pancreatitis requiring IV management, ACS, GI bleeding, perforation, biliary obstruction
• Discharge: mild gastritis/GERD with resolved symptoms, negative cardiac workup, ability to tolerate oral intake
• Follow-up: PCP in 1-2 weeks for new PPI starts; GI referral for suspected ulcer (H. pylori testing, EGD)
• Return precautions: worsening pain, vomiting blood, black stools, chest pain, lightheadedness

See Also

• Abdominal Pain
• Pancreatitis
• Peptic ulcer disease
• GERD