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Epigastric Pain – Causes, Symptoms, Diagnosis, Treatment

Epigastric pain is felt in the middle of the upper abdomen, just below the ribcage. Epigastric pain is pain that is localized to the region of the upper abdomen immediately below the ribs. Often, those who experience this type of pain feel it during or right after eating or if they lie down too soon after eating. It is a common symptom of gastroesophageal reflux disease (GERD) or heartburn. It may be associated with the gastric contents moving upward into the back of the throat, causing inflammation and a burning pain.Occasional epigastric pain is not usually a cause for concern and may be as simple as a stomach ache from eating bad food.

Causes of Epigastric Pain

Gastro-oesophageal reflux disease (GORD) – can cause epigastric pain as well as burning pain in the chest, a feeling of liquid coming up into the back of the throat and a persistent irritating cough. Many factors contribute to it, including:
- Obesity.
- Gastric irritants, such as alcohol, smoking and caffeine.
- Pregnancy.
- Hiatus hernia.
- Stress.
Gastritis – is a common cause of epigastric pain. It is often worse after eating and will generally improve with proton pump inhibitors. Test for the presence of Helicobacter pylori.
Peptic ulcer – tends to cause acute or chronic gnawing or burning pain. This may be improved by food if caused by a duodenal ulcer, and worsened by food if a gastric ulcer. Typically the pain is worse at night.
Heartburn – Characterized by a burning sensation and is a result of high gastric acid secretions that is refluxed back into the esophagus.
Peptic ulcer disease – Due to an ulcer formation in the stomach, pain may radiate up to the epigastric area. Ulcers are often the result of an H. Pylori infection.
Gastritis – An inflammation of the stomach lining leading to epigastric pain. Weight loss and persistent nausea and vomiting may also be present.
Duodenal ulcer – Much like a peptic ulcer, this condition can also cause epigastric pain and is linked to an H. Pylori infection.
Carcinoma of the stomach – May lead to epigastric pain often accompanied by weight loss.
Pancreatitis – A common cause of epigastric pain that may even radiate to other parts of the body.
Gastroenteritis – An inflammatory condition of the stomach and intestines that leads to persistent epigastric pain. Persistent nausea, vomiting, and diarrhea are also common.
Hepatitis – Inflammation of the liver due to a viral infection that may lead to epigastric pain. Yellowish discoloration of the skin and sclera, weakness, and fever also present in chronic cases.

Life-threatening causes of epigastric pain

Peritonitis – acute pain with signs of shock and tenderness (possibly rebound). This may be exacerbated by coughing. The abdomen may feel ‘rigid’.
Ruptured aortic aneurysm – acute pain that radiates to the back or groin. The patient may be in a cardiovascular collapse. A mass is felt swelling and contracting with the pulse.
Pre-eclampsia – epigastric pain is very significant, especially if severe or associated with vomiting.

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Surgical’ causes of epigastric pain

Pancreatic cancer – this should be considered in anyone with unexplained epigastric pain, especially with weight loss or new-onset diabetes.
Pancreatitis – acute pain that radiates to the back. It is usually accompanied by vomiting. The pain may be relieved by sitting forward. Signs vary but include jaundice, tachycardia, abdominal rigidity, tenderness, and discoloration around the umbilicus or flanks.
Gastrointestinal obstruction – acute colicky pain. Vomiting brings relief. Accompanied by distension and ‘tinkling bowel sounds’.
Gallbladder disease – acute constant pain with vomiting, fever, local tenderness and rigidity. It may be possible to palpate a gallbladder mass.
Gastric carcinoma – be suspicious particularly in male patients who are over 55 years old and who smoke. Advanced cases may also have weight loss, vomiting, palpable mass/nodes, hepatomegaly, vomiting and dysphagia.
Renal colic – typically causes unilateral loin pain radiating to the suprapubic area, but sometimes the pain can be experienced elsewhere.

Other causes of epigastric pain

Irritable bowel syndrome – by definition the pain has been present for at least six months and is associated with bloating and alteration in stool frequency or consistency.
The examination is usually normal or there may be mild tenderness/distension.
Lactose intolerance can cause pain, bloating and nausea.
Referred pain – this may be from the heart in myocardial infarction; also from pleural disease or spinal nerves.
Shingles – this may cause an intense pain which is more in the skin than the deeper tissues, but patients may find it hard to distinguish. The pain may occur a couple of days before the typical vesicular rash becomes visible.
Mesenteric adenitis – Mesenteric adenitis is quite a common cause of abdominal pain in children. It can occur in adults but is more unusual. It is caused by painful swelling of abdominal lymph nodes associated with an infection, generally a viral upper respiratory tract infection.

Symptoms of Epigastric Pain

Heartburn
Abdominal pain
Indigestion
Pain extending to the back
Abdominal tenderness
Swelling in the abdomen
Abnormal acidic taste in your mouth
Frequent belching
Constipation
Feeling a lump in your throat
Ongoing cough
Burning sensation in the abdomen or chest area
Diarrhea
Nausea and vomiting
Gas problems
Chest pain, tightness and pressure in the chest, even palpitations
Pain moving down the shoulder and arm
Difficulty in breathing may also lead to choking
Presence of blood or black components in vomiting
Weight loss
Loss of appetite
Feeling full as you begin to take food
Hoarse voice or sore throat
Pain when eating or pain that subsides when you take food or when you have bowel movements
Pain that is relieved or worsened by movement or when you are in a certain position.

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Diagnosis of Epigastric Pain

Blood tests may be useful:

CBC
ESR/CRP
U&Es
LFTs
Amylase
Clotting

You may wish to consider imaging

Abdominal ultrasound – will look for gallstones, as well as liver and renal problems.
CXR – if you suspect referred pleural pain.
Abdominal X-ray – may reveal bowel obstruction, constipation or kidney stones.
Computerized tomography (CT) scan.
X-rays – Allows for a visual representation of the abdominal cavity showing the kidneys, bladder, and ureters.
Endoscopy – The use of a camera on the end of a telescopic tube allows for direct visualization inside the body. Endoscopy also has the ability to take a tissue sample if need be.
Urinalysis – To assess for a urinary tract infection or another disorder related to epigastric pain.
Blood tests – Looking for any abnormality of the organs that may signal a more insidious underlying cause of epigastric pain.
Cardiac testing – Various tests such as looking for cardiac biomarkers, a stress test, and an EEG to help identify if the heart is the cause of epigastric pain

During endoscopy, gastric ulcers are graded using the Forrest classification scheme; this provides the estimated risk of ulcer bleeding and helps to distinguish which ulcers need endoscopic management such as injection therapy, cautery, or hemoclip placement. Below is a representation of the grading system.[rx]

Forrest classification:

Ia- jet arterial bleeding, 90% rebleeding risk
Ib- oozing, 50% rebleeding risk
IIa – visible vessel, 25-30% rebleeding risk
IIb – adherent clot, 10-20% rebleeding risk
IIc – black spot in the ulcer, 7-10% rebleeding risk
III – clean based, 3-5% rebleeding risk

Treatment of Epigastric Pain

Non Steroidal Anti-inflammatory Drug –These are quite helpful in providing relief from the pain as well as in resolving inflammation and fever too. Ibuprofen is particularly found helpful here in treating pain.
H2 Receptors Blockers – These are usually prescribed for the treatment of peptic ulcers and heartburn. These drugs prevent the formation of excessive gastric acid by the stomach, thus prevent ulcer formation as well as burning feelings behind the breastbone.
Antacids – It’s a substance that neutralizes stomach acidity. The salts containing aluminium and magnesium are usually given to treat peptic ulcer.
Nonprescription antigas – medications containing simethicone or bismuth
Antiulcerant drug – such as opeprazole, pantoprazole, Esomeprazole
Antibiotic – such ciprofloxacin to reduce the IBS or mal absorbtion syndrome

Prevention

Stop alcohol and cigarette smoking.
Eat bland diet which consists of non oily and non spicy food.
Reduce stress as it is one of the most common factors to produce peptic ulcer and gastritis in modern days. Meditation, yoga, is useful for relieving stress.
Eat food at frequent intervals instead of keeping a large gap between two meals.
Honey has natural anti inflammatory properties. Mix one teaspoon of honey in one glass of water. Mix it and drink daily in morning to alleviate epigastric pain.
Bananas contain certain substance which increases production of mucus in the stomach. As a result mucus protects the harmful effect of acid on the inner lining of stomach. The high fiber content is also beneficial in alleviating pain caused due to gastritis.
A mixture of mint leaves, Indian gooseberry juice, soothes epigastric pain.

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Home Remedies

While it is recommended to see a doctor if you have persistent epigastric pain, mild intermittent pain can be remedied at home using the following methods:

Aloe Vera juice – A common treatment for stomach problems. It is important not to dilute this juice in other liquids to get the full benefit.
Ginger tea – Considered an excellent treatment for the relief of stomach issues, ginger tea may help neutralize stomach acid and reduce inflamed or irritated tissue in the digestive tract.
Baking soda – Consuming a teaspoon of this powder in warm water can help neutralize the acidic nature of your stomach. If the problem persists after a few days, try two teaspoons.
Chamomile tea – A common remedy for indigestion, chamomile tea helps fight the symptoms of epigastric pain by soothing the stomach. This tea is also used to relieve heartburn.
Yogurt – Known for easing indigestion and pain caused by digestive problems. It does this by increasing the number of beneficial bacteria in the digestive tract.
Burnt toast – Used to help detoxify the stomach.
Peppermint tea – Made from peppermint leaves, it can be a great remedy for relieving epigastric pain. However, peppermint is not recommended in cases of GERD, as it may trigger acid reflux.