Differential Diagnosis for Epigastric Pain

The differential diagnosis for epigastric pain is broad and includes various conditions affecting the gastrointestinal, cardiovascular, and other systems. Here's a categorized approach to the differential diagnosis:

• Single Most Likely Diagnosis

  • Peptic ulcer disease (PUD): This is often the first consideration due to its high prevalence and the typical presentation of epigastric pain that may radiate to the back, worsen with food intake, and improve with antacids or food.

• Other Likely Diagnoses

  • Gastroesophageal reflux disease (GERD): Characterized by symptoms of heartburn and regurgitation, often triggered by lying down or eating certain foods.
  • Gastritis: Inflammation of the stomach lining, which can cause epigastric pain, nausea, and vomiting, often related to NSAID use or alcohol consumption.
  • Cholecystitis: Inflammation of the gallbladder, typically presenting with right upper quadrant pain, but can sometimes cause epigastric pain, especially if the gallbladder is inflamed and distended.
  • Pancreatitis: Inflammation of the pancreas, which can cause severe, persistent epigastric pain radiating to the back, often associated with nausea, vomiting, and elevated pancreatic enzymes.

• Do Not Miss Diagnoses

  • Myocardial infarction (MI): Although chest pain is the classic symptom, some patients, especially women and diabetics, may present with epigastric pain as a manifestation of an MI.
  • Aortic dissection: A life-threatening condition where there is a tear in the aorta's inner layer, which can cause severe, tearing chest or epigastric pain.
  • Esophageal rupture or perforation: A serious condition that can present with severe chest or epigastric pain, often accompanied by difficulty swallowing and shortness of breath.
  • Mesenteric ischemia: A condition where there is insufficient blood flow to the intestines, which can cause severe, diffuse abdominal pain, including epigastric pain, out of proportion to the physical examination findings.

• Rare Diagnoses

  • Gastric cancer: Although rare, it can present with epigastric pain, weight loss, and difficulty swallowing.
  • Pancreatic cancer: Can cause epigastric pain, weight loss, and jaundice, especially in older adults.
  • Splenic infarction: Can cause left upper quadrant or epigastric pain, often associated with splenomegaly and systemic symptoms like fever.
  • Diabetic ketoacidosis: A complication of diabetes that can cause abdominal pain, including epigastric pain, nausea, vomiting, and altered mental status, along with hyperglycemia and metabolic acidosis.