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 presses on adjacent structures.

• 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.
  • Pancreatitis: Both acute and chronic pancreatitis can cause severe epigastric pain radiating to the back, and missing this diagnosis can lead to significant morbidity and mortality.
  • Aortic dissection: A life-threatening condition where there is a tear in the aorta's inner layer, which can cause severe, tearing chest pain but sometimes presents with epigastric pain if the dissection involves the abdominal aorta.
  • Esophageal rupture or perforation: A serious condition that requires immediate medical attention, presenting with severe chest or epigastric pain, often after vomiting or an endoscopic procedure.

• Rare Diagnoses

  • Gastric cancer: Although rare, especially in younger populations, it can present with epigastric pain, weight loss, and other non-specific symptoms.
  • Pancreatic cancer: Similar to gastric cancer, it's a rare cause of epigastric pain but should be considered, especially in patients with risk factors or unexplained weight loss.
  • Splenic infarction: Typically presents with left upper quadrant pain, but can sometimes cause epigastric pain, especially if the spleen is enlarged and presses on adjacent structures.
  • Diabetic ketoacidosis: A serious complication of diabetes that can cause abdominal pain, including epigastric pain, nausea, vomiting, and other systemic symptoms.