What is the evaluation of epigastric pain?

From the Guidelines

Epigastric evaluation should involve a systematic assessment of the upper central abdominal region, starting with a thorough history and physical examination, followed by initial diagnostic tests such as complete blood count, liver function tests, lipase/amylase, and an upper abdominal ultrasound, and considering an upper endoscopy for persistent symptoms, as recommended by the most recent guidelines 1. The evaluation of epigastric pain requires a comprehensive approach to diagnose conditions affecting organs like the stomach, duodenum, pancreas, and liver.

• A thorough history should focus on pain characteristics (timing, quality, radiation), associated symptoms (nausea, vomiting, weight loss), and risk factors (alcohol use, medications like NSAIDs) 1.
• Physical examination should include inspection for distention, auscultation for bowel sounds, and palpation for tenderness, masses, or organomegaly.
• Initial diagnostic tests typically include complete blood count, liver function tests, lipase/amylase, and an upper abdominal ultrasound.
• For persistent symptoms, consider an upper endoscopy to directly visualize the esophagus, stomach, and duodenum, as it is the standard test of choice for diagnosing peptic ulcer disease and other conditions 1.
• H. pylori testing is recommended for suspected peptic ulcer disease, using either stool antigen, urea breath test, or endoscopic biopsy, as it can help identify the underlying cause of symptoms and guide treatment 1.
• More advanced imaging like CT scan or MRI may be necessary for suspected pancreatic or hepatobiliary pathology, although CT examination is not the test of choice for initial imaging if acid reflux, esophagitis, gastritis, peptic ulcer, or duodenal ulcer is strongly suspected 1. This systematic approach helps differentiate between common causes of epigastric pain such as gastritis, peptic ulcer disease, pancreatitis, and gallbladder disease, allowing for appropriate targeted treatment, and is supported by the most recent guidelines from the American College of Radiology 1.

From the Research

Evaluation of Epigastric Pain

The evaluation of epigastric pain involves a comprehensive approach to determine the underlying cause of the pain. Some of the key points to consider in the evaluation of epigastric pain include:

• The location and characteristics of the pain, such as whether it is relieved by food intake or antacids, and whether it occurs at night or between meals 2
• The presence of other symptoms, such as loss of appetite, weight loss, and alarm symptoms indicating a complication or malignancy 2
• The use of nonsteroidal anti-inflammatory drugs (NSAIDs) and the potential for NSAID-induced peptic ulcer disease 2
• The role of Helicobacter pylori infection in the development of peptic ulcer disease and the use of a test-and-treat strategy for patients with no alarm symptoms 2

Diagnostic Approaches

Diagnostic approaches for epigastric pain may include:

• Clinical bedside ultrasonography (US) as a first-line imaging modality in acute epigastric pain patients presenting to the Emergency Department (ED) 3
• Endoscopy and distal esophageal biopsies to assess esophageal function and pathological acid exposure 4
• Esophageal motility and 24-h ambulatory pH monitoring to evaluate esophageal function and acid exposure 4
• A scoring system based on the presence of symptoms and severity of findings to distinguish between gastroesophageal reflux disease (GERD), non-erosive reflux disease (NERD), and reflux-like dyspepsia (RLD) 4

Prevalence of Peptic Ulcer Disease

The prevalence of peptic ulcer disease among patients undergoing upper gastrointestinal endoscopy has been studied, with varying results:

• A study in a tertiary care centre found a prevalence of 10.62% among patients undergoing upper GI endoscopy 5
• The prevalence of peptic ulcer disease may be lower in some study centres compared to others, highlighting the need for further studies on associated risk factors and socio-demographic distribution 5

Classification and Characterization

Epigastric pain may be characterized and classified in different ways, including:

• The Rome II classification, which characterizes ulcer-like dyspepsia by predominant pain centered in the upper abdomen and dysmotility-like dyspepsia by discomfort 6
• The presence of epigastric pain as a specific and localized symptom, or as part of a group of symptoms that include heartburn, bloating, or early satiety 6