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 in an atypical location.
  • 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 (Boerhaave's syndrome): A rare but critical condition where the esophagus tears, leading to severe chest or epigastric pain, often accompanied by difficulty swallowing and breathing.
  • 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

  • Zollinger-Ellison syndrome: A rare disorder characterized by excessive gastric acid production due to a gastrin-secreting tumor, leading to severe peptic ulcers and epigastric pain.
  • Eosinophilic gastroenteritis: A rare condition where eosinophils infiltrate the gastrointestinal tract, causing abdominal pain, nausea, and vomiting, among other symptoms.
  • Gastric cancer: Although more common in certain populations, gastric cancer is a rare cause of epigastric pain in many parts of the world, often presenting with weight loss, anorexia, and abdominal pain.