Differential Diagnosis for Epigastric Pain Excluding Stomach Pathology

When considering epigastric pain not originating from the stomach, several conditions from adjacent organs or systems could be responsible. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Peptic ulcer disease of the duodenum: This condition is a common cause of epigastric pain and is closely related to stomach pathology but originates from the duodenum, making it a prime consideration when stomach pathology is excluded.
• Other Likely Diagnoses
  • Gastroesophageal reflux disease (GERD): Although primarily associated with the esophagus, GERD can cause epigastric pain due to the reflux of stomach contents into the esophagus.
  • Pancreatitis: Both acute and chronic pancreatitis can cause severe epigastric pain, often radiating to the back.
  • Cholecystitis: Inflammation of the gallbladder can cause epigastric pain, especially after eating fatty foods, due to the gallbladder's location under the liver.
  • Esophageal spasm or esophagitis: These conditions can cause chest pain or epigastric discomfort, especially if the esophagus is involved.
• Do Not Miss Diagnoses
  • Myocardial infarction: Although more commonly associated with chest pain, myocardial infarctions can present with epigastric pain, especially in women or diabetic patients, making it crucial not to miss this potentially fatal condition.
  • Pulmonary embolism: Similar to myocardial infarction, pulmonary embolism can occasionally present with epigastric pain if the embolism affects the lower parts of the lungs.
  • Aortic dissection: This is a life-threatening condition where there is a tear in the aorta's inner layer, which can cause severe, tearing chest or epigastric pain.
• Rare Diagnoses
  • Diabetic ketoacidosis: While more commonly associated with systemic symptoms like hyperglycemia and metabolic acidosis, diabetic ketoacidosis can occasionally present with abdominal pain, including epigastric pain.
  • Porphyrias: A group of disorders that can result in acute intermittent porphyria, which may cause severe abdominal pain, including epigastric pain, among other symptoms.
  • Intestinal ischemia: Reduced blood flow to the intestines can cause severe abdominal pain, which may be localized to the epigastric region, depending on the segment affected.

Each of these conditions has a distinct set of additional symptoms and diagnostic criteria that can help in narrowing down the differential diagnosis. A thorough clinical evaluation, including history, physical examination, and appropriate diagnostic tests, is essential for accurately diagnosing the cause of epigastric pain.