What are the causes of epigastric pain?

Causes of Epigastric Pain

The most common causes of epigastric pain include gastroesophageal reflux disease (GERD), esophagitis, peptic ulcer disease (PUD), gastritis, duodenal ulcer disease, gastric cancer, hiatal hernia, myocardial infarction, pancreatitis, and acute aortic syndromes. 1

Gastrointestinal Causes

Acid-Related Disorders

• GERD presents with epigastric pain often accompanied by heartburn and regurgitation, affecting approximately 7% of Americans daily and 42% at least once monthly 1
• Esophagitis manifests as fine nodularity or granularity of the mucosa, erosions or ulcers, thickened longitudinal folds, inflammatory esophagogastric polyps, and scarring with strictures 1
• Gastritis appears as enlarged areae gastricae, disruption of normal polygonal areae gastricae pattern by multiple uniform nodules, thickened gastric folds, or erosions 1
• Peptic ulcer disease has an incidence of 0.1% to 0.3% and can present with epigastric pain not relieved by antacids 1, 2
• Duodenal ulcers typically cause pain several hours after eating, often at night, and may improve with meals 3
• Gastric ulcers typically cause pain immediately after eating, with food consumption increasing the pain 3
• Bile reflux gastritis presents with epigastric pain not relieved by antacids, often with heartburn, dysphagia, or hematemesis 2

Structural Abnormalities

• Hiatal hernia can be detected on imaging studies and may contribute to reflux symptoms 1
• Gastric cancer may present with an ulcer associated with nodularity of the adjacent mucosa 1

Non-Gastrointestinal Causes

• Myocardial infarction can present with epigastric pain and should be considered in the differential diagnosis, especially with risk factors and exertional symptoms 1
• Pancreatitis typically presents with pain that radiates to the back 3
• Acute aortic syndromes can cause sudden, severe epigastric pain 1
• Renal or hepatic cyst bleeding or rupture can rarely cause acute epigastric pain 4

Pregnancy-Specific Considerations

• Preeclampsia can present with epigastric or right upper quadrant pain, headaches, visual changes, or swelling 5
• HELLP syndrome should be considered with epigastric pain, nausea, vomiting, and malaise in pregnant patients 5
• Acute fatty liver of pregnancy may present with malaise, headache, nausea, vomiting, jaundice, and epigastric pain 5

Diagnostic Approach

Clinical Assessment

• Evaluate timing and onset of pain (sudden vs. gradual) 5
• Assess severity on a scale of 1-10 5
• Inquire about associated symptoms: nausea, vomiting, hematemesis, heartburn, regurgitation 5
• Check for alarm symptoms: weight loss, anemia, dysphagia, persistent vomiting 1

Imaging Considerations

• Ultrasound is often the first-line imaging in acute epigastric pain as it is rapid, noninvasive, relatively inexpensive, focused, and reliable 6
• CT abdomen with IV contrast can help diagnose complications such as perforation, showing findings like:
  • Extraluminal gas (97% of perforations)
  • Fluid or fat stranding along gastroduodenal region (89%)
  • Ascites (89%)
  • Focal wall defect and/or ulcer (84%)
  • Wall thickening (72%) 1
• Fluoroscopic studies like barium esophagram or upper GI series can provide anatomic and functional information for GERD and esophagitis 1

Complications to Watch For

• Bleeding is the most common complication of duodenal ulcers and can present as hematemesis 7
• Perforation presents with sudden, severe epigastric pain that may generalize, accompanied by fever and abdominal rigidity, requiring immediate surgical intervention 7
• PUD-related complications occur in 2-10% of cases, with perforation having a mortality rate of up to 30% 1

Special Considerations

• Symptoms of different conditions often overlap, making clinical history, risk factors, and associated symptoms crucial for narrowing the differential diagnosis 1
• In pregnant patients, always consider preeclampsia, HELLP syndrome, and acute fatty liver of pregnancy when evaluating epigastric pain 5
• Patients with previous bariatric surgery presenting with epigastric pain should be evaluated for potential complications such as internal herniation 5