Epigastric Pain

Think MI = EKG, CE
Most Common Cause  = Non-ulcer Dyspepsia
What to do? Endoscopy if > 45 y
< 45 y + Alarm Symptoms:
 - Dysphagia
 - Blood in stool (Anemia)
 - Weight loss
 - Early Satiety.
Diagnosis Differentiating Signs/Symptoms Differentiating Tests
Non-Ulcer Dyspepsia At least 3 months of recurrent upper abdominal pain, bloating, and nausea, with no obvious structural cause No definitive differentiating tests. Esophagitis is absent on endoscopy for both nonerosive GERD and nonulcer dyspepsia, while peptic ulcer disease was excluded.
Achalasia Dysphagia is typically prominent Esophageal manometry and/or esophagram are abnormal and consistent with achalasia
Acute MI * Cardiac etiology must be ruled out before considering a diagnosis of GERD in people with chest pain.

Cardiac chest pain is typically substernal, precipitated by exertion, and relieved by rest
GERD History of heartburn or pain rising from the lower chest to the throat is typical.

May have associated laryngitis, cough, and atypical chest pain
Endoscopy shows absence of gastric/duodenal ulcers and, often, erosions in esophagus.

May require additional testing with ambulatory pH-metry to prove diagnosis
Barret's Esophagus Heart burn, Regurgitation, Dysphagia, Chest pain, Cough, SOB or wheezing, History of aspiration pneumonia EGD with biopsy, PPI trial.
Peptic Ulcer Burning pain in the epigastrium, which occurs hours after meals or with hunger.

The pain often wakes the patient at night and is relieved by food and antacids
Endoscopy demonstrates ulcer.

Testing for Helicobacter pylori infection is often positive, although not diagnostic
Gastritis Patient may have a hx of chronic NSAID use.
Mild epigastric tenderness common
Upper GI endoscopy with biopsy will show no Barrett esophagus findings on biopsy
Hiatal Hernia Bowel sounds in chest EGD, CT Abdomen
Zollinger-Ellison Syndrome (ZES) Refractory or recurrent peptic ulcer disease, diarrhea, steatorrhea, epigastric abdominal pain, gastroesophageal reflux disease, GI bleed
bone pain
Elevated fasting serum gastrin, secretin infusion test, upper GI endoscopy
Pancreatitis (Acute) History of gallstones or alcohol use.
Pain typically radiates to back
Elevated serum amylase and lipase levels.
CT scan shows inflammation of pancreas
Gallbladder Disorders Right upper quadrant or epigastric pain usually increasing in intensity and lasting several hours An ultrasound may show gallstones
Pneumonia* Green, Productive Cough, Fever, SOB CXR, Elevated WBC.
Gastroparesis Early satiety prominent.

Usually a history of longstanding diabetes with evidence of peripheral neuropathy and other end-organ damage
Endoscopy may show food stasis.

Definitive diagnosis with gastric emptying study (nuclear medicine imaging)
"Indigestion" from overeating, high-fat, coffee    
Pregnancy   HCG (+)
Intestinal Ischemia    
Esophageal Rupture    
Physical or sexual abuse    

ITE 2013, Q#108.
A 57-year-old male comes to the emergency department after several episodes of vomiting preceded by moderately severe epigastric pain. He says the vomitus looked like coffee grounds. He tells you he has had “heartburn” in the past that was sometimes severe, and occasionally associated with vomiting, but these episodes were almost always relieved by oral antacids. This problem was exacerbated recently after he began taking ketorolac for moderate arthritic pain in his knees and hands. His past medical history and a review of systems reveal no major comorbid disorders.

The patient’s blood pressure is 125/82 mm Hg and his heart rate is 95 beats/min with no signs of shock. His hemoglobin level is 9.5 g/dL (N 13.0–18.0). He is admitted to the hospital and placed on a proton pump inhibitor (PPI) infusion. Upper gastrointestinal endoscopy performed within 3 hours of admission shows no blood in the upper gastrointestinal tract, but reveals a Mallory-Weiss tear and a stomach ulcer containing a dark spot in an otherwise clear base.

Management at this time should include which one of the following?

A) Transfusion with whole blood
B) Repeat endoscopy within 24 hours
C) Arteriography
D) Continued in-hospital observation for at least 72 hours
E) Discharge from the hospital on oral PPI therapy