Epigastric pain differential diagnosis

Epigastric pain various causes differentiation

1. Differential Diagnosis of Abdominal Pain Localized in Epigastric Region

2. Epigastric pain - Pain localized in the upper abdominal area just under the ribs - History is crucial for differential diagnosis: Onset (Gradual or sudden), Duration (intermittent/constant) Character of pain (dull, achy, throbbing, sharp, piercing) Frequency, radiation Associated symptoms: nausea, vomiting, fevers, chills, diarrhea, constipation, weight loss, hematochezia, melena, jaundice, changes in urine or stool, Exacerbating or relieving factors Alcohol intake Medications intake (Aspirin, NSAIDS) Family history of bowel disorders Menstrual and contraceptive history in women

3. Etiology Biliary causes: Cholelithiasis , cholecystitis, and cholangitis Cardiac causes: Myocardial infarction, or pericarditis GI causes: Esophagitis , functional dyspepsia, GERD, peptic ulcer, gastritis Gastric outlet obstruction, or malignancy Early appendicitis could be a colonic cause Pancreatic causes – mass or pancreatitis Vascular causes: Aortic aneurysm, or mesenteric ischemia Other: herpes zoster, muscle strain, hernia, pneumonia

4. Evaluation of Epigastric Pain - Initially, the following: History of GI, pulmonary, and cardiac systems Physical exam Chest x-ray EKG CBC Serum amylase LFT - Ultrasonography Hepatobiliary tree/pancreatic pathologies must be excluded at first Liver , gallbladder, bile ducts, and pancreatic pathologies Increased amylase or lipase, or LFT – further evaluation with contrast CT may be used In case no abnormalities are detected, recurrent epigastric pain, and other symptoms – evaluate w/ GI endoscopy In case first episode of pain – start symptomatic treatment of dyspepsia

5. Biliary causes Cholelithiasis gallstones in gallbladder Biliary colic is the common symptom, a right upper quadrant pain which may radiate to epigastric area and right shoulder Often postprandial and lasts from 30-90 minutes Vomiting and nausea may be present Diagnosis: RUQ ultrasonography Findings on ultrasound: echogenic foci which show acoustic shadowing Cholecystitis and cholangitis are usually complications of cholelithiasis Cholecystitis Inflammation of gallbladder and cystic duct Biliary colic, plus: Murphy’s sign Fever and chills may be present Palpable gallbladder, tenderness, Leucocytosis , abnormal LFT Diagnosis through RUQ ultrasonography Findings: cholelithiasis combined with sonographic murphy sign, gallbladder wall thickening (>3 mm), and pericholecystic fluid

6. Cholangitis Bacterial infection and inflammation of biliary tract Abdominal pain, fever, altered mental status Right upper quadrant tenderness Jaundice Murphy’s sign negative Sepsis (hypotension, tachycardia) Elevated bilirubin and elevated LFT Leucocytosis Cholestasis Diagnosis: RUQ US, ERCP On ultrasound: thickening of the walls of the bile ducts, biliary dilation with calculi with/without pus ERCP allows for small ducts visualization, complete assessment of biliary tree showing the obstructive lesions and stenosis

7. Pancreatitis Epigastric pain relatively sudden in onset Radiates to the back Associated with nausea, vomiting, anorexia, steatorrhea Risk factors Gallstones Recent ERCP Alcohol use Trauma Lab tests Complete blood count Electrolytes , BUN, creatinine, and glucose Aminotransferases , alkaline phosphatase, and bilirubin Lipase (amylase is a less specific alternative, where lipase is not available) Elevation of serum lipase in the presence of epigastric pain is very suggestive of pancreatitis.

8. Workup Abdominal ultrasound to exclude gallstones CT scan is sensitive for pancreatitis US and CT are crucial for diagnosis in chronic pancreatitis where amylase and lipase may be normal Biliary etiology (gallstone-related) is suspected in the absence of US findings with elevated transaminases and pancreatitis Gallstones should be investigated with ERCP

9. Dyspepsia Pain limited to the epigastrium can be classified as dyspepsia once pancreatic and hepatobiliary pain are excluded Associated with bloating, abdominal fullness, heartburn, or nausea Evaluate which patients require further investigation and which can safely undergo a therapeutic trial of antisecretory therapy or watchful waiting Alarm features requiring further investigations include: Weight loss, age >50, persistent vomiting, dysphagia, anemia, hematemesis Palpable abdominal mass Family history of GI carcinoma Acuity and severity dictate the urgency of referral for endoscopy

10. Dyspepsia Diagnostic Testing Age <60 Perform upper gastroscopy in patients with >1 alarm feature to evaluate for organic disease Evaluate for functional dyspepsia and active H.pylori infection on gastric biopsy in case organic disease is absent 2. Or test for H.pylori infection with stool antigen or urea breath test Age >60 Upper gastroscopy is performed in all patients Evaluate for functional dyspepsia and active H.pylori infection in case organic disease is absent

11. Routine Laboratory Tests Routine blood counts and blood chemistry including liver function tests, serum lipase, and amylase to identify patients with alarm features ( e.g , iron deficiency anemia) and underlying metabolic diseases that can cause dyspepsia ( e.g , diabetes, hypercalcemia)

12. Organic disorders 1. GERD Heartburn and acid regurgitation are typical symptoms Burning sensation rises from stomach towards the neck Symptoms are exacerbated by fatty foods, caffeine, and recumbent position 10% of the US population has daily heartburn Diagnostic testing includes empirical trial of a PPI (40mg 2 times daily for 1 week) as a first step Barium radiography Upper GI endoscopy in severe disease: macroscopic or microscopic changes on biopsy (esophagitis) Barrett's esophagus - replacement of the squamous epithelium of the esophagus by columnar epithelium—develops in 10% to 15% of patients who have chronic gastroesophageal reflux disease (GERD). Barrett's esophagus is associated with an increased risk of esophageal adenocarcinoma.

13. 2. Peptic Ulcer Disease A total of 400,000 new cases of PUD are diagnosed each year H.pylori is the major cause of peptic ulcer disease Risk factors for PUD beyond H pylori infection include use of aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), male sex, family history, stress, smoking, chronic renal failure, chronic obstructive pulmonary disease, and alcoholism H.pylori is a gram-negative, urease-producing bacterium that colonizes gastric mucosa and produces chronic, superficial antral gastritis peptic ulcer disease is often improved when a patient either has an empty stomach or consumes food to satiety Diagnosis: double contrast Upper GI (barium swallow) and esophagogastroduodenoscopy (higher sensitivity) H.pylori testing: urea breath test or rapid urea test (invasive, requires EGD)

14. 3. Functional Dyspepsia Defined as chronic dyspeptic symptoms (episodic or persistent pain or discomfort localized to the epigastrium or upper abdomen), for which clinical evaluation and studies have failed to reveal a pathologic cause . It is, therefore, a diagnosis of exclusion Patients can be grouped by symptom pattern as ulcerlike , dysmotility -like, and refluxlike , but there is much overlap

15. 4 . Gastroesophageal malignancy Significant weight loss, anorexia, vomiting, dysphagia, odynophagia, and a family history of gastrointestinal cancers suggest the presence of an underlying gastroesophageal malignancy . Imaging tests: double-contrast barium upper GI examination, CT scan Diagnosis is confirmed with a biopsy and laboratory analysis

16. Myocardial Infarction Epigastric pain could possibly be an extension of cardiac pain, or referred pain Patient should be asked about exertional dyspnea In suspected acute coronary syndrome urgent evaluation and management is required Diagnostic criteria: Elevated cardiac troponins (T and I) is mandatory to establish diagnosis In addition to elevated troponins patient must display either symptoms or ECG changes consistent with myocardial ischemia / infarction ECG – ST elevations, ST depressions, T-wave inversions or hyperacute T-waves, and pathological Q-waves Symptoms – ischemic chest pain, dyspnea, nausea, fatigue

17. Pericarditis Acute pericarditis presents with acute retrosternal sharp, pleuritic, chest pain that radiates to neck, jaw, or arms, similar to MI. In contrast to MI, chest pain is exacerbated in the supine position, by coughing, and with inspiration. Pain improves in the sitting position or by leaning forward Not relieved with nitrates Diagnostic criteria: at least two of the following Non-ischemic chest pain ECG evidence of PR depression or ST segment deviation Detection of pericardial rub on auscultation Pericardial effusion on echocardiography MRI can detect small pericardial effusions that aren’t detected on echocardiography

18. Abdominal Aortic Aneurysm Is defined as focal dilatation with enlargement of the diameter of abdominal aorta to 3 cm or more Caused by atherosclerosis Symptoms include back, flank, abdominal, or groin pain Pain may radiate to lower extremities Local compression: early satiety, nausea, vomiting, An expanding aortic aneurysm causes sudden, severe, and constant low back, flank, and abdominal pain. Syncope may be the main complaint, with pain less prominent Diagnosis is made with US A CT scan may be needed to determine exact location, size, and involvement of other vessels.

19. Mesensteric Artery Ischemia Refers to ischemia that affects the blood vessels of small intestine Secondary to occlusive (thrombosis) or nonocclusive (spasms) obstruction of the arteries Or can be caused by obstruction of venous outflow (venous thrombosis) Acute or chronic Acute mesensteric ischemia is sudden in onset with sudden abdominal pain associated with nausea, vomiting, or diarrhea Chronic mesensteric ischemia is seen in atherosclerosis, it causes intermittent ischemia that usually worsens with eating History of a prior embolic event or family history of DVT or pulmonary emboli is important Diagnosis : mesenteric angiography or CT angiography Lab tests findings: leukocytosis, elevated d-dimer and lactate

20. Herpes zoster Pain rising from abdominal wall rather than due to inflammation of the underlying viscera Positive Carnett’s sign Burning/stinging pain, may be associated with itching Other symptoms, such as malaise, myalgia, headache, photophobia, and, uncommonly, fever Pneumonia Fever Respiratory symptoms: dyspnea, cough, sputum, chest pain CXR findings of a new pulmonary infiltrate .

21. Sources Uptodate.com Medscape.com Ncbi.nlm.nih.gov