BD TLEAD 18 (Chronic Epigastric Pain)
Esophageal
Gastro-esophageal reflux (GERD) causing Esophagitis
[epigastric
or retrosternal discomfort ("heartburn"), exacerbated by lying flat,
with acid brash (acid taste in mouth due to reflux); pain alleviated by eating, hematemesis, dysphagia. PE: Dental/oral mucosa changes/erosion].
Duodenal
Stomach
Gastritis (H. pylori, can lead to gastric ulcer. precursor to ulcers, but mucosa intact. Clinically may be indistinguishable from ulcers. Mild dyspepsia (epigastric pain & bloating): rarely requires extensive workup, but screen for alarm
symptoms of anemia, loss of weight, recent onset or rapid progression of symptoms, melena or hematemesis, and dysphagia, as well as risk factors.)
[Hx of autoimmune disease]
Gastroparesis [postprandial pain; pain a/w emesis of undigested food with acidic, digestive juices from the stomach but no bile]
Peptic Ulcer Disease (PUD) (burning epigastric pain and fullness, postprandial belching, early satiety, bloating, anorexia, nausea and vomiting, hematemesis (red-blood or coffee-ground emesis), melena (black, tarry stool), pain radiate to back)
Gallbladder
Cholecystitis (Pain as in cholelithiasis, but more severe, lasting longer (> few hours) ± radiating to the right shoulder. With inflammation, there may be a low-grade fever and Murphy’s sign. LFT may be mildly elevated, but jaundice should not be marked.) [pain often with guarding or rebound].
Pancreas
Chronic Pancreatitis (a close ddx of pancreatic
cancer – this presents with epigastric pain (initially
episodic then continuous), steatorrhoea (pancreatic
insufficiency), and new or worsening diabetes, pain radiate to back)
[postprandial pain, worse supine, Hx of alcohol abuse or gallstones]
Peptic Ulcer (Classically, pain from gastric ulcers is exacerbated by food and relieved by vomiting, while duodenal ulcers are relieved by food. Complications include bleeding leading to malena or hematemesis, and perforation causing peritonitis. Seek to identify its etiology, taking a careful drug hx (esp NSAIDs, steroids), risk fx for H. pylori (past hx, contact hx, developing country, smoking), and bearing in mind that some ulcers are malignant). [Pain relieved by eating; relieved more to antacid therapy or food as compared to gastric ulcer]
Gastric Ulcer [pain worse by eating (postprandial pain)].
Biliary Colic (episodic right hypochondrial or epigastric pain, often after fatty meals. Pain peaks over hours, resolving when the gallbladder relaxes. Characteristically, pain is constant without pain-free intervals (hence ‘colic’ is a misnomer – true colic has pain free intervals). There may be nausea and vomiting, but the patient is not jaundiced, pain radiates to right shoulder) [postprandial pain]
Malignancy (Asymptomatic early, then causing vague constant epigastric pain, with no relationship to meals. Hematemesis or melena may result from tumor bleed. Late symptoms include early satiety, vomiting of undigested food (intermittent in gastric outlet obstruction, post-meal in linitis plastica), dysphagia (in tumors near the cardia), loss of appetite and weight, or symptoms due to mets.)
[chronic progressive pain; Virchow's node; Hx of stomach cancer; Sister Mary Joseph nodule, hematemesis]
Malignancy (a cancer in the body or tail of
pancreas may present with chronic progressive
epigastric pain radiating to the back. A head of
pancreas tumor is more likely to present with
obstructive jaundice).
Cardio
Myocardial Ischemia (can cause dull epigastric discomfort and is sometimes confused with PUD, pain radiate to left arm or neck)
Liver (chronic hepatitis)