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Potential Causes of Epigastric Pain

The term 'epigastrium' refers to the area of the upper abdominal region that lies under the rib cage, between the costal margins and the subcostal plane. This Buzzle write-up provides information on the potential causes of epigastric pain.
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Causes of epigastric pain
Did You Know?
Peptic ulcer disease, which is one of the common causes of epigastric pain and discomfort, affects about 4.6 million people in the United States annually.
The human abdomen is divided into nine anatomical regions called the epigastric region, right hypochondriac region, left hypochondriac region, umbilical region, right lumbar region, left lumbar region, hypogastric region, right iliac region, and left iliac region. The epigastric region is located in the center of the upper abdomen. The term 'epigastric' is derived from two words 'epi', which means above, and 'gastric', which refers to the stomach.

The epigastric region lies over the stomach, and is superior to the umbilical region (navel). It is located between the costal margins (an inverted V-shaped margin formed by the anterior surface of the sternum and the cartilages of the seventh to the tenth pair of ribs) and the subcostal plane (a horizontal plane that passes through the inferior-most margin of the ribs).

Epigastric Pain Causes

The epigastric region contains organs and anatomical structures such as the pancreas, pyloric end of the stomach, aorta, and a part of the liver and the duodenum. Thus, pain in this region could occur if any of these organs are affected by trauma or a disease. Though the pain is usually localized to the upper abdominal region below the ribs, it could even radiate to the surrounding regions of the abdomen. Pain in this region could be indicative of the following medical conditions:

Peptic Ulcer Disease

Peptic ulcer disease is characterized by the formation of ulcers/sores in the mucosa or the lining of the esophagus, stomach, or the duodenum (the first section of the small intestine). Ulcers that form in the esophagus, stomach, and the duodenum are medically referred to as esophageal, gastric, and duodenal ulcers respectively. The major causes of this condition include corrosive action of the hydrochloric acid (digestive juice secreted by the cells in the inner lining of the stomach), infection caused by Helicobacter pylori bacterium, and the prolonged use of non-steroidal anti-inflammatory drugs (NSAIDs). Heavy smokers are at an increased risk of developing ulcers and the complications associated with ulcers.

Symptoms

Epigastric pain is often experienced by individuals affected by this condition. Usually, the pain is localized to this region. Other symptoms that might accompany pain in this region include:

Discomfort and tenderness in the epigastric region
Burning or gnawing pain, which is often misinterpreted as heartburn, indigestion, or hunger
Abdominal pain that is felt during meals in case of people affected by a gastric ulcer
Pain that is felt 2-3 hours after the meal in case of people affected by a duodenal ulcer
Nausea
Vomiting
Bloating
Loss of appetite
Vomiting of blood

The major complications of this condition include gastrointestinal bleeding, perforation of the mucosa, and gastric obstruction. It must be noted that this condition could sometimes be asymptomatic. Though the mortality rate of this disease is quite low, it can cause extreme discomfort.

Diagnosis and Treatment

This condition can be diagnosed with the help of esophagogastroduodenoscopy (EGD), which involves the insertion of a thin, flexible, lighted tube through the mouth and pharynx into the esophagus. The image of the esophagus, stomach, and duodenum is transmitted to a monitor, which helps the physician identify the location and size of the ulcer. Air may be introduced into the stomach, so as to get a better view of the stomach. Certain tests might be conducted, if the underlying cause of peptic ulcers seems to be an H. pylori infection. These tests include:

Urea breath test
Rapid urease test
Stool antigen test
Culture from the EGD biopsy sample
Examination and staining of an EGD biopsy

The treatment options for this condition include drug therapy that involves the use of drugs such as:

Antacids
H2 antagonists such as ranitidine and famotidine
Carafate, which binds to the ulcer site and coats it
Prostaglandin analog drugs to reduce the side effects of NSAIDs
Antibiotic therapy for ulcers caused by H. pylori

Gastritis

Gastritis refers to the inflammation of the lining of the stomach. Acute gastritis usually occurs due to an infection caused by Helicobacter pylori. The prolonged use of NSAIDS can also erode the lining of the stomach. Other risk factors for this condition include irritation of the stomach lining due to alcohol abuse, smoking, chronic bile reflux, autoimmune response, traumatic injury/burns, trauma during a surgery, surgery involving the reconstruction of the GI tract for weight loss, etc.

Symptoms

The characteristic symptom of this condition is pain in the epigastric region. The other symptoms include:

Nausea
Vomiting
Discomfort in the abdominal region
Heartburn
Indigestion
Loss of appetite
Belching
Tarry stools

Diagnosis and Treatment

This condition can be diagnosed with the help of the tests given below:

Gastroscopy
H. pylori test
Complete blood count
Urinalysis
Stool test
Liver, kidney, gallbladder, or pancreas function test
Stomach biopsy
ECG
X-ray examination

The treatment mainly involves drug therapy. The drugs that are usually prescribed include:

Antacids (magnesium trisilicate, aluminum hydroxide, hydrotalcite, Asilone, Gaviscon, Peptac, Gastrocote, Topal, and Tums)
H2-receptor antagonists (cimetidine, ranitidine, famotidine, and nizatidine)
Proton-pump inhibitors (omeprazole, lansoprazole, esomeprazole, pantoprazole, and rabeprazole)
Other drugs such as sucralfate, tripotassium dicitratobismuthate, and misoprostol

Gastroesophageal Acid Reflux Disease (GERD)

GERD is characterized by serious and chronic form of gastroesophageal acid reflux, which is characterized by the backflow of the gastric juices or contents of the stomach towards the esophagus. This regurgitation of gastric contents can irritate the esophagus, thereby causing discomfort. Under normal circumstances, a bundle of muscle fibers located at the bottom of the esophagus called lower esophageal sphincter (LES) prevents the backflow of stomach contents and acid into the esophagus. If LES doesn't close completely, the stomach contents could move towards the esophagus. This can even cause damage to the esophagus. Smoking, obesity, hiatal hernia (a condition wherein the upper part of the stomach protrudes towards the chest through an opening or weak spot in the diaphragm), scleroderma (an autoimmune disease affecting the blood vessels and connective tissue), and pregnancy are believed to be the risk factors for GERD.

Symptoms

The symptoms of this condition include:

Sensation of food being stuck behind the breastbone
Burning sensation in the chest (heartburn)
Nausea after meals
Pain in the chest or epigastric region of the abdomen
Difficulty while swallowing
Chronic sore throat or voice changes

Diagnosis and Treatment

There is no single test that can diagnose GERD accurately. The following tests can help detect changes in the shape of esophagus and extent of damage:

Upper GI series
Upper endoscopy
Esophageal pH
Esophageal manometry

As far as the treatment is concerned, drug therapy coupled with lifestyle modification can prove beneficial. The affected individual must avoid food items that trigger acid reflux. In severe cases, fundoplication (anti-reflux surgery) might be recommended. The drugs that might be prescribed include:

Antacids
H2 blockers (cimetidine, famotidine, and ranitidine) to decrease the amount of acid released in the stomach
Proton-pump inhibitors (omeprazole, lansoprazole, pantoprazole, and esomeprazole) to decrease acid production in the stomach

Pancreatitis

The term 'pancreatitis' refers to the inflammation of the pancreas, which is a glandular organ located behind the stomach. The pancreas stretches across the back of the abdomen. Pancreatitis could be acute (sudden onset of severe symptoms that last for a short duration) or chronic (long-lasting symptoms that develop over time). Infections, high levels of triglycerides in the blood, trauma, gallstones, alcohol abuse, and prolonged use of certain drugs are the common contributing factors for the inflammation of this organ. Abdominal pain in the center of the abdomen is the characteristic symptom of pancreatitis. Pain could also radiate to the epigastric region of the abdomen.

Symptoms

The symptoms of this condition include:

Abdominal pain that may radiate to the back
Swollen and tender abdomen
Vomiting
Nausea
Bloating
Fever

In case of chronic pancreatitis, the affected individual might experience weight loss, back pain, and malabsorption.

Diagnosis and Treatment

The physician might order certain diagnostic tests, if he/she suspects that the patient might be affected by pancreatitis. These include:

Blood tests to check serum amylase, lipase, and trypsinogen levels
Complete blood count with differential
Metabolic panel (blood urea nitrogen, creatinine, glucose, and calcium)
C-reactive protein
Triglyceride levels
Urinalysis
Arterial blood gases

Imaging tests that might be conducted include:

Abdominal ultrasound
CT scans
Endoscopic retrograde cholangiopancreatography (ERCP)
Endoscopic ultrasonography
Magnetic resonance cholangiopancreatography (MRCP)

The treatment is aimed at reducing the inflammation to provide relief from pain. In case of acute pancreatitis, hospitalization might be required. During the hospital stay, antibiotics, fluids, and anti-inflammatory drugs might be administered intravenously. The patient is not allowed to eat or drink, so as to allow the pancreas to rest. Therapeutic endoscopic retrograde cholangiopancreatography might be conducted to view the pancreas and surrounding organs, and perform the following procedures, if needed:

Removal of gallstones
Treating blockage of the pancreatic duct or bile ducts
Drainage of a pancreatic pseudocyst
Stent placement or balloon dilatation to keep a bile or pancreatic duct open

Besides the aforementioned conditions, pain in this part of the abdomen could also be caused due to hepatobiliary disorder, which is characterized by the formation of gallstones (stone-like deposits that develop due to the crystallization of cholesterol or bile). In some cases, pain might occur due to the formation or inflammation of diverticula (abnormal sac-like structures that form when the waste in the large intestine puts pressure on the weak spots present in the walls of the large intestine). Pain in the epigastric region could sometimes be experienced by women affected by pre-eclampsia (a condition characterized by hypertension, fluid retention, and albuminuria during the course of pregnancy).

On a concluding note, the possible causes of epigastric pain might range from less serious stomach-related conditions, such as indigestion, to life-threatening conditions such as myocardial infarction/heart attack, aortic aneurysm, or gastric cancer. Therefore, medical assistance must be immediately sought by anyone who has been experiencing a persistent pain in this region so that the underlying cause can be diagnosed and treated.

Disclaimer: The information provided in this article is solely for educating the reader. It is not intended to be a substitute for the advice of a medical expert.
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Published: May 5, 2014
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