Understanding Epigastric ‘stomach’ pain

The most common cause of epigastric pain is indigestion. Indigestion often occurs with over-eating, combining alcohol with food or eating rich, spicy or greasy foods. Bloating and nausea may also be associated.

Indigestion is a clinical diagnosis and is usually managed with antacids. Indigestion may also occur if one is lactose intolerant. A trial of eliminating certain foods that contain lactose may aid in managing the pain. Diet and lifestyle changes may also assist in reducing pain^2,3,4,5.

Acid reflux occurs when stomach contents tend to push back up the oesophagus and cause burning sensations in the epigastrium and chest. This may lead to a burning sensation in the chest, bitter taste in your mouth, indigestion, throat pain or hoarseness and chronic coughing. The pain may be worsened by eating or when lying down. The pain is usually responsive to antacids^2,3,4,5.

Ongoing or persisting acid reflux may lead to gastro-oesophageal reflux disease, which requires more monitoring and treatment^2,3,4,5.

GORD can be evaluated using specialized x-ray screening techniques such as a Barium swallow, where once swallowing the Barium fluid, the direction the Barium moves can be monitored on the x-ray screen.

Epigastric pain may occur when your gallbladder is inflamed, a condition known as cholecystitis. Cholecystitis usually occurs in association with gallstones in the gallbladder. The pain may be associated with decreased appetite, nausea and vomiting, worsening pain with eating, bitter taste in the mouth, right shoulder and/or back pain, fever, jaundice and clay coloured stools. Gallstones with cholecystitis may result in the gallbladder needing to be removed^2,3,4,5. 

Ultrasound is the imaging modality or test of choice to evaluate for gallstones or cholecystitis and is the quickest and cheapest test to rule out the difference between organ causes or gastrointestinal causes.

Gallstones are seen on ultrasound as bright white structures/balls with strong black shadowing behind them. They are usually mobile in the gallbladder. Cholecystitis can be seen on ultrasound as thickening of the gallbladder wall after a fasting period^2,[i].

Other gallbladder diseases that may be associated with epigastric pain include gallbladder cancer, gallbladder polyps, or gallbladder disease from other obstructive causes².

Pancreatitis is inflammation of the pancreas which may be acute (sudden onset) or chronic (continuous inflammation for a period of time). It is often associated with sudden pain in the back and vomiting. 

Pancreatic cancer should be considered if the pain is associated with sudden weight loss, new onset of diabetes or unexplained epigastric pain^2,3,4[i],[ii].

Ultrasound is usually the first imaging modality to visualize the pancreas, as it is useful when screening for growths such as cancer or visualizing pancreatitis.

Ultrasound does, however, have its limitations with visualizing the pancreas due to stomach and bowel gas shadowing and other technical factors. In these instances, computed tomography also known as a CT scan is the modality of choice to visualize and diagnose pancreas diseases. Magnetic resonance imaging or MRI is also a specific imaging technique for accurate diagnosis and evaluation. CT scans and MRI’s are especially useful to determine the extent and spread in the case of cancer^2,8.

A hiatus hernia occurs when the top part of the stomach pushes into the chest through the hole in the diaphragm where the oesophagus passes through, which is known as the hiatus. A hiatus hernia does not always cause pain but may be associated with indigestion, burning chest, throat pain and hoarseness and loud burping^3,4,5,6,[i].

A hiatus hernia may be detected on a plain chest x-ray, however other specialized imaging modalities such as Barium swallow screening or a CT scan may be needed to evaluate the extent of the disease⁹.

Heart attack symptoms other than that of epigastric pain may include shortness of breath, pain and tightness of the chest, nausea, indigestion and heartburn, dizziness and pain in the left or right arm. This is a medical emergency and needs quick diagnosis and monitoring[i].

A heart attack may be diagnosed during an electrocardiogram. Doctors will need to assess what caused the attack and may order additional tests such as a heart ultrasound, CT scan or MIBI Scan.

Is a condition more commonly found in children and is caused by swelling of lymph nodes in the mesenteric lining of the stomach usually due to bacterial or viral infections⁵.

The swollen lymph nodes can easily be detected using high-frequency ultrasound techniques.

This diagnosis should be considered especially in men over 55 years of age and smokers. Some of the distinguishing factors include sudden weight loss, vomiting, palpated masses and other associated symptoms depending on the stage of cancer.

Other conditions that may also occur with epigastric pain include peptic ulcers, Barret’s disease, esophagitis or gastritis^3,4,5,6,7.