Red flag symptoms
- Abdominal mass
- Central pulsatile mass with radiating pain
- Rebound tenderness with rigid abdomen
- Absent bowel sounds
- Acute pain and vomiting
- Ecchymosis of flanks or abdomen
Pain in the epigastrium is common and causes range from the benign, such as indigestion, to life-threatening conditions including MI. Eliciting the pain history is key in the assessment of these patients. Other factors that should be taken in to consideration include:
- alcohol intake
General initial examination should begin with assessing whether the patient is acutely unwell or in obvious severe pain. Ensure the patient is haemodynamically stable by checking temperature, pulse and blood pressure.
Look for signs of liver disease (jaundice, ascites, spider naevi). Systemic signs, such as jaundice, may be present in pancreatitis or gall bladder disease.
Abdominal examination can give very obvious clues. Abdominal inspection may show abdominal distension. A central pulsatile mass may be present with abdominal aortic aneurysm (AAA). Discolouration (ecchymosis) in the flanks (Gray-Turner’s sign) or periumbilical region (Cullen’s sign) may show pancreatitis. Right upper quadrant pain may indicate the possibility of biliary calculi.
On palpation, there may be guarding in the epigastric region. Check for masses: epigastric hernias can strangulate and present as an acute abdomen. Rebound tenderness and a rigid abdomen may indicate peritonitis.
Auscultation may reveal tinkling bowel sounds in partial obstruction, and absent bowel sounds may suggest complete bowel obstruction. Rectal examination may show fresh blood or malaena.
There are many causes of epigastric pain, with gastric acid being responsible for much of it.
A burning or gnawing pain, which may be worse at night, is suggestive of gastritis or peptic ulcer disease. Chronic presentation may suggest lactose intolerance, IBS or GORD.
Life-threatening causes include:
- Peritonitis – acute pain with signs of shock, rebound tenderness and a rigid abdomen.
- Ruptured AAA – pain radiating to the back or groin, patient may be in shock, pulsatile mass present.
- Pre-eclampsia – epigastric pain is significant and may be associated with vomiting.
Other causes that may require surgery include:
- Acute pancreatitis - pain radiating to the back, relieved on sitting forward, accompanied by vomiting.
- Acute colicky pain, relieved by vomiting, could point to GI obstruction.
- Acute cholecystitis may present with acute constant pain, vomiting, fever, and a positive Murphy’s sign. It may be possible to palpate the gallbladder.
Pancreatic carcinoma should be considered in anyone with unexplained gastric pain, weight loss or new onset diabetes.
Suspect gastric carcinoma especially in smoking males over 55 years of age. Other suggestive symptoms include weight loss, vomiting, palpable mass/lymph nodes, hepatomegaly and dysphagia.
Referred causes, such as pleural disease, angina and MI, should not be missed.
- Irritable bowel syndrome
- Peptic ulcer
- Bowel obstruction
- Gall bladder disease
- Ruptured aortic aneurysm
- Referred pain - MI, pleurisy
- Gastric carcinoma
Gastric ulcers are three times as likely in males than females, with the incidence increasing with age.
The use of NSAIDs raises the risk of a gastric ulcer three to four-fold.
H. pylori eradication helps healing of a gastric ulcer, and there is evidence of a causal association with gastric cancer.
Investigations and referral
In primary care, investigations include:
- H pylori testing
- Urine dipstick
- Blood tests including FBC, U&Es, ESR/CRP, LFTs, amylase and clotting.
In the presence of red flags, urgent referral to secondary care is advisable.
If the patient cannot tolerate oral fluids or has comorbidities, there should be a low threshold for admission to secondary care.
Imaging may include abdominal X-ray, abdominal ultrasound, erect chest X-ray, CT abdomen and chest and endoscopy or oesophago-gastroduodenoscopy (OGD).
If the patient is to be managed in the community, adequate safety-netting and appropriate follow-up should be arranged.
- Dr Jaiswal is a GP in London
This article, originally by Dr Mehul Mathukia and published in August 2010, was reviewed and updated by Dr Roopa Jaiswal in May 2018.