Red flag symptoms - Epigastric pain

It is vital to ensure the patient is haemodynamically stable, says Dr Mehul Mathukia.

CT scan showing pancreatitis (Photograph: SPL)
CT scan showing pancreatitis (Photograph: SPL)

Pain in the epigastrium is common and causes range from the benign, such as indigestion, to life-threatening conditions including MI.

It is important to determine the aetiology of the pain. A burning or gnawing pain may be suggestive of gastritis or peptic ulcer disease. Colicky pain could point to GI obstruction.

Radiation to the back may suggest a diagnosis of acute pancreatitis or ruptured aortic aneurysm. Relieving factors, such as defecation, may point to irritable bowel syndrome (IBS). Relief on sitting forward may suggest pancreatitis, and relief with eating may suggest a duodenal ulcer.

An acute presentation may suggest diagnoses of pancreatitis, cholecystitis, peritonitis and a ruptured aortic aneurysm.

Chronic presentation may suggest IBS or GORD. Referred causes, such as angina and MI, should not be missed.

Vital signs
On examination, it is imperative to assess the vital signs of the patient and ensure the patient is haemodynamically stable (check for tachycardia and hypotension).

General examination can give very obvious clues. Is the patient lying still or writhing around in distress? Systemic signs, such as jaundice, may be present in pancreatitis or gall bladder disease. Pyrexia may also present in gall bladder disease.

Abdomen inspection may show abdominal distension. A central pulsatile mass may be present with abdominal aneurysm and discolouration in the flanks may show pancreatitis. On palpation, there may be tenderness and guarding in the epigastric region. A rigid abdomen may suggest peritonitis but may also be present in pancreatitis, for example.

Auscultation may reveal bowel sounds in obstruction, and absent bowel sounds may suggest an acute abdomen.

Rectal examination may show bleeding or malaena.

  • Dr Mathukia is a GP principal in Ilford, Essex
Possible causes
  • Irritable bowel syndrome
  • Peptic ulcer
  • Pancreatitis
  • Peritonitis
  • Bowel obstruction
  • Gall bladder disease
  • Ruptured aortic aneurysm
  • Referred pain - MI, pleurisy
  • Gastric carcinoma

Investigations
In primary care, investigations are limited to urine dipstick. Blood tests including FBC, U&Es, ESR, amylase and clotting, should be arranged in primary care. In the presence of red flags, urgent referral to secondary care is advisable. Imaging may include abdominal X-ray, erect chest X-ray and CT abdomen and chest.

If the patient cannot tolerate oral fluids or has comorbidities, there should be a low threshold for admission to secondary care.

If the patient is to be managed in the community, adequate safety-netting and appropriate follow-up should be arranged.

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