Epigastric pain or discomfort is one of the commonest presentations of abdominal pain in primary care. Although no specific diagnosis is made in a large number of patients, the following pathology should be considered:
- Duodenal ulcer
- Gastric ulcer or gastritis
- Gastric cancer
- Hiatus hernia, esophagitis and gastro-esophageal reflux
- Gallbladder disease
- Irritable bowel syndrome (colicky pain, abdominal bloating and alternating bowel habit).
The majority of patients with dyspepsia will recover spontaneously or with a prescription of antacids or acid suppression. A number of red flag signs and symptoms suggest the need for further investigation:
- Documented weight loss
- Loss of appetite
- Early satiety
- Pallor or bleeding (blood positive on stool test, black tarry stool or blood with vomitus)
- Enlarged supraclavicular lymph node (Virchow’s sign)
- Age > 55 years when cancer becomes more likely
- Persistent vomiting - may indicated gastric-duodenal junction whether duodenal ulcer or gastric cancer
- Yellowish discolouration of skin
- Abdominal swelling or mass
- Poor response or recurrence after a course of empirical treatment.
In cases with dyspepsia, it is important to ask about medication and lifestyle circumstances that may be initiating or contributing:
- Non-steroidal anti-inflammatory drugs and corticosteroids
- Cigarette smoking
- Excessive alcohol intake
- Psychosocial stress
- Spicy, hot or acidic foods, or carbonated drinks
The work-up of choice is endoscopy to exclude peptic ulcer disease, cancer, esophagitis and hiatus hernia. Gallbladder disease will require liver function test and ultrasound. Reflux may require nanometry and pH testing to confirm. If gastric ulceration is a possibility, work-up for Helicobacter pylori should be considered. The work-up include histological examination, urease testing of biopsies at endoscopy, antibodies in the blood and breath tests.