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Epigastric Pain
Epigastric pain is a common presenting symptom in clinical practice, affecting up to 25% of the population and accounting for 5-10% of primary care visits. The approach to epigastric pain is age-dependent, with functional causes predominating in patients <50 years and organic diseases becoming more common after age 60.
The differential diagnosis includes gastrointestinal causes (functional dyspepsia, peptic ulcer disease, GERD), pancreaticobiliary conditions (acute pancreatitis – high-yield for boards), and extra-abdominal causes (myocardial infarction). Pain-food relationships are crucial for differentiating ulcer types: gastric ulcers worsen with food, while duodenal ulcers improve with food.
Last updated: July 20, 2025
- Epigastric pain is discomfort or pain localized to the upper central abdomen (epigastrium), defined as the region below the xiphoid process and above the umbilicus.
- Prevalence: Affects up to 25% of the population at some point in their lives
- Healthcare utilization: Accounts for 5-10% of primary care visits
- Gender: Functional dyspepsia more common in women (2:1 ratio)
- Age distribution: Functional causes predominate in younger patients; organic causes increase with age >50 years
Most Common Causes by Age Group
| Age Group | Most Common Cause | Frequency | Key Features |
|---|---|---|---|
| <50 years | Functional dyspepsia | 50–90% | Normal endoscopy, chronic symptoms |
| 40–60 years | Peptic ulcer disease | 15–25% | H. pylori, NSAID use |
| >60 years | Organic disease | >50% | Requires endoscopic evaluation |
Gastrointestinal Causes
- Functional dyspepsia (most common overall)
- Peptic ulcer disease (gastric vs. duodenal)
- Gastroesophageal reflux disease (GERD)
- Gastroparesis
- Gastric cancer (especially >50 years)
Pancreaticobiliary Causes
- Acute pancreatitis (high-yield for boards)
- Acute cholecystitis
- Choledocholithiasis
- Chronic pancreatitis
Extra-abdominal Causes
- Myocardial infarction (especially inferior wall MI)
- Pneumonia (lower lobe)
- Diabetic ketoacidosis
Pain Characteristics by Diagnosis
| Abdominal Pain Patterns – Condition-Based Comparison | ||||
| Condition | Pain Pattern | Food Relationship | Radiation | Board Buzzword |
| Gastric ulcer | Gnawing, burning | Worsens with food | Epigastrium to back | "Food-fear" |
| Duodenal ulcer | Gnawing, burning | Improves with food | Epigastrium | "Food-relief" |
| Acute pancreatitis | Severe, constant | No relationship | To back | - |
| GERD | Burning | Worse lying down | To chest/throat | Heartburn |
| Gastroparesis | Early satiety | Postprandial fullness | None | Diabetic history |
Red Flag Features
⚠️ Immediate evaluation required:
- Age ≥60 years with new-onset dyspepsia
- Unintentional weight loss (>10% body weight)
- Dysphagia or odynophagia
- Signs of GI bleeding (melena, hematemesis)
- Iron deficiency anemia
- Family history of gastric cancer
- Persistent vomiting