Pain originating or radiating to epigastric region
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Here is a comprehensive overview of pain originating in or radiating to the epigastric region.
Anatomical Basis
The epigastric region lies between the subcostal and intertubercular planes, flanked by the right and left hypochondrium. Visceral pain from foregut structures (lower esophagus, stomach, duodenum, pancreas, liver, gallbladder) is referred to the epigastric region.
Causes of Epigastric Pain
Gastrointestinal / Hepatopancreatic
| Condition | Key Features |
|---|---|
| Peptic ulcer disease (PUD) | Epigastric burning pain; relief with food/antacids/milk; classic "gnawing" quality |
| Gastritis | Often due to NSAIDs or H. pylori; burning or aching epigastric discomfort |
| Gastroesophageal reflux disease (GERD) | Burning pain, worsened by lying down, relieved by antacids |
| Functional dyspepsia | Bothersome epigastric pain or burning ≥1 day/week without structural cause (Rome IV criteria); subtypes: Epigastric Pain Syndrome & Postprandial Distress Syndrome |
| Acute pancreatitis | Severe, constant epigastric pain radiating to the back; nausea/vomiting; worsened by eating |
| Chronic pancreatitis | Recurrent epigastric pain, steatorrhea, weight loss |
| Esophageal cancer | Progressive dysphagia + epigastric/retrosternal pain |
| Gastric cancer | Persistent epigastric pain ± alarm features (weight loss, dysphagia, bleeding) |
| Pancreatic cancer | Dull, constant epigastric/back pain; painless jaundice in head-of-pancreas tumors |
Biliary
| Condition | Key Features |
|---|---|
| Biliary colic | Acute severe epigastric / RUQ pain after fatty meal; crampy, lasts 30 min–6 hrs |
| Acute cholecystitis | RUQ pain radiating to epigastric region ± Murphy's sign, fever |
Cardiovascular (Referred)
| Condition | Key Features |
|---|---|
| Myocardial infarction / ischemia | Inferior MI (RCA territory) can present as epigastric pain ± nausea/vomiting — a critical diagnosis not to miss |
| Cardiopulmonary disease | May mimic GI epigastric pain |
Obstetric / Gynaecologic
| Condition | Key Features |
|---|---|
| Pre-eclampsia / HELLP syndrome | Severe epigastric or RUQ pain, raised transaminases, hypertension, thrombocytopenia |
Functional Dyspepsia — Rome IV Subtypes
Epigastric Pain Syndrome (EPS):
- Bothersome epigastric pain or burning, severe enough to impact usual activities
- Occurring on ≥1 day per week
- No structural disease on endoscopy
Risk factors: female sex, smoking, NSAIDs, acute gastroenteritis, anxiety, H. pylori infection.
H. pylori eradication has a statistically significant but modest benefit; if symptoms resolve post-eradication, the diagnosis is reclassified as H. pylori gastritis.
Acute Epigastric Pain — A Quick Differential at a Glance
| Cause | Radiation | Associated Symptoms |
|---|---|---|
| Peptic ulcer | None / to back | Relieved by food/antacids |
| Acute pancreatitis | To the back ("belt-like") | Nausea, vomiting, elevated lipase |
| Biliary colic | To right shoulder/scapula | Post-fatty meal, colicky |
| GERD | Retrosternal | Heartburn, worse supine |
| MI (inferior) | To jaw, left arm | Diaphoresis, ECG changes |
| HELLP/Pre-eclampsia | RUQ | Hypertension, proteinuria |
| Gastric/Pancreatic cancer | To back | Alarm features, weight loss |
Sources:
- Yamada's Textbook of Gastroenterology, 7th ed. — Table of epigastric pain causes
- Goldman-Cecil Medicine — Functional Dyspepsia / Epigastric Pain Syndrome (Rome IV)
- Gray's Anatomy for Students — Referred pain and the nine abdominal regions
- Rosen's Emergency Medicine — Pancreatitis: epigastric pain radiating to back
- Tintinalli's Emergency Medicine — PUD classic history
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