Chapter 13 Epigastric Pain in a 47-Year-Old Male (Case 3)
Editor’s Note: Given the overlap of Cases 2 and 3 (Chapters 12 and 13), we suggest reading them as a single unit.
| Peptic ulcer disease (PUD)/gastritis | Esophageal reflux/esophagitis | Biliary colic/cholecystitis |
| Hepatitis | Pancreatitis | Pneumonitis |
| Myocardial ischemia |
PATIENT CARE
History
• Peptic ulcer disease/gastritis: typically persistent pain. Eating causes exacerbation of pain in gastric ulcers, but tends to alleviate pain in duodenal ulcers. Response to prior acid suppression is important as well as findings on prior endoscopy, if done. Consider symptoms of ulcer complications including melena, hematemesis, and early satiety. Weight loss and family hx of gastric cancer may suggest a malignant gastric ulcer. PUD risk factors include aspirin, NSAIDs, and ETOH.
• GERD/esophagitis: Important considerations include burning pain with radiation up the chest, response to antacids and acid suppression, exacerbation when supine, prior symptoms, and acid regurgitation. Consider complications of disease, including dysphagia to solids or liquids, bleeding, and weight loss.
• Biliary tract symptoms: Elicit any prior similar symptoms or food intolerance, even if previously mild. Radiation to back, right side, and referred pain to the shoulder. Pain is constant typically for hours, and is not fleeting. It is usually postprandial, but delayed (awakened from sleep), and not during a meal. Often associated with nausea and vomiting. Symptoms of disease complications include jaundice and fever. Risk factors included family hx, obesity, and irritable bowel disease (IBD).
• Hepatitis: Typically has constant pain; may radiate to back, RUQ, or shoulder. Prior episodes of pain or jaundice. The onset of pain is not usually abrupt. Disease complications may include jaundice. Risk factors to elicit include IV drug use, blood transfusion, travel hx, sexual exposure, medications, and ETOH use.
• Pancreatitis: Pain is constant and can bore through to the back. Often associated nausea/vomiting. Prior symptoms of biliary colic may suggest biliary pancreatitis. Prior hx of pancreatitis important. Family hx of pancreatitis should be sought. Risk factors include ETOH use, medications, and major trauma.
• Pneumonitis: Prodrome symptoms of the common cold may be present. Rigors tend to be more frequent, fever present at the onset, and vomiting less common in pulmonary disease compared to abdominal pathology. The pain often has a thoracic component as well as abdominal. Risk factors include exposure to pneumonia contacts and underlying pulmonary disease.
• Myocardial ischemia: Epigastric pain as a manifestation of acute cardiac ischemia is not uncommon, and therefore must be considered seriously in addition to abdominal causes such as cholecystitis which can mimic each other. Review carefully prior symptoms, including initiating factors, such as exertion. The pain can radiate to the neck and left arm. Elicit important risk factors, including family hx, diabetes, hypertension, hypercholesterolemia, and known cardiac disease. Also consider other cardiac conditions such as acute cardiac failure with passive hepatic congestion, pericarditis, and endocarditis.
Physical Examination
• Peptic ulcer disease/gastritis: Melena or occult positive stool on rectal examination. Tenderness may be present in epigastrium. Supraclavicular adenopathy with malignant gastric ulcer.
• GERD/esophagitis: Erythema may be present in the hypopharynx. Typically mild to absent abdominal tenderness.
• Hepatitis: Examine for hepatomegaly; often there is diffuse tenderness, including the lateral aspect, elicited by pressure on the lower intercostal spaces. Jaundice, including scleral icterus.
• Pancreatitis: Epigastric tenderness and fullness. Ecchymosis in the back (Grey Turner’s sign) or at umbilicus (Cullen’s sign) may occur several days after symptom onset.
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