Epigastric Distress
Epigastric Distress: Excerpt from The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
Cindy Barter
Epigastric distress is a very common presenting complaint in both the emergency room setting and the outpatient setting. Of the multitude of diseases or diagnoses that can present with epigastric distress, gastroesophageal reflux disease (GERD) is commonly encountered; it affects approximately 25% to 35% of Americans during their lifetime (1).
Approach
The complaint of epigastric distress creates a very long differential diagnosis that involves many organ systems. A careful, thorough history will narrow, if not define, the diagnosis in most cases. It is important to differentiate between urgent and nonurgent causes of epigastric distress. Immediate evaluation is indicated when patients present with acute onset of pain. Possible diagnoses in such cases include, but are not limited to, the following: appendicitis, cardiac disease (acute myocardial infarction), cholecystitis, gastrointestinal (GI) bleed, ischemic bowel, pancreatitis, small bowel obstruction, and ruptured abdominal aortic aneurysm. Diagnoses made more often in patients who present with chronic epigastric distress and who can be evaluated and monitored over longer period of time include, but are not limited to, the following: GERD, nonulcer dyspepsia, peptic ulcer disease (PUD), gastritis, cholecystitis or cholelithiasis, hepatitis, gastroenteritis, constipation, pneumonia, pyelonephritis, neoplasms, inflammatory bowel disease, and irritable bowel syndrome (2).
History
A. Pain is the usual presentation of epigastric distress. First priority is to ask questions about the onset, intensity, frequency, pattern, and location of the pain. Onset: When did the pain start? Is there any prior history of similar pain?
B. Intensity and quality. Can you describe the pain? (sharp, dull, burning, radiating, pressure). Burning pain is often used to describe GERD. Pressure sensation “like an elephant sitting on me” suggests cardiac ischemia (Chapter 7.1).
C. Frequency and pattern. Does the pain occur at any particular time of day? Is there anything that makes the pain better or worse? Pain that is worse at night when lying down suggests GERD. Pain that occurs after a high fat meal increases the likelihood of gallbladder disease (Chapter 9.1).
D. Location. Where is the pain? Does the pain radiate anywhere? Radiation to the back suggests pancreatitis. Pain radiating to the scapula can indicate gallbladder disease.
E. Associated symptoms. Has there been any nausea, vomiting, or hematemesis? The previous symptoms can indicate a Mallory-Weiss tear or PUD. If diarrhea is present, is there bright red blood or melena in the stool? The presence of blood or melena in the stool requires further workup for GI bleed.
F. Past medical history. Has the patient had any prior GI problems? Obtain a drug history, including the use of aspirin, nonsteroidal antiinflammatory drugs, alendronate sodium (Fosamax), steroids, antibiotics. Is there a history of tobacco or alcohol use? Both tobacco and alcohol use are associated with an increased incidence of GERD and PUD. Multiparity and obesity increase the risk of gallbladder disease. Are there risk factors for sexually transmitted diseases? Hepatitis B and human immunodeficiency virus can be transmitted sexually and can be causative factors in epigastric distress.
Physical examination
A. General assessment. Obtain vital signs. Is the patient febrile—indicating an infectious cause? Tachycardia and hypotension can indicate dehydration or GI bleed. Is the patient in acute distress? Jaundiced?
B. Cardiopulmonary assessment. Evaluate the heart and lungs to rule out any cardiac or pulmonic process that could present with epigastric distress. Is there evidence of an arrhythmia, myocardial infarction, or congestive heart failure? Are there crackles or rales suggesting a pneumonia?
C. Abdominal examination. Are bowel sounds present? Decreased or absent bowel sounds can indicate a small bowel obstruction, acute surgical abdomen (appendicitis, perforated ulcer), or pancreatitis. Rebound tenderness should prompt consideration of an acute surgical abdomen. The right upper quadrant (RUQ) should be palpated. A palpable liver warrants evaluation for other signs of liver disease—jaundice, ascites, skin changes. Murphy’s sign—sudden cessation of the patient’s inspiratory effort during deep palpation of the RUQ—is suggestive of acute cholecystitis (3). Tenderness to palpation of the left upper quadrant can indicate splenic infarct such as seen with sickle cell disease. Tenderness of the midepigastric area can represent peptic ulcer disease, dyspepsia, “nonclassical” presentation of acute appendicitis, or any other of the above-mentioned conditions. A rectal examination with testing for occult blood should be a part of the examination, particularly with any concern about GI bleeding (Chapter 9.7).
Testing
A. Clinical laboratory tests. Laboratory tests should be directed by the history and physical examination. A complete blood count is indicated if signs are seen of infection or bleeding. An elevated white blood cell count is consistent with appendicitis or pneumonia. A decreased hemoglobin or hematocrit warrants further evaluation for GI bleed. Other laboratory tests that might be indicated by the history and physical examination include liver function tests (hepatitis, gallbladder disease), amylase and lipase (pancreatitis—although no single laboratory test is diagnostic for pancreatitis), creatine kinase-MB (CK-MB), and/or troponin (cardiac pathology). Laboratory testing for Helicobacter pylori is controversial except for those with documented PUD. Keep in mind that of patients who have PUD, 90% are infected with H. pylori and only 10% to 20% of patients infected with H. pylori develop PUD (4).
B. Diagnostic imaging. Plain film x-ray studies are helpful only if bowel obstruction or perforation is suspected. RUQ ultrasound is warranted if gallbladder disease or pancreatitis is suspected. Computed tomography scan of the abdomen could be considered in cases of difficulty in differentiating acute abdominal pain or when needed to evaluate for possible complications. Barium studies are not indicated in the acute setting, but can be helpful in the diagnostic workup for gastric ulcer, GERD, and esophagitis.
C. Endoscopy. Esophagogastrodoudenoscopy in the setting of an upper GI bleed may help to identify the source of the bleeding, assuming the patient is sufficiently stable to tolerate the procedure (Chapter 9.7). The diagnoses of PUD, gastritis, and esophagitis are best made using endoscopy, which also allows evaluation for the presence of H. pylori (5).
D. Other tests. Other tests useful in the evaluation of epigastric distress include an electrocardiogram to assess for possible cardiac disease and chest radiographs and a pulmonary function test to evaluate for possible pulmonary disease.
Diagnostic assessment
The key to the successful approach to a patient presenting with epigastric distress begins with a careful history. If the distress is of acute onset, a more urgent and directed evaluation is needed. Vital signs and physical examination should be directed to evaluate for fever (infection), hypotension (GI bleed), and non-GI causes (MI, ruptured aneurysm). Epigastric distress of a chronic nature can be evaluated using history, directed laboratory testing, and diagnostic imaging.
References
1. Scott M, Gelhot AR. Gastroesophageal reflux disease: diagnosis and management. Am Fam Physician 1999;59(5):1161–1169.
2. Isselbacher KJ, Podolsky DK. Approach to the patient with gastrointestinal disease. In: Fauci AS, ed. Harrison’s principles of internal medicine. New York: McGraw-Hill, 1998:1579–1583.
3. Swartz MH. Textbook of physical diagnosis, history and examination. Philadelphia: WB Saunders, 1994:324.
4. NIH Consensus Conference. Helicobacter pylori in peptic ulcer disease. JAMA 1994;
272(1):65–69.
5. Rank JM, Vennes JA. Gastrointestinal endoscopy. In: Bennet JC, Plum F, eds. Cecil textbook of medicine. Philadelphia: WB Saunders, 1996:636–642.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
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