Syndrome of the Epigastrium

Syndrome of epigastrium

1.	Acute appendicitis


 * Begins as visceral epigastric pain in the middle (pain increases when pressing on the right lower abdomen – Rovsing’s sign), muscle guarding, rebound and percussion tenderness. Anorexia is an important feature and vomiting is rarely prominent.

2.	Acute cholecystitis


 * Pain below the right costal arch radiating below the right scapula ( boas’s sign).


 * Usually begins as colic, the transition in the inflammation affects pain lasting more than 6 hours and change it character to constant pain, elevated temperature, peritonitism and subicterus.


 * Most often in middle-aged women and obese.


 * Murphy’s sign – deep breath taken by the patient elicits acute pain when the examiner presses downwards into the right upper quadrant.


 * Diagnostic – abdominal US, increase CRP and leucocyte

3.	Perforation of gastroduodenal ulcer


 * Perforation of ulcer appears as a sudden very strong pain in the upper abdomen leading to acute peritonitis.


 * 80% with history of peptic ulcer.


 * Diagnostic – AXR with pneumoperitonium in 70 % of cases or CT if AXR in negative.


 * Imaging can be perfomed with contrast (leaking of contrast is expected)

4.	Acute pancreatitis


 * Appears as shock-like state with strong epigastric pain, radiating to the back, and accompanied by paralytic ileus.


 * Vomiting is prominent and sitting forward may relieve the pain.


 * Grey Turner’s and Cullen’s sign – bruising and discoloration can be seen around umbilicus (Cullen’s) and left flank (Gray Turner)


 * Diagnostic – raised serum amylase, CT, MRI

5.	Ruptured or dissecting abdominal aortic aneurysm


 * Hypotension and abdominal pain, tenderness and rigidity.


 * Expansile pulsatile mass and bruit over mass


 * Diagnostic – abdominal US / CT

6.	Gastritis


 * Epigastric pain, dull or burning discomfort, nocturnal pH


 * Diagnostic – oesophagogastroscopy, barium meal and pH study

7.	Duodenal ulcer


 * Epigastric pain, dull or burning discomfort, typically relieved by food, nocturnal pain


 * Diagnostic - oesophagogastroscopy, barium meal and pH study, H. pylori present in mucosa or serology

8.	Gastric ulcer


 * Epigastric pain, dull or burning discomfort, typically exacerbated by food


 * Diagnostic – oesophagogastroscopy, barium meal and pH study