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