A patient with epigastric pain
If a patient presents with epigastric pain, one should consider a lot of differential diagnoses considering site such as
- Peptic ulcer disease
- Gastritis
- GERD
- Esophagitis
- Pancreatitis
- Myocardial infarction
- Pericarditis
- Ruptured aortic aneurysm
But chronological events and other features of pain narrow down the differential diagnoses.
- a. A patient presenting with epigastric pain and vomiting.
A 30 years gentle man presents with epigastric pain and vomiting for 2 days after taking some drugs for traumatic pain.
What are the diagnoses striking in your mind?
- Gastritis (NSAID induced)
- Peptic ulcer disease
- Acute pancreatitis
What key questions would you ask?
Pain-epigastric discomfort or burning or gnawing pain with anorexia and vomiting, no radiation- gastritis or peptic ulcer.
High epigastric constant pain with radiation to back, relieved by sitting up or stooping forward- Acute pancreatitis.
Vomiting- content of vomitus
vomiting of blood- gastritis or peptic ulcer
History of NSAIDS- gastritis or gastric ulcer
History of alcohol- acute pancreatitis
What will you examine?
General examination- may be anaemic
Abdominal examination- diffuse mild discomfort/tenderness in epigastrium on palpation-gastritis or peptic ulcer
Inappropriate tenderness (e.g. severe tenderness with little guarding and rigidity)- acute pancreatitis.
Clinical diagnosis– History of NSAIDS intake, epigastric pain and diffuse epigastric tenderness clinch the diagnosis of NSAID induced gastritis.
Investigation-
CBC –Hb may be low.
Urinary amylase and USG of pancreas to exclude acute pancreatitis
Other essential investigations- Endoscopy of upper GI tract-usually not available at primary and secondary level.
Treatment-
Discontinuation of the NSAID, reduction to the lowest effective dose, or administration with meals.
An empiric 2–4 week trial of an oral proton pump inhibitor (omeprazole, rabeprazole, or esomeprazole 20–40 mg/d; lansoprazole, 30 mg/d; pantoprazole, 40 mg/d) is recommended for patients with NSAID-related gastritis.
If symptoms do not improve, diagnostic upper GI endoscopy should be conducted.