Upper Abdominal Pain

Causes of Acute Upper Abdominal Pain

Right Upper Quadrant (RUQ)
Hepatitis (Acute)
Gallbladder Disease
Stomach Ulcer [?]
Muscle Strain
Herpes Zoster (Shingles)

[?] = sometimes in this area (but usually another)

Stomach Diseases:
โ€ข Ulcer / Gastritis / Dyspepsia
xxxEsophageal Reflux (GERD)
โ€ข Gastric Cancer
Heart Attack
Gallbladder Disease [?]
Muscle Strain
Early Appendicitis
NOT โ€œGastroenteritisโ€

[?] = sometimes in this area (but usually another)
Left Upper Quadrant (LUQ)
Stomach Ulcer / Gastritis [?]
Dyspepsia [?]
Heart Attack [?]
Muscle Strain
Herpes Zoster (Shingles)

[?] = sometimes in this area (but usually another)

How Clinicians Approach Upper Abdominal Pain

1a.  Decide if the patient may be having a Heart Attack (if so, call 911):

  • โ€œHeavyโ€ pain or pressure (Epigastric or LUQ) with short of breath, nausea, cold sweats on forehead, lightheaded.  Worse with exertion.
  • Risk Factors: Male >35 or female after menopause; smoker; high blood pressure; diabetes; high cholesterol; family history of parent or sibling with heart attack (at around same age); cocaine or amphetamine in past 1-2 days
  • See also Diagnosing Coronary Artery Disease


1b.  Decide if patientโ€™s symptoms are bad enough to maybe need surgery, hospitalization, or same-day tests (if so, may send to E.R.):

  • Doubled-over, clutching belly
  • Very tender & board-like abdomen during exam
  • Abdominal pain + Fever
  • Patient who is immunocompromised
  • Vomiting enough to become dehydrated
  • Vomiting blood (at least a handful, not just specks), or vomiting coffee-ground material (could be blood)
  • Stools look pitch-black [= clotted blood] (not just “dark”) (stools also turn black from iron pills, or medications like Pepto-Bismolยฎ)


2.  Consider Non-Stomach Diseases (we order tests / diagnose if disease likely):

**  Hepatitis (Acute)  — 

  • Loss of appetite, nausea.  Pain isn’t severe
  • Jaundice (eyes / skin turn yellow)
  • Right lower ribs tender when gently punched
  • Diagnosis: blood test for Liver function Tests (ALT & AST)
  • If positive, need additional tests to determine type of hepatitis and severity
  • IF LIKELY, we order same-day tests, but don’t send to ER.

**  Gallbladder Disease  —  Gallstones, etc.

  • Abrupt onset pain, may radiate to right shoulder or right back
  • Nausea, usually vomiting
  • Tender to palpation under Right rib cage while breathing in
  • History of prior episodes lasting up to 6 hrs. is convincing
  • Diagnose by Ultrasound
  • We SEND TO ER if fever, jaundice (yellow eyes), or pain lasting >6 hrs.

**  Pneumonia (right lung)  —

  • Maybe just sudden, severe pain in the RUQ area, hurts worse with breathing
  • Cough & fever eventually occur soon (usually the same day)
  • Diagnose by chest x-ray, NEEDS IT SAME DAY

**  Pancreatitis  —

  • Moderate-to-severe pain in the Epigastric or LUQ areas, tender to palpation
  • Nausea / Vomiting very common
  • Suspect in alcoholics, & patients with very high blood triglycerides (>500-1,000)
  • Diagnose by high Lipase in blood; CT Scan to confirm diagnosis & rule-out complications

**  Muscle Strain —  Very common cause of abdominal pain

  • Pain increased with motions of torso
  • Most tenderness to palpation occurs while patient flexes abs (like doing a partial sit-up); less or no tenderness while lies relaxed
  • No nausea / vomiting / fever
  • No suggestion of anything more serious

**  Herpes Zoster (Shingles)  —

  • Red splotchy rash, usually with same blisters, in a stripe-like area from spine to mid abdomen, on one side
  • Impossible to diagnose before the rash appears

3.  IF NONE OF THE ABOVE diseases seems likely, diagnose a condition of the STOMACH

Try to distinguish between Ulcer or Gastritis on the one hand, versus Dyspepsia or Gastro-Esophageal Reflux Disease (GERD) on the other:

  • Ulcer & Gastritis occur daily, last the better part of the day, are more bothersome
  • Dyspepsia often doesn’t occur daily, comes & goes, lasts less time each day
  • GERD provokes burning or discomfort going up into the chest, is otherwise similar to Dyspepsia

a)  If suspect Ulcer or Gastritis:

b)  If suspect Dyspepsia / GERD

  • Treat with a Proton Pump Inhibitor (PPI) for a few wks.  If gets better, change to another antacid medicine
  • If age >45-50 yrs-old and pain recurs, send to Gastroenterologist for endoscopy (to rule out Stomach Cancer)
  • If age <45, test for H. pylori (treat if positive) before sending to Gastroenterologist.

4.  Don’t forget Early Appendicitis during the first 1-2 days of upper abdominal pain.

  • If patient not very ill, we instruct that if pain gets worse, moves to the Right Lower Quadrant, and nausea starts, GO TO E.R.

See Upper Abdominal Pain โ€” Full Text for more in-depth explanations and discussions.

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