Upper Abdominal Pain

Causes of Acute Upper Abdominal Pain

Right Upper Quadrant (RUQ)   Hepatitis (Acute) Gallbladder Disease Pneumonia Stomach Ulcer [?] Muscle Strain Herpes Zoster (Shingles) [?] = sometimes in this area (but usually another)

xxxxxxxEpigastric Stomach Diseases: • Ulcer / Gastritis / Dyspepsia xxxEsophageal Reflux (GERD) • Gastric Cancer Pancreatitis Heart Attack Hepatitis [?] Gallbladder Disease [?] Muscle Strain Early Appendicitis NOT “Gastroenteritis” [?] = sometimes in this area (but usually another)

Left Upper Quadrant (LUQ)   Pancreatitis 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):

• “Heavy” 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

IF NOT…

1b.  Decide if patient’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-Bismol®)

IF NOT…

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
• NEED BLOOD TESTS THAT SAME DAY

**  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:

• Order a test for H. pylori bacteria   →  Treat if positive.
• If no H. pylori   →  Treat with a Proton Pump Inhibitor (PPI) for 2 months
• If age >45-50 yrs-old, give PPI for 3 weeks.  If gets better, change to another antacid medicine
• If pain recurs, send to Gastroenterologist for endoscopy (to rule out Stomach Cancer)

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 — Full Text for more in-depth explanations and discussions.