The epigastrium is the area of central abdomen lying just below the sternum and above the umbilicus.

Aetiology

• Irritable bowel syndrome - by definition this has been present for at least 3-6 months and is either relieved by defaecation, or associated with altered stool frequency or consistency. Examination is usually normal or there may be mild tenderness/distension.
• Peptic ulcer - acute or chronic gnawing or burning pain. May be improved by food if duodenal ulcer, and worsened if gastric ulcer. Typically the pain is worse at night.
• Pancreatitis - acute pain which radiates to the back. Usually accompanied by vomiting. The pain may be relieved by sitting forward. Signs vary, but include jaundice, tachycardia, abdominal rigidity, tenderness, discolouration around umbilicus or flanks.
• Peritonitis - acute pain with signs of shock and tenderness (possibly rebound). May be exacerbated by coughing. Abdomen may feel 'rigid'.
• Pre-eclampsia - epigastric pain is very significant, especially if severe or associated with vomiting.
• Gastrointestinal obstruction - acute colicky pain. Vomiting brings relief. Accompanied by distension and 'tinkling bowel sounds'.
• Gall bladder disease - acute constant pain with vomiting, fever, local tenderness and rigidity. It may be possible to palpate a gall bladder mass.
• Ruptured aortic aneurysm - acute pain which radiates to the back or groin. The patient may be in cardiovascular collapse. A mass is felt swelling and contracting with the pulse.
• Gastric carcinoma - be suspicious in patients with gastric ulcers. Advanced cases may also have weight loss, vomiting, palpable mass/nodes, hepatomegaly, vomiting and dysphagia.
• Referred pain - this may be from the heart in myocardial infarction. Also from pleural disease or spinal nerves.