Epigastralgia

Specialty: Gastrointestinal.

• Epigastric pain
• pain in the pit of the stomach
• gastroduodenal pain

Why it occurs

• Peptic ulcer (gastric or duodenal) associated with Helicobacter pylori infection or chronic consumption of NSAIDs
• Functional dyspepsia (epigastric pain syndrome under the Rome IV criteria)
• Acute or chronic pancreatitis with pain radiating from the belt to the back
• Acute erosive gastritis of infectious, ischemic or toxic etiology
• Acute cholecystitis or choledocholithiasis with atypical presentation in the epigastrium
• Inferior myocardial ischemia (angina pectoris or acute myocardial infarction that simulates upper digestive pathology).

Initial workup

12-lead electrocardiogram and immediate ultrasensitive troponins to rule out cardiac origin | Upper digestive endoscopy (EDA) with taking biopsies for histology and urease (H. pylori) test | Ultrasound of the upper abdomen to evaluate the gallbladder and bile ducts | General analysis: amylase, lipase, transaminases, total and fractionated bilirubin, alkaline phosphatase, blood count and C-reactive protein | Abdominal CT with intravenous contrast if pancreatitis or perforation is suspected.

Standard management

• Proton pump inhibitors — omeprazole 20-40 mg daily, pantoprazole 40 mg or esomeprazole 40 mg orally or intravenously, indicated to suppress the secretion of hydrochloric acid and promote mucosal healing
• Local antacids — aluminum magnesium hydroxide, 10-20 ml administered 1 hour after meals for rapid, temporary symptomatic relief
• Gastric mucosa protectors — sucralfate 1 g administered 1 hour before meals and at bedtime to form a protective barrier over the ulcer
• Quadruple eradication therapy for H. pylori if positive (PPI every 12 hours + bismuth subcitrate 120 mg every 6 hours + metronidazole 500 mg every 8 hours + tetracycline 500 mg every 6 hours for 14 days).