By mental dissection of the epigastrium layer by layer from the skin

to the thoracolumbar spine, one encounters all the important organs

that are the sites of origin of epigastric   pain (Table 11). Anatomy,

therefore, is the basic science used to develop this

differential   diagnosis .

ABDOMINAL PAIN, EPIGASTRIC

TABLE 11. EPIGASTRIC PAIN

 V I N D I

 Vascular

Inflammator

yNeoplasm

Degenerati

ve and

Deficiency

Intoxicatio

n

Idiopathic

Skin 

Herpes

zoster      

   Cellulitis

     

Muscle

and

Fascia 

Diaphragma

tic abscess      

   Trichinosis

     

Stomac

h

  Gastritis Carcinoma Atrophic Gastritis

gastritis

   Ulcer Sarcoma

 Ulcer

   Syphilis

     

Duoden

um  Ulcer

   Ulcer

Intestine

s

Mesenteri

c

thrombosi

s

Appendicitis Polyp 

Dumping

syndrome

   Ileitis Carcinoma

   

   Colitis Sarcoma

   

   Parasites

     

Pancrea

s  Pancreatitis

Pancreatic

carcinoma  

Pancreatit

is

           

Lymph

Nodes  

Mesenteric

adenitis

Hodgkin

disease    

     

Lymphosarco

ma    

Blood

Vessels

Aortic

aneurysm        

 

Abdominal

angina        

Nerves 

Herpes

zoster    Lead colic

           

         

Arachnidis

m

Thoracic

Spine  

Tuberculosi

s

Primary tumor

or metastasis

Osteoporo

sis  

   

Osteomyeliti

s  Arthritis

 

Local

Referred

Coronary

insufficien

cy

HepatitisHepatic

carcinoma    

 

Myocardia

l infarction

Cholecystiti

s      

 

Congestiv

e heart

failure

Pyelonephri

tis      

Systemi

c

Referred

Pulmonary

embolismPneumonia Endometriosis Epilepsy

 

   Epididymitis

Peritoneal

carcinomatosi

s

Migraine 

       

Electrolyte

imbalance  

The skin may be the site of the pain in herpes zoster, as it is in other

types of pain, although it is less likely to be midline. Cellulitis and other

lesions of the skin will be readily apparent. However, muscle and

fascial conditions may be missed if one does not specifically think of

this layer. Thus, epigastric hernia, hiatal hernia, or contusion of the

muscle will be missed, as will diaphragmatic abscesses and

trichinosis of the diaphragm.

The stomach and duodenum are the next organs encountered; both

are prominent causes of epigastric pain. Ulcers, especially perforated

ulcers, cause severe pain. Gastritis (syphilitic, toxic, or atrophic)

causes a milder form of pain. Pyloric stenosis (from whatever cause),

cascade stomach, diverticula, and carcinoma or sarcoma round out

the differential diagnosis here. Good collateral circulation makes

vascular occlusion a less likely cause.

The colon and small intestines lie just below the stomach, so one

must not forget ileitis, colitis (ulcerative or granulomatous),

appendicitis, diverticulitis, Meckel diverticulum, and transverse colon

carcinoma that ulcerates through the wall. Intestinal parasites and

mesenteric thrombosis are additional causes that originate here. The

various forms of intestinal obstruction are more important than

parasites and mesenteric thrombosis.

The pancreas sits at the next layer, and acute pancreatitis is a

particularly severe form of epigastric pain. Chronic pancreatitis,

carcinoma, cysts of the pancreas, and mucoviscidosis cause less

severe forms of epigastric pain. The lymph nodes may be involved

by Hodgkin disease and lymphosarcoma, leading to intestinal

obstruction, but mesenteric adenitis is a much more likely cause.

When the retroperitoneal nodes are involved by neoplasms (e.g.,

sarcoma), the pain is usually referred to the back.

The blood vessels are contained in the next layer, and one is

reminded of aortic aneurysm, abdominal angina, periarteritis nodosa,

and other forms of vasculitis. The sympathetic and parasympathetic

nerves are involved by lead colic, porphyria, and black widow spider

venom. Conditions of the thoracic spine are present in the final layer.

Cord tumor, tuberculosis, herniated disc, osteoarthritis, and

rheumatoid spondylitis can all lead to midepigastric pain.

Omission of the systemic diseases and diseases of other abdominal

organs that sometimes cause epigastric pain is inexcusable.

Pneumonia, myocardial infarction (inferior wall, particularly), rheumatic

fever, epilepsy, and migraine are just a few systemic conditions that

are associated with epigastric or generalized abdominal pain.

Cholecystitis, hepatitis, and pyelonephritis are some local diseases that also produce midepigastric or generalized abdominal pain, which is why the target system has a useful application here. The center circle of the target is the stomach, the pancreas, and other organs in Table 11. The next circle covers the liver, kidney, gallbladder, heart, and ovaries. A further circle covers the brain and the testicles.