Epigastric burning and pain are one of the common complaints in general practice and usually they are related to acid peptic disorders.
There are four common presentations:
1. Peptic ulcer
Burning or sharp pain in the epigastric region, more to the right side. This pain is always related to meals in duodenal ulcers, it is relieved by food only to reappear after 2-3 hours and in gastric ulcer and gastritis it increases immediately after food. Early morning pain at 3:00 a.m. or 5:00 a.m. in the morning is typical of duodenal ulcer.
2. Reflux esophagitis
Regurgitation of sour fluid in the throat and retrosternal burning pain. Most of the patients of hyperacidity and ulcer have sour regurgitation after meal and when reflux esophagitis develops, it is associated with retrosternal burning pain which is more after meals, if this symptom is very severe then hiatus hernia should be suspected.
3. Gallstones or Pyloric Obstruction
Many patients complain of epigastric fullness and bloating sensation after meals & though there are other causes for this symptom, more commonly it is a manifestation of very mild peptic pain, but if it is not relieved by antacids and enzymes then gallstones and pyloric obstruction should be ruled out by ultrasonography and gastroscopy.
4. Chronic Pancreatitis
The epigastric pain may sometimes radiate to the back, if it is radiating to the back asking details whether the pain is related to the meals. If it is related to the meals usually relieved by meals, then it is more likely to be due to duodenal ulcer, when the ulcer is on the posterior wall of the duodenum. But if the pain is continuous not related to food, one must think of chronic pancreatitis which will be diagnosed by ultrasonography or CT scan.
When the symptoms are of very short duration, general practitioner will give medical treatment and observe.
- The symptomatic treatment will comprise of one acid inhibiting drug like:
- Omeprazole 20 milligrams o.d. or
- Ranitidine 150 milligrams b.d. or
- Rabeprazole 20 milligrams o.d. or
- Famotidine 40 milligrams o.d.
- Secondly, one antacid like Gelusil MPS (aluminum hydroxide-magnesium hydroxide-simethicone) or Digene (Aluminium Hydroxide, Magnesium Hydroxide, Magnesium Aluminium Silicate Hydrate and Simethicone ) is a must, as it gives instant soothing effect on the mucosa and immediate pain relief.
- Very important part of the treatment is to remove the factor that is causing hyperacidity. Whenever a patient tells about hyperacidity symptoms or pain, always reflexly and unmistakably, always ask whether he is taking any medications ??? Has he taken any anti inflammatory drugs or steroids for joint pain or severe backache or asthma ??? Is it drug induced gastritis ??? If yes, the most important thing would be to stop the irritant drug immediately.
- Also ask the patient not to eat chillies and sour foods till the pain subsides
- Ask him not to smoke or not to take alcohol if he has been taking it.
- If the patient is anxious, give tablet of alprazolam.
So look for a irritation factor for the hyper acidity and remove it. If the symptoms do not subside within a few days of treatment or if they keep recurring after stopping the treatment or if there very severe regurgitation and vomiting, then the patient needs to be investigated by asking for a gastroscopy and ultrasonography.
- If gastritis or duodenitis or gastric or duodenal ulcer detected, test for H. pylori must be done at the same time.
Treatment of the various common disorders:
1. Chronic duodenal ulcer
- For chronic duodenal ulcer, first give a complete 7 day course of h pylori eradication Combi pack. It contains three drugs:
- Omeprazole or Lansoprazole
- Clarithromycin or Amoxicillin and
- Tinidazole or Ornidazole
- After 7 day course, continue Omeprazole or Lansoprazole for at least three months.
- Give one antacid TDS till complete symptomatic relief is obtained, that is for at least 10 to 15 days.
- In the acute phase, give a tranquilizer like alprazolam 0.25 milligram hs, not for sleep but for removing anxiety, an important hidden factor for the occurrence of the ulcer.
- Lastly give a high dose of B complex also.
- Apart from the drug treatment advise bland diet, no chillies, no sour foods, more of cold milk, no smoking, no alcohol, no starvation, no late Nights, regular meals and regular sleep and most important no gastric irritation drugs like aspirins, NSAIDS or steroids.
2. Gastric ulcer or Gastritis
The treatment for gastric ulcer and gastritis is also basically the same but in a gastric ulcer it is very important to repeat gastroscopy after 8 weeks to confirm whether the ulcer is healed or not, because there are significant chances of a gastric ulcer being malignant.
3. Gastroesophageal reflux disease
Gastroesophageal Reflux disease which includes Reflux esophagitis and hiatus hernia. The aim of treatment in this disorders is to suppress acid secretion and prevent regurgitation. So prescribe,
- Proton pump inhibitor like Omeprazole 20 milligram theory and an antacid.
- If retrosternal burning is severe, give an antacid with anesthetic, like Mucaine gel or Solacid O which numbs the mucosa and gives better symptomatic relief.
- To regularise the esophageal mobility give itopride.
- Homely Advice: Lastly, to prevent regurgitation, instruct the patient to sit upright not to lie down for at least half an hour after meals and head of the cot should be raised by 6 inches so that you sleep in slide head high position. If this is not possible, take pillows under the shoulders and head to get a head high position.
Epigastric pain is not always due to hyperacidity and ulcer. Few other conditions should also be kept in mind when the symptoms are different or when the response to antacid treatment is not satisfactory.
4. Amoebic Colitis
If the pain is colicky and if epigastrium is tender, think of amoebic colitis.Ask about history of mucus and blood in the stool, increased frequency of motions and whether there is urgency of motions after food. Get the stools checked.
- Treat with tab tinidazole 500 milligrams BD for 5 days.
5. Chronic cholecystitis
If the pain is more in right hypochondrium, if there is fullness of upper abdomen after meals and if there is tenderness under the right costal margin then chronic cholecystitis should be considered. Ask for ultrasonography and the diagnosis will be clear. If the pain radiates to the back, again chronic pancreatitis should be ruled out by ultrasonography or CT scan.
6. CCF or Hepatitis
Sometimes, tender left lobe of liver in congestive cardiac failure or in hepatitis may also give epigastric pain but careful and gentle palpation in the epigastrium will always detect the liver and its soft lower edge.
Lastly, one must also be aware that cardiac pain due to Angina or Myocardial Infarction sometimes radiate to the epigastric region. If the pain appears on exertion Angina must be suspected irrespective of its location. ECG should be taken and if there is associated sweating or low BP then cardiac pain due to myocardial infarction must be thought of .