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

Vascular

Inflammator y

Degenerati Neoplasm ve and Deficiency

Intoxicatio n Idiopathic

Skin

Herpes zoster

Cellulitis

Muscle and Fascia

Diaphragma tic abscess

Trichinosis

Gastritis Stomac

Carcinoma Atrophic

Gastritis

gastritis

Ulcer

Sarcoma

Ulcer

Syphilis

Duoden um

Ulcer

Ulcer

Mesenteri Intestine s c thrombosi s Appendicitis Polyp Dumping syndrome

Ileitis

Carcinoma

Colitis

Sarcoma

Parasites

Pancrea s

Pancreatitis

Pancreatic carcinoma

Pancreatit is

Lymph

Mesenteric

Hodgkin

Nodes

adenitis

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 Hepatitis

Hepatic carcinoma

Myocardia

Cholecystiti

l infarction

Congestiv e heart failure

Pyelonephri tis

Systemi c Referred

Pulmonary embolism

Pneumonia

Endometriosis

Epilepsy

Peritoneal Epididymitis 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.