Acute pain in the upper abdomen

Trying to localise pain in the upper abdomen to the right, left or middle may be difficult for the patient.

Some differential diagnoses and typical outline evidence

Oesophagitis	Suggested by: retrosternal pain, heartburn.
	Confirmed by: oesophagogastroscopy.
	Management: OHCM p216.
Acute coronary syndrome (unstable angina or infarction)	Suggested by: chest tightness or pain on exertion.
	Confirmed by: exercise ECG ± coronary angiography if troponin normal, or later if troponin ↑.
	Management: OHCM pp120–4, 782.
Hiatus hernia	Suggested by: heartburn, worsens with stooping or lying, relieved by antacids.
	Confirmed by: oesophagogastroscopy, barium meal.
	Management: OHCM p532.
Gastritis	Suggested by: epigastric pain, dull or burning discomfort, nocturnal pain
	Confirmed by: oesophagogastroscopy, barium meal and pH study.
	Management: OHCM p214.
Gallstone colic (with no acute inflammation or infection)	Suggested by: jaundice, biliary colic, pain in epigastrium or RUQ radiating to right lower scapula. No fever or ↑WBC.
	Confirmed by: ultrasound of gallbladder and biliary ducts.
	Management: OHCM pp484, 485.
Acute cholecystitis	Suggested by: fever, guarding and positive Murphy's sign (abrupt stopping of inspiration when the palpating hand meets the inflamed gall bladder descending with the liver from behind the sub-costal margin on the right side—but not on the left side). ↑WBC.
	Confirmed by: ultrasound gallbladder and biliary ducts.
	Management: OHCM p484.
Duodenal ulcer	Suggested by: epigastric pain, dull or burning discomfort, typically relieved by food, nocturnal pain.
	Confirmed by: oesophagogastroscopy, barium meal and pH study: (Helicobacter pylori often present in mucosa or serology).
	Management: OHCM p214.
Gastric ulcer	Suggested by: epigastric pain, dull or burning discomfort, typically exacerbated by food, nocturnal pain.
	Confirmed by: oesophagogastroscopy, barium meal and pH study.
	Management: OHCM p214.
Gastric carcinoma	Suggested by: marked anorexia, fullness, pain, Troisier's sign (a ‘Virchow's’ node i.e. large lymph node in the left supraclavicular fossa).
	Confirmed by: upper GI endoscopy with biopsy.
	Management: OHCM p508.
Pancreatitis	Suggested by: pain radiating straight through to the back, better on sitting up or leaning forward.
	Confirmed by: ↑serum amylase, CT pancreas.
	Management: OHCD p478.