DD is a 57 year old business executive. He experienced burning pains in his abdomen, below the ribs, over a period of three years. He had used many medications and herbs with no satisfactory relief. An unexpected weight loss of about 7kg got him scared. He had gastroscopy done following evaluation by his personal physician. Cancerous growth was found in his stomach. Surgical removal of the tumor and chemotherapy (cancer medications) helped him to recover fully.
Pain in the upper abdomen or dyspepsia has been interpreted by many persons to mean indigestion, constipation, heartburn, reflux, regurgitation, nausea, anorexia, internal heat, etc. It can lead to poor quality of life, multiple hospital visits and absence from work. Most clinicians define dyspepsia as the presence of upper abdominal pain or discomfort with or without belching, flatulence, nausea, heartburn, etc.
Causes: Some persons have the wrong impression that upper abdominal pain is as a result of “ulcer” only. The pain is a manifestation of problems in one or more structures located in the upper abdomen or lower chest.
Abdominal structures that can cause upper abdominal pain include:
- Stomach, duodenum (first part of the small intestine), liver, gall bladder, pancreas, spleen, the aorta, transverse colon and other parts of the colon.
In the lower chest, structures that can cause upper abdominal pain include:
- Esophagus, lungs, ribs, heart, overlying skin and muscle.
Therefore, any disease affecting one or more of the above structures may manifest as upper abdominal pain. For a focused discussion in this article, upper abdominal pain (dyspepsia) will be limited to pain arising from the esophagus, stomach, and duodenum.
Approach to an individual with upper abdominal pain: The following are important questions, among others; an individual with upper abdominal pain needs to answer.
- Has the individual taken medications/drugs such as steroids and/or pain relievers (such as ibuprofen, piroxicam, and diclofenac)?
- Does the individual use medications (such as warfarin, or heparin) to prevent the blood from clotting in some individuals who are at risk of it? These medications, if unchecked, may trigger bleeding in the stomach or intestine. This may cause pain.
- Has the individual ingested toxic agents which could have caused erosion in the esophagus, stomach, or duodenum? This raises an alarm of possible suicidal attempt.
- Does the individual vomit blood, passes dark and tarry stool, or frank blood in stool? This is also indicative of bleeding in the stomach or intestine.
- Does the individual smoke or drink alcohol in excess? These can cause damage to the lining of the stomach or duodenum which gives the individual pain.
- Does the individual have any of these conditions- diabetes mellitus, liver disease and kidney disease? These diseases may cause upper abdominal pain in some cases.
Answers from the above questions are noted along with findings during examination of the individual. Investigations are ordered to confirm the source of the pain and other possible complications. The blood is assessed for blood loss, infection, liver and kidney functions. Stool sample is taken to assess for presence of blood from gastrointestinal bleeding. Abdominal ultrasound or CT scan may be necessary to further identify the specific organ causing the pain.
- Upper abdominal pain may result from a heart condition (especially cardiac arrest). If this is suspected, other appropriate investigations become necessary.
Among adults 40 years old and above, upper abdominal pain with any of these symptoms (weight loss, yellowness of the eyes or jaundice, abdominal swelling, and passage of blood in stool) raises an alarm of possibility of cancer as the cause of the pain. The cancer is assessed by gastroscopy (a visual inspection of the esophagus, stomach, and duodenum using a tubular camera device). During the gastroscopy, tissue samples may be taken from the gastrointestinal lining to confirm presence of cancer or Helicobacter pylori (H. pylori) bacterium. H. pylori bacterium is a confirmed cause of peptic ulcer disease.
For sake of clarification of terms, in peptic ulcer disease, the individual has upper abdominal pain resulting from a patchy loss of the lining (‘ulcer’) in the stomach and/or duodenum. The ulcer is seen during gastroscopy. In functional dyspepsia, there is upper abdominal pain without an ‘ulcer’ seen during gastroscopy.
Treatment: This depends on the cause(s). Options include
– Anti-ulcer medications.
– Antibiotics, where there’s evidence of an infection.
– Surgery for cancers.
– Chemotherapy and/or radiotherapy may be used in addition to surgery. They are also alternative treatments if the patient is unable to tolerate surgery.
– Counseling: In functional dyspepsia, lifestyle and feeding modifications help the individual to cope with the pain. If these fail, one may resort to medications which are used to relieve symptoms of anxiety and depression. These medications help to reduce the intensity of pain.
Opeyemi O. Owoseni is a Gastroenterologist and Hepatologist. She is a Fellow of the Medical College of Physicians, Nigeria. She is a member of the Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) and that of the American Society for Gastrointestinal Endoscopy (ASGE). She currently consults for several hospitals and performs liver biopsies, fibroscans, diagnostic and therapeutic endoscopies. She can be reached on firstname.lastname@example.org