Family medicine
Epigastric Pain
Epigastric pain is discomfort localized to the upper central abdomen, commonly associated with gastritis, peptic ulcer disease, pancreatitis, or gastroesophageal reflux.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Peptic Ulcer Disease (GU/DU) [1] | Burning/gnawing epigastric pain; meal-related; Hx NSAIDs / H. pylori | 「食完嘢之後個痛好啲定差啲？有冇食止痛藥？」 |
| Functional Dyspepsia [8] | Young, chronic, no alarm features, normal OGD | 「你幾大？呢個情況持續咗幾耐？」(Age < 40, no red flags) | |
| GERD | Burning retrosternal/epigastric, worse lying flat, heartburn | 「有冇胃酸湧上嚟嘅感覺？瞓低有冇差啲？」 | |
| Serious Not To Miss | Gastric carcinoma [7] | Age > 45 + alarm features (weight loss, dysphagia, anaemia, FHx) | 「有冇瘦咗？食嘢吞唔吞到？」 |
| Acute pancreatitis [2][3] | Severe pain radiating to back, relieved leaning forward, Hx alcohol/gallstones | 「痛去唔去背脊？向前傾有冇好啲？飲唔飲酒？」 | |
| Acute coronary syndrome / MI [9] | Epigastric pain + sweating, SOB, risk factors (DM, HTN, smoking) | 「有冇標冷汗？有冇氣促？」 | |
| Perforated PUD | Sudden severe pain → rigid abdomen, board-like guarding | PE: 板狀腹 (board-like rigidity), rebound tenderness | |
| Pancreatic carcinoma [10] | Painless jaundice, weight loss, new-onset DM, gnawing back pain | 「有冇眼黃？大便有冇變淺色？」 | |
| Pitfalls | Biliary colic / cholecystitis [5] | Intense constant RUQ/epigastric pain after fatty meal; not true colic | 「食完肥膩嘢有冇右邊肋骨下面痛？」Murphy's sign |
| Mesenteric ischaemia [2] | Pain out of proportion to signs, Hx AF/vascular disease | 「有冇心律不齊？」Check for AF | |
| Masquerades | Drug-induced dyspepsia | NSAIDs, aspirin, steroids, iron, bisphosphonates [8] | 「有冇食以下嘅藥？」(List drugs) |
| DKA [2] | Known DM + abdominal pain, polyuria, polydipsia, Kussmaul breathing | 「你有冇糖尿病？」Check Hstix | |
| Depression | Chronic dyspepsia with somatisation | 「心情點？瞓得好唔好？」 | |
| Trying to Tell Me Something? | Work stress / fear of cancer / family issues | Patient worried about cancer after relative's diagnosis; stress-related FD | 「你最擔心係咩？」「屋企或者工作有冇特別壓力？」 |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, set agenda | 「你好，我係今日嘅醫生，請問點稱呼你？」「今日想了解下你嘅情況，我會問你幾個問題，之後睇下可以點樣幫到你，好唔好？」 | Friendly opening + signposting = interpersonal marks |
| 0:30–2:30 | HPI – SOCRATES + associated Sx | 「可唔可以話俾我聽，你邊度唔舒服？」「呢個痛幾時開始？」「個痛係咩感覺？好似火燒定係脹痛？」「有冇去到其他地方，例如背脊？」「食完嘢之後好啲定差啲？」「有冇嘔、作嘔、嘔血、痾黑色屎？」「有冇食少咗嘢或者瘦咗？」 | Covers chief complaint, red flags, and discriminators for PUD vs biliary vs pancreatitis vs malignancy [1][2] |
| 2:30–3:30 | Red flags + systems review | 「有冇覺得吞嘢困難？」「有冇皮膚或者眼白變黃？」「大便習慣有冇改變？」「有冇心口痛或者氣促？」 | Screens for GI malignancy, cardiac cause, cholangitis |
| 3:30–4:30 | PMH, Drug, Family, Social Hx | 「以前有冇乜嘢病？有冇食止痛藥例如布洛芬？」「有冇飲酒、食煙？飲幾多？」「屋企人有冇胃癌或者胃病？」「做咩工作㗎？」 | NSAIDs, aspirin, H. pylori and alcohol are top risk factors per GC slides [1][2]. Occupation/stress → biopsychosocial |
| 4:30–5:15 | ICE – uncover hidden agenda | 「你自己覺得呢個痛可能係咩原因？」(Ideas) 「你最擔心啲乜嘢？」(Concerns) 「你今日嚟想我點樣幫到你？」(Expectations) 「點解揀今日嚟睇醫生呢？」(Hidden agenda – RFC) | ICE = direct Case Report Form marks. "Why today?" often reveals the real RFC (e.g. worried about cancer, pain affecting work) |
| 5:15–5:45 | Summarise back to patient | 「等我重複一次你講嘅嘢，睇下有冇遺漏：你話上腹痛咗XX日，食完嘢會…，你擔心…，啱唔啱？」 | Checking understanding = high interpersonal mark |
| 5:45–6:00 | Close + safety net | 「我會安排幫你做檢查，如果痛得好厲害、嘔血或者痾黑色屎，要即刻去急症室，好嗎？」 | Safe closure; safety-net statement essential |
Hidden agenda tip: If the patient is middle-aged with new-onset epigastric pain, the hidden concern is often fear of stomach cancer, especially if a relative had it. Always ask 「你有冇擔心係唔好嘅嘢？」
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Point with one finger | 「可唔可以用手指指下邊度痛？」 | Localises to epigastrium vs RUQ vs diffuse [2] | Epigastric → PUD, pancreatitis; RUQ → biliary |
| Onset/Duration | When did it start? Sudden or gradual? | 「幾時開始痛？突然定係慢慢嚟？」 | Sudden severe → perforation, pancreatitis, ACS [1] | Acute pancreatitis, perforated PUD |
| Character | What does the pain feel like – burning, cramping, tearing? | 「個痛係咩感覺？好似火燒、實實哋、定係痙攣咁？」 | Burning/gnawing = PUD; intense dull constant = biliary; severe radiating to back = pancreatitis [1][2] | See discriminators |
| Radiation | Does the pain go to your back? | 「有冇痛去背脊？」 | Radiation to back → pancreatitis, posteriorly penetrating PUD, dissecting aneurysm [2][3] | Pancreatitis, AAA |
| Meal relationship | Does eating make it better or worse? | 「食完嘢之後好啲定差啲？」 | GU pain ↑ with food; DU pain ↓ with food (relieved by eating/antacid) [1][4] | GU vs DU |
| Aggravating | Worse lying flat? Leaning forward? Fatty food? | 「瞓低有冇差啲？向前傾有冇好啲？食肥膩嘢有冇差啲？」 | Relieved by leaning forward → pancreatitis [3]; worse after fatty meal → biliary [5] | Pancreatitis, biliary colic |
| Nausea/Vomiting | Any nausea or vomiting? | 「有冇作嘔或者嘔？」 | Associated with pancreatitis, biliary, GOO [2] | Pancreatitis, GOO |
| GI bleeding | Any vomiting blood or black tarry stools? | 「有冇嘔血？大便有冇黑色好似柏油咁？」 | Red flag for bleeding PUD or malignancy [6] | Bleeding PUD, gastric CA |
| Weight loss | Any unintentional weight loss? | 「體重有冇無啦啦輕咗？」 | Alarm feature for malignancy [7][8] | Gastric CA, pancreatic CA |
| Dysphagia | Any difficulty swallowing? | 「吞嘢有冇困難？」 | Alarm feature [7] | Oesophageal/gastric CA |
| Jaundice | Have your eyes or skin turned yellow? | 「眼白或者皮膚有冇變黃？」 | Obstructive jaundice → CBD stone, pancreatic head CA [5] | Choledocholithiasis, pancreatic CA |
| NSAIDs/Drugs | Are you taking any painkillers like ibuprofen or aspirin? | 「有冇食止痛藥例如布洛芬？有冇食薄血丸？」 | NSAIDs/aspirin = major risk factor for PUD [1][2][6] | Drug-induced PUD |
| H. pylori | Have you ever been tested or treated for stomach bacteria? | 「有冇驗過幽門螺旋菌？有冇食過殺菌藥？」 | H. pylori = commonest cause of PUD [1][2] | H. pylori–related PUD |
| Alcohol | How much alcohol do you drink? | 「你飲唔飲酒？大約飲幾多？」 | Alcohol → pancreatitis, gastritis, Mallory-Weiss [2][3] | Acute pancreatitis |
| Smoking | Do you smoke? | 「你有冇食煙？」 | Risk factor for PUD, gastric CA [1] | PUD, gastric CA |
| Family Hx | Any family history of stomach cancer or GI disease? | 「屋企人有冇胃癌或者胃病？」 | FHx GI cancer = alarm feature [7] | Gastric CA |
| Cardiac Sx | Any chest tightness, shortness of breath, or jaw pain with exertion? | 「行路嗰陣有冇心口翳、氣促、或者下巴痛？」 | MI can present as epigastric pain – must not miss [1][9] | Inferior MI / ACS |
| Stress/Mood | Have you been under a lot of stress? Any low mood? | 「最近壓力大唔大？心情點？」 | Functional dyspepsia; psychosocial axis [8] | FD, anxiety, depression |
| Functional impact | Does the pain affect your work or daily life? | 「呢個痛有冇影響到你返工或者日常生活？」 | Biopsychosocial / social problem for Case Report | Social problem |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Safety; mandatory to ask | — |
Case Report Form Answer Builder
- CC: Epigastric pain × [duration]
- HPI high-yield points to capture:
- SOCRATES: site, onset, character, radiation, associations, timing, exacerbating/relieving, severity
- Meal relationship (better/worse with food)
- Associated GI symptoms: nausea, vomiting, haematemesis, melaena, heartburn, dysphagia, weight loss, change in bowel habit
- Risk factors: NSAIDs/aspirin, H. pylori status, alcohol, smoking
- Red flags/alarm features: age > 45, weight loss, GI bleeding, dysphagia, family history GI CA
- Relevant PMH (DM, IHD, previous PUD/OGD), drug history, allergy
- Not always "epigastric pain" — look for why today?
- Likely examples:
- "Worried the pain may be stomach cancer after a relative was diagnosed"
- "Pain is now affecting work/sleep"
- "Wants referral for endoscopy"
- "Pain not relieved by over-the-counter antacids"
- Phrasing: Write the patient's own reason, e.g. "Patient is concerned that persistent epigastric pain may indicate a serious stomach disease and would like investigation."
| Component | Likely Example | Exact Wording for CRF |
|---|---|---|
| Ideas | "I think I might have a stomach ulcer" / "Maybe it's from the painkillers" | Patient thinks the pain may be due to stomach ulcer / medication side effect |
| Concerns | "I'm worried it could be stomach cancer" | Patient is worried the pain could be due to gastric cancer, especially as [relative had it / symptoms worsening] |
| Expectations | "I want to have a scope done" / "I want medicine to stop the pain" | Patient expects referral for endoscopy / wants medication for symptom relief |
- In a typical FM station with a middle-aged patient on NSAIDs or with meal-related burning pain: Peptic Ulcer Disease [1][2]
- If young patient < 40, no alarm features, chronic vague discomfort: Functional Dyspepsia [8]
- Minimum supporting evidence for PUD:
- Burning/gnawing epigastric pain
- Meal relationship (GU worse / DU better with food)
- Risk factors: NSAID use and/or H. pylori
- ± epigastric tenderness on exam
| DDx | One Key Discriminator |
|---|---|
| GERD | Burning retrosternal/epigastric pain, worse lying flat, heartburn, acid regurgitation [8] |
| Biliary colic / Cholecystitis | Intense constant RUQ/epigastric pain after fatty meal, radiates to scapula, Murphy's sign +ve [5] |
| Gastric carcinoma | Age > 45, alarm features (weight loss, anaemia, dysphagia), epigastric mass [7] |
Alternative high-yield DDx if the stem suggests:
| Domain | Problem |
|---|---|
| Biological | Epigastric pain with risk of complications (bleeding, perforation); need investigation to exclude malignancy |
| Psychological | Anxiety about possible stomach cancer / health anxiety; or low mood if chronic |
| Social | Pain affecting work productivity / sleep disturbance / dietary limitations / financial burden of investigations |
| Diagnosis / DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| PUD (most likely) | Epigastric tenderness | Palpate epigastrium with flat hand, observe for tenderness | Localised tenderness at the site of ulcer; PE: epigastric tenderness is the most reliable sign in PUD [1][4]. Note: PE is often unremarkable in uncomplicated PUD — epigastric tenderness is the best available sign. |
| Biliary colic / Cholecystitis | Murphy's sign (inspiratory arrest on RUQ palpation) | Hook fingers under right costal margin, ask patient to breathe in deeply | Positive Murphy's = inflamed gallbladder contacts examining hand → specific for cholecystitis [5] |
| Acute pancreatitis | Epigastric tenderness with guarding ± Grey Turner's / Cullen's sign | Inspect flanks and periumbilical area; palpate epigastrium | Ecchymosis = retroperitoneal haemorrhage in severe necrotising pancreatitis [3] |
| Gastric carcinoma | Palpable epigastric mass ± Virchow's node (left supraclavicular LN) | Palpate epigastrium; palpate left supraclavicular fossa | Palpable mass = advanced disease; Virchow's node = intra-abdominal malignancy [7] |
| GERD | No reliable specific physical sign in a brief FM station | — | Diagnosis is clinical (typical symptoms); best exam clue: no epigastric mass, no tenderness, symptom pattern |
| ACS / MI | Diaphoresis, hypotension, new murmur | Vitals; auscultate heart | Sweating + epigastric pain + abnormal vitals → suspect cardiac; order ECG [9] |
| Perforated PUD | Board-like rigidity, rebound tenderness | Palpate abdomen gently | Peritonism = surgical emergency |
Top Traps That Lose Marks
- Forgetting to exclude ACS/MI – epigastric pain CAN be inferior MI. Always ask about cardiac risk factors and sweating. Per GC slides, MI can radiate to the epigastrium [9].
- Not asking about NSAIDs/aspirin – this is the most commonly tested drug history for epigastric pain. Drug history is critical [1][2][6].
- Calling biliary colic a "true colic" – per GC lecture, biliary pain is intense, constant and dull, NOT truly colicky [2][5].
- Forgetting alarm features – age > 45, weight loss, dysphagia, GI bleeding, anaemia, FHx GI cancer → mandatory OGD referral [7][8].
- Not asking ICE – easy marks lost. Always ask all three explicitly.
- Writing "epigastric pain" as the RFC – the RFC is WHY they came TODAY, not the symptom. Dig for the hidden agenda.
- Confusing GU vs DU pain pattern – GU: pain worse with food; DU: pain relieved by food, worse at night [1][4].
Must-not-miss red flags for urgent referral:
- Haematemesis / melaena → urgent OGD
- Sudden severe pain + rigid abdomen → suspect perforation → A&E
- Chest pain + sweating + SOB → suspect ACS → ECG + troponin
- Progressive dysphagia + weight loss → urgent OGD for malignancy
- Jaundice + epigastric mass → suspect pancreatic CA → urgent imaging + surgical referral
Safety-net closing line: 「如果痛得好厲害、嘔血、痾黑色屎、或者心口好翳，要即刻去急症室。」(If the pain becomes very severe, you vomit blood, pass black tarry stools, or have severe chest tightness, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES for pain, meal relationship (GU vs DU), radiation to back (pancreatitis), NSAIDs/aspirin, H. pylori, alcohol, alarm features (weight loss/dysphagia/GI bleeding/age > 45/FHx CA), cardiac symptoms, ICE, and "why today?"
What to WRITE: CC with duration → HPI in SOCRATES → risk factors → red flags → ICE → RFC (the real reason, not just the symptom) → Most likely Dx = PUD (if typical) or FD (if young, no alarms) → DDx = GERD, biliary, gastric CA → Biopsychosocial → Physical sign = epigastric tenderness
What NOT to MISS: ACS masquerading as epigastric pain; perforated PUD; gastric malignancy in patient > 45 with alarm features; NSAIDs as the culprit; biliary pain is constant not colicky
Active Recall - Family Medicine Clinical Test
[1] GC 092. Upper abdominal pain: peptic ulcer; pancreatitis and gallstone.pdf [2] Block A - Upper abdominal pain_ peptic ulcer; pancreatitis and gallstone.pdf (Pain severity & DDx sections) [3] MBBS Final MB (Surgery) (Felix PY Lai).pdf (Pancreatitis: pp. 580–581, 593) [4] MBBS Final MB (Surgery) (Felix PY Lai).pdf (PUD: p. 389–391) [5] MBBS Final MB (Surgery) (Felix PY Lai).pdf (Gallstones & biliary colic: p. 510) [6] Block A - Coffee ground vomitus tarry stool upper GI bleeding.pdf (Risk factors for UGIB) [7] GC 212. Weight loss and vomiting gastric cancer; abdominal imaging.pdf [8] Ryan Ho GI.pdf (Approach to Dyspepsia & Functional Dyspepsia: pp. 53–54); Ryan Ho Fundamentals.pdf (pp. 263–264) [9] CFB (MED05) Cardiovascular (I) Physical Examination (History Taking).pdf (Chest pain DDx table) [10] WCS 056 - Painless jaundice and epigastric mass - by Prof R Poon.ppt (1).pdf
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