Stomach Pain (Epigastric Pain) — Causes, Diagnosis & Treatment — Causes, Diagnosis & When to See a Doctor | MyMedicPlus

Stomach pain (epigastric pain) describes discomfort, burning, cramping, or aching felt in the upper-central abdomen — the epigastric region between the navel (umbilicus) and the lower end of the breastbone (xiphisternum). It is one of the most common complaints in primary care and gastroenterology settings, affecting people of all ages. The epigastric region contains several important structures including the stomach, duodenum, lower oesophagus, liver, gallbladder, bile ducts, and pancreas — any of which can generate pain perceived in this area. Referred pain from the heart — particularly in women, older adults, and diabetics — can also manifest as epigastric rather than central chest discomfort, making accurate triage essential. The relationship of epigastric pain to meals is among the most diagnostically useful features: GERD and peptic ulcers may worsen with meals or shortly after; duodenal ulcers characteristically improve temporarily with eating then return two to three hours later (food buffers acid, then acid surges); pancreatitis typically worsens dramatically after a large meal or alcohol intake. Identifying the pattern, character, and associated symptoms guides appropriate investigation and management, and ensures that serious causes — including upper gastrointestinal bleeding, malignancy, and acute pancreatitis — are not missed.

Gastro-oesophageal reflux disease (GERD) causes heartburn — burning epigastric or retrosternal pain worsening after meals, on lying down, and in the morning — from acidic gastric contents refluxing into the oesophagus. Gastritis (stomach lining inflammation) from Helicobacter pylori infection, long-term NSAID or aspirin use, or alcohol causes persistent epigastric burning or gnawing pain. Peptic ulcer disease (gastric or duodenal ulcers) causes deeper, more consistent epigastric pain, often related to acid output. H. pylori infection is present in approximately 44% of the global population and is responsible for 60-70% of gastric ulcers and 70-90% of duodenal ulcers. Functional dyspepsia (pain without structural cause on investigation) affects up to 15% of the population. Food-related causes include indigestion from overeating or fatty meals, gastroenteritis (viral or bacterial), food intolerances (lactose, gluten), and food poisoning. Gallstones (biliary colic) cause episodic severe right upper quadrant or epigastric pain lasting 30 minutes to several hours, often after fatty meals, with radiation to the right shoulder. Acute pancreatitis causes severe, constant epigastric pain radiating through to the mid-back, precipitated by alcohol or gallstones, with elevated amylase and lipase. More serious causes include gastric cancer (rarely presents with pain alone — usually weight loss, early satiety, dysphagia), oesophageal cancer, and — as a critical differential — acute myocardial infarction presenting as epigastric pain, particularly in elderly women and diabetics.

Seek emergency care immediately for vomiting of bright red blood (haematemesis) or passing black tarry foul-smelling stools (melaena) — both are signs of upper gastrointestinal bleeding requiring emergency endoscopy, which can be simultaneously diagnostic and therapeutic. Also seek emergency assessment for sudden, severe, constant epigastric pain radiating to the mid-back, especially after alcohol or a large meal (acute pancreatitis — potentially severe with multi-organ involvement), and for new epigastric pain with sweating, breathlessness, nausea, or radiating to the jaw or left arm in an adult over 40 years (possible myocardial infarction masquerading as stomach pain). Seek urgent assessment within one to two days for epigastric pain with fever, rigors, and jaundice (yellow skin) — possible ascending cholangitis from biliary obstruction, which is a serious systemic infection requiring urgent ERCP. Report urgent symptoms — called alarm or red flag features — that mandate fast-track gastroscopy: unintentional weight loss greater than 5% body weight, progressive difficulty swallowing (dysphagia), persistent vomiting, iron deficiency anaemia, new epigastric mass on palpation, and new dyspepsia in any person over 55 years. These features raise concern for upper gastrointestinal malignancy and require investigation within two weeks under a cancer fast-track pathway.

Clinical history examines the timing of pain relative to meals (immediately after — GERD or gastritis; two to three hours later — duodenal ulcer; constant — pancreatitis or malignancy), character (burning, gnawing, cramping, or stabbing), radiation pattern, relationship to posture (worse lying down — GERD), and associated symptoms including nausea, bloating, early satiety, weight change, and stool colour changes. Blood tests assess liver function (ALT, AST, ALP, bilirubin), pancreatic enzymes (amylase and lipase — markedly elevated in acute pancreatitis), H. pylori antibody (IgG), full blood count (anaemia from chronic ulcer bleeding), C-reactive protein, and troponin when cardiac cause cannot be excluded. Non-invasive H. pylori diagnosis uses the urea breath test (most accurate, with 95% sensitivity and specificity) or stool antigen test (validated for diagnosis and post-treatment eradication confirmation). Abdominal ultrasound is the first-line imaging for gallstones, biliary dilatation, and liver pathology. CT abdomen is performed for pancreatitis severity assessment, abdominal mass, or unclear acute presentations. Upper endoscopy (gastroscopy) directly visualises the oesophagus, stomach, and duodenum, allows biopsy for H. pylori testing and histology, and permits therapeutic intervention for bleeding ulcers. Ambulatory pH monitoring or oesophageal manometry evaluates refractory GERD.

Antacids (magnesium hydroxide, calcium carbonate) provide rapid but short-lived symptom relief by neutralising gastric acid, suitable for occasional mild heartburn. Proton pump inhibitors (PPIs — omeprazole, lansoprazole, pantoprazole) are the most effective pharmacological treatment for GERD-related oesophagitis, erosive gastritis, and peptic ulcers, reducing gastric acid secretion by 90% or more. H2 receptor antagonists (famotidine) are an alternative for mild GERD. Helicobacter pylori eradication uses standard triple therapy: a PPI plus two antibiotics (clarithromycin and amoxicillin, or metronidazole where clarithromycin resistance is high) for seven to fourteen days, achieving over 80% eradication rates — confirmed by urea breath test four to six weeks later. Bismuth quadruple therapy is recommended in areas with high clarithromycin resistance. Dietary modification — reducing fatty foods, spicy food, caffeine, citrus, alcohol, carbonated drinks, chocolate, and late-night eating — reduces GERD and functional dyspepsia symptoms. Elevation of the bed head by 15-20 cm (using bed risers, not extra pillows) reduces nocturnal reflux. Biliary colic from gallstones typically requires laparoscopic cholecystectomy (keyhole surgery) to prevent recurrence. Acute pancreatitis requires hospitalisation with intravenous fluid resuscitation, bowel rest (nil by mouth), adequate pain management, and treatment of the underlying cause (endoscopic removal of gallstones via ERCP, or abstinence from alcohol).

Eat smaller, more frequent meals rather than large ones — large meals distend the stomach, delay gastric emptying, and increase intra-abdominal pressure, worsening GERD. Allow at least three hours between the last meal and lying down. Avoid common dietary triggers for acid reflux and dyspepsia: fatty or fried foods, spicy food, caffeine, alcohol, carbonated drinks, chocolate, mint, and citrus. If taking NSAIDs or aspirin long-term for cardiovascular or musculoskeletal indications, always co-prescribe a PPI to protect the gastric mucosa and prevent peptic ulcer development — this is a NICE-recommended standard of care. Avoid smoking, which impairs gastric mucosal healing, stimulates gastric acid secretion, and promotes H. pylori colonisation and persistence. Achieve and maintain a healthy body weight — obesity increases intra-abdominal pressure, promotes gastric acid reflux, and is strongly associated with GERD severity and oesophageal adenocarcinoma. Test for and eradicate H. pylori if detected — eradication significantly reduces ulcer recurrence and lowers stomach cancer risk by approximately 30-40%. Limit alcohol consumption — heavy alcohol use directly causes gastritis, peptic ulcer, and acute pancreatitis.

Seek emergency care immediately for vomiting blood or black material, passing black tarry stools (melaena), or sudden severe epigastric pain with collapse or shock — these are life-threatening upper GI emergencies. Also go to an emergency department for severe constant epigastric pain radiating to the back with vomiting (pancreatitis), or any epigastric pain with sweating, breathlessness, and feeling very unwell in an adult over 40 (exclude myocardial infarction). Seek urgent assessment within 24-48 hours for epigastric pain with fever, jaundice, and rigors (biliary sepsis), or pain with severe vomiting preventing any oral intake. Arrange an urgent two-week wait (fast-track cancer) referral for epigastric pain with unexplained weight loss, progressive difficulty swallowing, iron deficiency anaemia, or new dyspepsia in anyone over 55 years — these alarm features mandate endoscopy within two weeks. See a doctor within one to two weeks for stomach pain persisting beyond a few days without clear cause, pain waking you from sleep, or pain associated with loss of appetite or nausea. Do not self-treat persistent stomach pain with long-term antacids or PPIs without medical investigation — this may mask important diagnoses. Recurrent stomach pain in children requires paediatric assessment to exclude H. pylori infection, eosinophilic oesophagitis, and other structural causes.