Epigastric Pain Causes
Epigastric pain is pain in the upper abdomen. It can be a sign of disease. Common causes include:
Acid reflux (stomach acid flowing up into the esophagus) Gastritis (irritation of the stomach lining) Most often this is from aspirin or NSAID medicines such as ibuprofen, bacteria called H. pylori, or frequent alcohol use. Peptic ulcer disease Inflammation of the pancreas Gallstone Infection in the gallbladder
Pain may be dull or burning. It may spread upward to the chest or to the back. There may be other symptoms such as belching, bloating, cramps or hunger pains. There may be weight loss or poor appetite, nausea or vomiting. Since the cause of your pain is not certain yet, you may need more tests.
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What does epigastric pain indicate?
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We do the research so you can find trusted products for your health and wellness. Epigastric pain refers to pain or discomfort right below your ribs in the area of your upper abdomen. It can have many causes, including acid reflux, gallstones, or indigestion.
Depending on the cause, you may need medical attention and monitoring. Is this cause for concern? Epigastric pain is a name for pain or discomfort right below your ribs in the area of your upper abdomen. It often happens alongside other common symptoms of your digestive system. These symptoms can include heartburn, bloating, and gas.
Epigastric pain isn’t always cause for concern. This condition has many possible causes, especially when it happens right after eating. It’s important to be able to tell the difference between pain that’s a result of something harmless, like overeating or lactose intolerance, and pain that happens because of an underlying condition, such as GERD, inflammation, or infection.
Keep reading to learn more about what may be causing your symptoms. Heartburn is a result of acid reflux. This can cause burning chest pain. Indigestion (dyspepsia) is a name for digestive symptoms that happen when you eat types of foods that don’t seem to agree with you. The most common symptom of heartburn is a burning feeling in your chest after you eat.
This burning feeling usually is worse when you lie or bend down. This is because the acid moves farther up your esophagus. Common symptoms of indigestion include:
feeling bloatedburpinggetting full even if you haven’t eaten muchnauseapressure in your abdomen from gas
Learn more: How to stop overeating » Lactose intolerance happens when your body has trouble digesting dairy products, such as milk or cheese. Dairy products all contain a type of sugar called lactose. Typically, symptoms will occur every time you eat dairy.
feeling bloatedstomach painspressure in your abdomen from gasdiarrheanauseathrowing up
Drinking alcohol in moderation, or about one drink per day, normally doesn’t cause stomach pain. But drinking too much alcohol at one time or over a long period of time can cause your stomach lining to become inflamed. Long-term inflammation can lead to bleeding. Drinking too much can also cause conditions such as:
gastritis, or stomach inflammation pancreatitis, or inflammation of the pancreasliver disease
These conditions can all cause epigastric pain, too. Check out: Gastritis diet: What to eat and what to avoid » When you eat too much, your stomach can expand beyond its normal size. This puts a lot of pressure on the organs around it. This pressure can cause pain in your gut.
It can also make it hard to breathe because your lungs have less room to expand when you inhale. Overeating can also cause stomach acid and contents to back up into your esophagus. This can cause heartburn and acid reflux. These conditions can make the epigastric pain that you feel after eating much worse.
If you have an eating disorder related to binge eating, repeated vomiting after eating can also cause epigastric pain. Learn more: Identifying gallbladder problems » A hiatal hernia happens when part of your stomach gets pushed up towards your diaphragm through the hole that the esophagus passes through, which is called the hiatus.
indigestionburning feeling in your chestirritated or sore throatburping loudly
Esophagitis happens when your esophagus lining becomes inflamed. Common causes include acid coming back up from your stomach, allergies, infection, or chronic irritation from medications. If you don’t treat it, over time esophagitis can eventually lead to scarring on your esophagus lining. Common symptoms of esophagitis include:
burning in your chest or throatabnormal acidic taste in your mouthcoughinghaving trouble swallowing or having pain when swallowing
Gastritis happens when the lining of your stomach (mucosa) becomes inflamed due to a bacterial infection, an immune system disorder, or ongoing damage to your stomach. It can be acute and last for only a brief time, or it can be chronic, lasting for years or more if you don’t get treatment. Common symptoms of gastritis can include:
pain or discomfort in your upper body or chestnauseavomiting, or throwing up blood or something that looks like coffee groundspassing black stool
Peptic ulcer disease happens when the lining of your stomach or small intestine gets damaged due to a bacterial infection or by taking too much of certain medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) for pain relief. Common symptoms of peptic ulcer disease can include:
nauseavomitingfeeling easily fullstomach pains that food can make better or worsesigns of bleeding that can include tiredness, paleness, or shortness of breath
Barrett’s esophagus happens when the tissue that lines your esophagus starts to become more like the tissue lining your intestines. This is known as intestinal metaplasia. This condition requires close follow-up. Unchecked, Barrett’s esophagus can lead to cancer of the esophagus.
throat soreness or hoarsenessabnormal acidic taste in your mouthburning in your stomachheartburnhaving trouble swallowing
Epigastric pain can develop when your gallbladder becomes inflamed as gallstones block the opening of your gallbladder. The condition is known as cholecystitis, This can be painful and may require hospitalization or surgery. Common symptoms of gallbladder inflammation can include:
not having an appetiteintense pain around your gallbladder (upper right side of your stomach)nausea and vomitingbloating and gashigh feverclay-colored stoolsskin that looks yellow ( jaundice )
Mild epigastric pain is common while you’re pregnant due to the pressure that your growing pregnancy puts on your abdominal area. It’s also common because of the changes in your hormones and your digestion. You may also experience frequent heartburn while you’re pregnant.
However, significant epigastric pain in pregnancy is sometimes a symptom of a serious condition known as preeclampsia, It requires close monitoring by your doctor and can become life-threatening if severe. You’ll require close observation, blood pressure checks, blood tests, and urine tests to rule this out as a cause of epigastric pain.
Treatment for epigastric pain depends on the cause. If your pain is a result of your diet or overeating, your doctor may recommend that you change your diet or lifestyle. This may include exercising for about 30 minutes each day or eating healthier foods.
Eating foods like ginger and taking vitamin B supplements may help relieve symptoms like nausea and throwing up. Shop for vitamin B supplements online. If the pain is a result of taking certain medications, such as NSAIDs, your doctor may tell you to stop taking these medications and help you find another way to manage pain.
Your doctor may recommend antacids or even acid-blocking medicines to relieve your pain. If an underlying condition such as GERD, Barrett’s esophagus, or peptic ulcer disease is causing your epigastric pain, you may require antibiotics as well as long-term treatment to manage these conditions.
trouble breathing or swallowingthrowing up bloodblood in your stool or black, tarry stoolhigh feverchest paindifficulty breathingpassing out
You should also see your doctor if your symptoms last for more than a few days without getting any better with over-the-counter or home treatments. Many causes of epigastric pain can easily be treated, including chronic conditions. Seeing your doctor as soon as you notice epigastric pain that isn’t going away can help you relieve your symptoms and get any underlying conditions under control.
What can cause sudden epigastric pain?
Gastric acid is responsible for much epigastric pain –
Gastro-oesophageal reflux disease (GORD) can cause epigastric pain as well as burning pain in the chest, a feeling of liquid coming up into the back of the throat and a persistent irritating cough. Many factors contribute to it, including:
Obesity.Gastric irritants, such as alcohol, smoking and caffeine.Pregnancy. Hiatus hernia,Stress.
Gastritis is a common cause of epigastric pain. It is often worse after eating and will generally improve with proton pump inhibitors, Test for the presence of Helicobacter pylori, Peptic ulcer tends to cause acute or chronic gnawing or burning pain. This may be improved by food if caused by a duodenal ulcer, and worsened by food if a gastric ulcer. Typically the pain is worse at night.
What organ causes epigastric pain?
Common epigastric pain causes – Due to the body organs located within the epigastric area, epigastric pain is commonly caused by:
Pancreatitis – The pancreas produces enzymes which helps your body digest food and hormones including insulin which helps regulate your blood sugar level. These enzymes leave the pancreas and become active in the small intestine. If the enzymes become active within the pancreas then they can cause pancreatic inflammation, which is known medically as pancreatitis. Other symptoms include burning stomach pain, nausea, vomiting, stomach swelling and tenderness around the stomach. Gallstones – The gallbladder is a small pear-shaped organ on the right side of your abdomen beneath the liver. The gallbladder stores bile which is released into the small intestine when you eat and breaks down the fats in the food you consume. When the bile constituents become out of balance gallstones can form and if one becomes trapped in the opening of the gallbladder then it can cause severe epigastric pain. If gallstone disease is left untreated or isn’t recognized, then symptoms of yellowing of the eyes and the skin, known as jaundice, and a fever may occur. If the gallstones move into the pancreas then pancreatic inflammation may occur resulting in pancreatitis (see above). Peptic ulcer or stomach ulcer – These are sores that occur in the stomach lining and are known as gastric or peptic ulcers. The sores occur due to an imbalance of digestive fluids within the stomach or small intestine. As well as causing epigastric pain, other symptoms are indigestion, heartburn, nausea, vomiting blood (hematemesis) and rectal bleeding Gastritis – This is inflammation or irritation of the stomach lining. Excessive alcohol use, chronic vomiting, stress or the use of medications including aspirin or anti-inflammatory drugs can cause gastritis. As well as epigastric pain, other symptoms include stomach bloating, vomiting, nausea, indigestion, loss of appetite and vomiting blood.
How serious is epigastric pain?
What is Epigastric Pain and When should I be Concerned? Epigastric pain is pain that is localized to the region of the upper abdomen immediately below the ribs. Often, those who experience this type of pain feel it during or right after eating or if they lie down too soon after eating.
It is a common symptom of gastroesophageal reflux disease (GERD) or heartburn. Some people have mild epigastric pain that occurs after eating and subsides quickly, while others may have a severe burning feeling in the abdomen, chest and neck that prevents sleep. Other symptoms that may accompany epigastric pain include abdominal bloating, constipation, diarrhea, and vomiting, depending on the underlying cause.
In rare cases, epigastric pain is due to heart conditions such as heart attack and angina (chest pain due to the heart not getting enough oxygen). Epigastric pain is not a serious symptom on its own. However, if it occurs with other life-threatening symptoms, it may be a sign of a condition that should receive immediate medical treatment, such as a heart attack.
Seek prompt medical care if you are being treated for epigastric pain but mild symptoms recur or are persistent. If you see or experience emergency symptoms, head to: Highland Park Emergency Room 5150 Lemmon Ave. Suite #108call us at 972-268-6346or Preston Hollow Emergency Room 8007 Walnut Hill Lanecall us at 214-217-0911
A free-standing emergency room right in your neighborhood. We are open 24-hours a day — the only no-wait emergency rooms around. An emergency room physician can see you quickly, evaluate your condition, and take steps to alleviate your symptoms immediately. If appropriate, they will admit you to the hospital if needed. : What is Epigastric Pain and When should I be Concerned?
Can stress and anxiety cause epigastric pain?
Can stress or anxiety cause stomach pain? – Absolutely. Stress and anxiety are common causes of stomach pain and other GI symptoms.
Is epigastric pain a symptom of pancreatitis?
History and Physical –
- Nonsurgical conditions that mimic an acute abdomen: gastroenteritis, acute adrenal insufficiency, sickle cell crisis, diabetic ketoacidosis, acute porphyria, pelvic inflammatory disease, kidney stones, and pyelonephritis.
- Patients with pancreatitis typically present with epigastric pain radiating to the back, nausea, vomiting, anorexia, fever, and tachycardia.
When should you seek medical attention for epigastric pain?
Sometimes you may be able to wait it out and it will go away on its own. Some causes, such as an upset stomach, can be managed at home. But if you are experiencing pain that does not go away, or you’re having other symptoms like a high fever, nausea or vomiting, you should see a medical professional.
What is epigastric distress syndrome?
Are there different types of functional dyspepsia? – Some healthcare specialists classify functional dyspepsia symptoms into two categories:
Epigastric pain syndrome (EPS) refers to only those symptoms associated with upper abdominal pain and burning. Postprandial distress syndrome (PDS) refers to only those symptoms that occur after eating, such as early fullness, bloating and nausea.
Not everyone’s symptoms fall neatly into these two categories, but when they do, it helps healthcare specialists focus on treating those symptoms as a group.
When should I go to the doctor for epigastric pain?
Stomach pain; Pain – abdomen; Belly ache; Abdominal cramps; Bellyache; Stomachache Abdominal pain is pain that you feel anywhere between your chest and groin. This is often referred to as the stomach region or belly. You know that awful feeling: you’re nauseous; your stomach feels like it’s tied in a knot, and you don’t even want to move. What does your pain mean? Well, let’s talk today about abdominal pain. So, what causes abdominal pain? Almost everyone has pain in their belly at one time or another.
- Most of the time, a serious medical problem is not the cause, and how bad your pain is doesn’t always reflect the seriousness of the problem causing your pain.
- You may feel very bad pain if you are having gas or stomach cramps due to viral gastroenteritis, better known as a stomach virus.
- And some life-threatening conditions, such as colon cancer or a very early case of appendicitis, may cause only mild pain, or no pain at all.
The important thing to know about abdominal pain is when you need immediate medical care. Less serious causes of abdominal pain include constipation, irritable bowel syndrome, food allergies, lactose intolerance, food poisoning, and a stomach virus. Other, more serious, causes include appendicitis, an abdominal aortic aneurysm, a bowel blockage, cancer, and gastroesophageal reflux.
Sometimes, you may have abdominal pain from a problem that isn’t in your belly, like a heart attack, menstrual cramps, or pneumonia. So, what do you do about abdominal pain? Well, if you have mild abdominal pain, here are some helpful tips; Try sipping water or other clear fluids. Avoid solid food for the first few hours.
If you’ve been vomiting, wait 6 hours and then eat small amounts of mild foods like rice, applesauce, or crackers. If your pain is high in your abdomen and occurs after meals, antacids may help, especially if you are feeling heartburn or indigestion. You should seek medical attention if you have abdominal pain and are being treated for cancer, you can’t pass any stool, you’re vomiting blood, or you have chest, neck, or shoulder pain. There are three body views (front, back, and side) that can help you to identify a specific body area. The labels show areas of the body which are identified either by anatomical or by common names. For example, the back of the knee is called the “popliteal fossa,” while the “flank” is an area on the side of the body. The process of digesting food is accomplished by many organs in the body. Food is pushed by the esophagus into the stomach. The stomach mixes the food and begins the breakdown of proteins. The stomach propels the food then into the small intestine. The small intestine further digests food and begins the absorption of nutrients. Since the abdominal area contains many different organs it is divided in smaller areas. One division method, uses one median sagittal plane and one transverse plane that passes through the umbilicus at right angles. This method divides the abdomen into four quadrants. Medical personnel can easily refer to these quadrants when describing pain or injury regarding a victim. The appendix is a small finger-shaped tube that branches off the first part of the large intestine. The appendix can become inflamed or infected causing pain in the lower right part of the abdomen. Blood from the aorta reaches the kidneys so it can be filtered and cleaned. Among other functions, the kidneys remove toxins, metabolic waste, and excess ions from the blood which leaves the body in the form of urine. You know that awful feeling: you’re nauseous; your stomach feels like it’s tied in a knot, and you don’t even want to move.
What does your pain mean? Well, let’s talk today about abdominal pain. So, what causes abdominal pain? Almost everyone has pain in their belly at one time or another. Most of the time, a serious medical problem is not the cause, and how bad your pain is doesn’t always reflect the seriousness of the problem causing your pain.
You may feel very bad pain if you are having gas or stomach cramps due to viral gastroenteritis, better known as a stomach virus. And some life-threatening conditions, such as colon cancer or a very early case of appendicitis, may cause only mild pain, or no pain at all.
The important thing to know about abdominal pain is when you need immediate medical care. Less serious causes of abdominal pain include constipation, irritable bowel syndrome, food allergies, lactose intolerance, food poisoning, and a stomach virus. Other, more serious, causes include appendicitis, an abdominal aortic aneurysm, a bowel blockage, cancer, and gastroesophageal reflux.
Sometimes, you may have abdominal pain from a problem that isn’t in your belly, like a heart attack, menstrual cramps, or pneumonia. So, what do you do about abdominal pain? Well, if you have mild abdominal pain, here are some helpful tips; Try sipping water or other clear fluids.
Avoid solid food for the first few hours. If you’ve been vomiting, wait 6 hours and then eat small amounts of mild foods like rice, applesauce, or crackers. If your pain is high in your abdomen and occurs after meals, antacids may help, especially if you are feeling heartburn or indigestion. You should seek medical attention if you have abdominal pain and are being treated for cancer, you can’t pass any stool, you’re vomiting blood, or you have chest, neck, or shoulder pain.
Call your doctor if you have abdominal pain that lasts 1 week or longer, if your pain doesn’t improve in 24 to 48 hours, if bloating lasts more than 2 days, or if you have diarrhea for more than 5 days.
When should you seek medical attention for epigastric pain?
Sometimes you may be able to wait it out and it will go away on its own. Some causes, such as an upset stomach, can be managed at home. But if you are experiencing pain that does not go away, or you’re having other symptoms like a high fever, nausea or vomiting, you should see a medical professional.
Can epigastric pain be cardiac?
Unexplained chest/epigastric pain in patients with normal endoscopy as a predictor for ischemic heart disease and mortality: A Danish 10-year cohort study 1 Department of Clinical Epidemiology, Aarhus and Aalborg Hospital, Aarhus, University Hospital, DK-8000 Aarhus C, Denmark Find articles by 2 Department of Clinical Epidemiology, Aarhus University Hospital, DK-8000 Aarhus C, and Department of Applied Research and Health Technology Assessment, Odense University Hospital, DK-5000 Odense C.
1 Department of Clinical Epidemiology, Aarhus and Aalborg Hospital, Aarhus, University Hospital, DK-8000 Aarhus C, Denmark 2 Department of Clinical Epidemiology, Aarhus University Hospital, DK-8000 Aarhus C, and Department of Applied Research and Health Technology Assessment, Odense University Hospital, DK-5000 Odense C. Denmark 3 Center for Cardiovascular Research, Aalborg Hospital, Aarhus University, Hospital, DK-9000 Aalborg, Denmark 4 Center of Visceral Biomechanics and Pain, Department of Gastroenterology, Aalborg Hospital, Aarhus University Hospital, DK-9000 Aalborg, Denmark 5 Department of Surgical Gastroenterology L, Aarhus Hospital, Aarhus University, Hospital, DK-8000 Aarhus C, Denmark Corresponding author. Estrid Muff Munk: ; Bente Nørgård: ; Claus Dethlefsen: ; Hans Gregersen: ; Asbjørn Mohr Drewes: ; Peter Funch-Jensen: ; Henrik Toft Sørensen:
Received 2007 Sep 21; Accepted 2008 Jul 15. © 2008 Munk et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Normal upper endoscopy may be a marker of ischemic heart disease in patients with unexplained chest/epigastric pain. We examined the 10-year risk of ischemic heart disease and mortality in a cohort of 386 Danish patients with chest/epigastric pain, normal upper endoscopy, and no prior hospital discharge diagnosis of ischemic heart disease (defined as patients with unexplained chest/epigastric pain), compared with 3,793 population controls matched by age, gender, and residence. Outcome data were obtained from population-based health registries. Cox regression analysis was used to estimate the relative risk of hospitalization for ischemic heart disease and the adjusted mortality rate ratio (MRR). The 10-year relative risk of hospitalization for ischemic heart disease following a normal upper endoscopy among patients with unexplained chest/epigastric pain was 1.6 (95% CI, 1.1–2.2), compared with controls. The 10-year MRR was 1.1 (95% CI, 0.9–1.5). Within the first year after the upper endoscopy the MRR was 2.4 (95% CI, 1.3–4.5). The cause-specific MRR among patients with unexplained chest/epigastric pain compared with controls was up to threefold higher for deaths related to alcohol dependence, pneumonia, and lung cancer. Unexplained chest/epigastric pain in patients with normal endoscopy is a strong marker for ischemic heart disease and increased mortality. Pain originating in the upper and lower gastrointestinal tract is complex and common in the general population, Unexplained chest/epigastric pain (UCEP) may reflect either undiagnosed thoracic or abdominal organic diseases or upper functional gastrointestinal disorders (FGIDs), Patients with chest and epigastric pain are often referred to gastroenterologists for evaluation of possible organic or functional causes, In two recent cohort studies, we suggested that UCEP might reflect early symptoms of gastrointestinal cancer, pancreatitis, and gallstone, Whether UCEP may also be a marker of increased risk of death or ischemic heart disease (IHD) remains unclear. The evidence primarily consists of small case series and a few follow-up studies with inconsistent results and significant limitations, Half of the studies failed to include a control group, and UCEP was defined in most cases on the basis of only chest pain and a normal coronary angiography, More importantly, none of the studies excluded patients whose pain could have been caused by an underlying gastrointestinal disease, such as peptic ulcer or gastro-esophageal reflux disease (GERD), Thus, it is uncertain whether all study subjects had truly unexplained pain. We conducted a follow-up study in Denmark to examine hospitalization for IHD, all-cause mortality, and cause-specific mortality in UCEP patients compared with population controls (using the same study population of patients as in our two previous prognostic studies on UCEP patients ). This 10-year follow-up study was conducted at the Aarhus University Hospital in Aarhus County, Denmark. The county has a population of approximately 650,000 (12% of the Danish population). The Aarhus University Hospital has the county’s largest departments of gastroenterology and surgery, and most upper endoscopies in the county are performed there. We obtained data on all patients who underwent upper endoscopy at the hospital between January 1, 1992 and December 31, 1993, with a 10-year follow-up period extending until December 31, 2003. Records in all registries used in this study contain the Danish Civil Registration System’s unique 10-digit civil registration number, which is assigned to all Danish citizens at birth, Use of the civil registration number allows valid linkage between registries. The Aarhus University Hospital Endoscopy Registry contains both paper files and electronic medical records for all patients who underwent upper endoscopy since 1976. Since 1977 the electronic record has been maintained by the Hospital Administrative Patient Registry. Each record includes information on the patient’s civil registration number, dates of admission and discharge, date and type of procedures performed, and diagnoses coded by physicians according to the International Classification of Diseases (ICD). ICD-8 codes were used in 1977–1993, and ICD-10 codes thereafter (ICD-9 was never used in Denmark), Hard-copy medical records consist of referral notes (nearly 90% of the patients are referred from general practitioners as outpatients) and endoscopy records written by the physicians who performed the procedures. The latter include information on presenting symptoms (indication for the procedure), diagnoses made during the endoscopy, biopsies taken, and description of subsequent pathological findings. This information is both standardized by means of a checklist and described in free text. General practitioners’ referral notes are not standardized and mainly include information on the patients’ history and symptoms. We ascertained patients’ symptoms both from the endoscopy records and from the referral notes, and for the majority of patients the descriptions of the presenting symptoms from the two sources were in agreement. One of the study physicians (EMM) coded and entered data from the hard-copy medical records into an electronic research database. The physicians who performed the upper endoscopy did not take part in the evaluation of the data of the study, selection of patients for the study, study analyses, or interpretation of the results in the study. During the recruitment period we identified 1,799 patients with a first-time normal upper endoscopy. These patients were classified into four groups according to their symptoms: (a) only chest/epigastric pain, (b) reflux-like symptoms ( e.g., heartburn and/or acid reflux), (c) neither chest/epigastric pain nor reflux-like symptoms, and (d) both chest/epigastric pain and reflux-like symptoms. The subcohort of interest was comprised of the first group: 410 (23%) patients with only chest/epigastric pain and a first-time normal upper endoscopy. Thus, we excluded patients with symptoms such as specified/unspecified dyspepsia, heartburn and/or acid reflux or with other symptoms listed in the endoscopy record and in the referral note. Our study subcohort of patients with only chest/epigastric pain and a first-time normal upper endoscopy was defined and chosen a priori, Through linkage to the nationwide Danish Hospital Discharge Registry (HDR), we identified patients with discharge diagnoses of ischemic heart disease (IHD) (myocardial infarction, angina, and/or heart failure ) prior to the date of upper endoscopy, coded according to the ICD diagnoses in Appendix 1. The HDR, established in 1977, electronically tracks all non-psychiatric hospitalizations throughout Denmark, including dates of admission and discharge, procedures performed, and up to 20 discharge diagnoses coded by medical doctors at the time of discharge. Data also on out-patients were included from 1995. We excluded 24 patients with a discharge diagnosis of IHD prior to the date of upper endoscopy. The remaining 386 patients comprised the study cohort of UCEP patients, who may resemble patients with upper FGIDs, The study cohort was identical to the study cohort used in two recently published studies on other prognostic outcomes among UCEP patients, For each UCEP patient, controls residing in Aarhus County were identified from the Civil Registration System and matched by age and gender (N = 4,100). The controls were selected on the date of the corresponding patient’s first-time normal upper endoscopy (the index date). Ten controls per UCEP patient were randomly chosen to achieve statistical precision, On the basis of information from HDR, 67 controls with discharge diagnoses of IHD prior to the index date were excluded. The remaining 3,793 controls were included in the analyses, Data on hospitalizations for IHD (defined as a discharge diagnosis of myocardial infarction, angina and/or heart failure) during the 10 years of follow up were obtained from the HDR. Mortality was ascertained from the Civil Registration System, which tracks Danish citizens’ births, deaths, and migrations. In addition, death certificates, available from the Danish Causes of Deaths Registry, provided information on cause-specific mortality up to December 31, 2003. Since 1970, death certificates have included information on cause and manner of death (natural death, accident, suicide, or unknown) for 100% of deceased Danish residents. Because few patients and controls died of unnatural causes, we did not consider manner of death in our analyses. In our cohort of UCEP patients, we focused on the seven most common causes of deaths occurring after the date of normal upper endoscopy: IHD, pneumonia, stroke, arteriosclerosis (in the absence of IHD or stroke), lung cancer, alcohol dependence, and chronic obstructive pulmonary disease. HDR data were used to compute a comorbidity index score – the Charlson Index – for each UCEP patient and control, The Charlson Index, covering 19 major disease categories weighted according to their prognostic impact on patient survival, has been adapted for use with hospital discharge registry data. We computed the Index based on diagnoses recorded during all previous hospitalizations since 1977. We used discharge diagnoses of alcohol- and smoking-related diseases as proxies for alcohol abuse and tobacco smoking (ICD codes provided in Appendix 1), Alcohol- and smoking-related diagnoses were excluded from the Index to reduce the risk of residual confounding from these diseases. Three index levels were defined to capture increasing degrees of comorbidity: no comorbidity (Charlson Index 0), comorbidity level 1 (Charlson Index 1–2), and comorbidity level 2 (Charlson Index > 2), Demographic and clinical variables such as gender, age, presence of alcohol- and smoking-related diseases, level of comorbidity, subsequent discharge diagnosis of IHD, overall mortality, and cause-specific mortality were presented as proportions or means, as appropriate. Follow up began on the date of normal upper endoscopy or the corresponding index date for controls, and ended on the date of initial diagnosis of IHD, the date of death, the date of emigration, or at the end of the study period on December 31, 2003, whichever came first. We constructed Kaplan-Meier survival curves and used life table techniques to estimate the risk of hospitalization for IHD and death and to summarize risk over time, Cox regression was used to calculate the incidence rate ratio as an estimate of the relative risk and associated 95% confidence interval (CI) of hospitalization for IHD among UCEP patients compared to that for controls, while adjusting for alcohol- and smoking-related diseases and level of comorbidity, Cox regression was also used to estimate the mortality rate ratio (MRR) and associated 95% CI for UCEP patients, relative to controls, while adjusting for alcohol- and smoking-related diseases and level of comorbidity. Similarly, Cox regression was used to estimate the MRR for cause-specific deaths. All-cause MRRs also were calculated after <1 year, 1–2 years, 3–4 years, and ≥ 5 years of follow up. For pneumonia, cause-specific MRRs were estimated for the following time periods: within <7 days, 7–31 days, and ≥31 days after the index date. Separate analyses were performed for each type of IHD (myocardial infarction, angina, and heart failure) and stratified by time elapsed since the index date (<1 year, 1–2 years, 3–4 years, and ≥ 5 years). Proportional hazards assumptions for the models within time periods were assessed graphically and found to be adequate. Analyses were performed using STATA version 9.1 SE (StataCorp, College Station, Texas, USA). The study was approved by the Danish Data Protection Agency (# 2001-41-1590). Table presents selected characteristics of the UCEP patients and the matched population controls. Compared with the population controls, UCEP patients had a higher prevalence of subsequent hospitalization for IHD (11% vs.6%), were more likely to have comorbidity scores in Charlson Index category 1–2 (12% vs.7%), and more likely to have alcohol-related diseases (8% vs.2%). There was a slight difference between the two groups in ten-year all-cause mortality (16% of UCEP patients vs.13% of controls). Except for deaths from alcohol dependence (1% vs.0.1%) and pneumonia (3% vs.1%), we found no difference in proportions of cause-specific deaths between the two groups. Characteristics of patients with unexplained chest/epigastric pain (UCEP) and matched population controls.
| UCEP patients* (N = 386) | Population controls** (N = 3,793) | |
| Age, n (%) | ||
| ≤ 39 years | 155 (40) | 1,553 (41) |
| 40–56 years | 114 (30) | 1,100 (29) |
| ≥ 57 years | 117 (30) | 1,140 (30) |
| Mean age (years) | 46.4 | 46.1 |
| Median age (years) | 44 | 44 |
| Gender, n (%) | ||
| Female | 222 (58) | 2,195 (58) |
| Male | 164 (42) | 1,598 (42) |
| Comorbidity level, n (%)† | ||
| No comorbidity | 337 (87) | 3,473 (92) |
| Comorbidity level 1–2 | 45 (12) | 286 (7) |
| Comorbidity level > 2 | 4 (1) | 34 (1) |
| Discharge diagnoses, n (%) | ||
| Alcohol-related diseases | 29 (8) | 79 (2) |
| Smoking-related diseases | 19 (5) | 133 (4) |
| Patients who developed ischemicheart disease, n (%) | 39 (11) | 241 (6) |
| 10-year risk of ischemic heart disease, % | 11 | 6 |
| Deaths, total, n (%) | 62 (16) | 508 (13) |
| Death from ischemic heart disease# | 8 (2) | 76 (2) |
| Death from stroke | 4 (1) | 34 (1) |
| Death from arteriosclerosis(not ischemic heart disease, not stroke) | 4 (1) | 51 (1) |
| Death from pneumonia | 12 (3) | 41 (1) |
| Death from lung cancer | 5 (1) | 27 (1) |
| Death from alcohol dependence | 3 (1) | 5 (0.1) |
| Death from chronic obstructivepulmonary disease | 3 (1) | 38 (1) |
| Death from other causes | 21 (5) | 217 (6) |
| 10-year mortality, % | 16 | 13 |
Compared with population controls, the crude relative risk of hospitalization for IHD among UCEP patients was 1.7 (95% CI, 1.2–2.4) (Table ). Adjustment for alcohol- and smoking-related diseases and for level of comorbidity did not change the estimate. The relative risk of hospitalization for IHD within <1 year, 1–2 years, 3–4 years, and ≥ 5 years following upper endoscopy remained consistently elevated (Table ). By type of IHD, the adjusted relative risk was 1.4 (95% CI, 0.8–2.4) for myocardial infarction, 1.9 (95% CI, 1.2–3.0) for angina, and 1.7 (95% CI, 1.0–2.9) for heart failure. The adjusted relative risk for angina and heart failure was highest in the first and the second years following upper endoscopy, For myocardial infarction, the relative risk was the highest ≥ 5 years following upper endoscopy, Risk of hospitalization for ischemic heart disease in patients with unexplained chest/epigastric pain patients (UCEP).
| UCEP patients* (N = 386), n (%) | Population controls** (N = 3,793), n (%) | Crude relative risk | Adjusted relative risk‡ | |
| Ischemic heart disease: myocardial infarction, angina, and/or heart failure | 39 (11) | 241 (6) | 1.7 (1.2-2.4) | 1.6 (1.1-2.2) |
| Time of diagnosis of ischemic heart disease after upper endoscopy | ||||
| <1 year | 5 (1.3) | 24 (0.6) | 2.1 (0.8–5.4) | 1.9 (0.7–5.0) |
| 1–2 years | 5 (1.3) | 19 (0.5) | 2.7 (1.0–7.2) | 2.5 (0.9–6.7) |
| 3–4 years | 8 (2.1) | 57 (1.5) | 1.5 (0.7–3.1) | 1.4 (0.6–2.8) |
| ≥ 5 years | 21 (5.4) | 141 (3.7) | 1.6 (1.0–2.5) | 1.5 (0.9–2.3) |
Survival curves for UCEP patients and controls are shown in Figure, The crude overall MRR was 1.2 (95% CI, 1.0–1.6) (Table ). The estimate remained unchanged after adjustment for alcohol- and smoking-related diseases and level of comorbidity. The adjusted overall MRRs for UCEP patients within <1 year and 1–2 years after upper endoscopy were 2.4 (95% CI, 1.3–4.5) and 1.7 (95% CI, 0.8–3.9), respectively (Table ). Thereafter, mortality among UCEP patients was comparable to that of controls (Table ). Mortality in patients with unexplained chest/epigastric pain (UCEP).
| UCEP patients* (N = 386), n (%) | Population controls** (N = 3,793), n (%) | Crude MRR | Adjusted MRR† | |
| Total deaths | 62 (16) | 508 (13) | 1.2 (1.0–1.6) | 1.1 (0.9–1.5) |
| Time to death after upper endoscopy | ||||
| <1 year | 10 (3) | 40 (1) | 2.7 (1.5–5.0) | 2.4 (1.3–4.5) |
| 1–2 years | 14 (4) | 83 (2) | 1.9 (0.9–4.3) | 1.7 (0.8–3.9) |
| 3–4 years | 6 (2) | 93 (2) | 1.0 (0.6–1.8) | 0.9 (0.6–1.6) |
| ≥ 5 years | 32 (8) | 292 (8) | 1.0 (0.7–1.5) | 0.9 (0.6–1.4) |
| Cause-specific deaths | ||||
| Deaths from ischemic heart disease‡ | 8 (2) | 76 (2) | 1.1 (0.5–2.2) | 1.1 (0.5–2.2) |
| Deaths from arteriosclerosis (not ischemic heart disease, not stroke) | 4 (1) | 51 (1) | 0.8 (0.3–2.1) | 0.7 (0.3–2.1) |
| Deaths from pneumonia | 12 (3) | 41 (1) | 2.8 (1.5–5.4) | 2.7 (1.4–5.2) |
| Deaths from stroke | 4 (1) | 34 (1) | 1.1 (0.4–3.1) | 1.1 (0.4–3.2) |
| Deaths from lung cancer | 5 (1) | 27 (1) | 1.9 (0.7–4.9) | 1.7 (0.6–4.4) |
| Deaths from alcohol dependence§ | 3 (1) | 5 (0.1) | 3.4 (0.7–16.8) | 1.5 (0.3–8.2) |
| Deaths from chronic obstructive pulmonary disease¶ | 3 (1) | 38 (1) | 0.7 (0.2–2.4) | 0.8 (0.2–2.5) |
Adjusted cause-specific MRRs are shown in Table, Elevated mortality was found for death from alcohol dependence, pneumonia, and lung cancer, Except for one case, all pneumonia deaths occurred more than 31 days after the upper endoscopy date. We found no indication of increased mortality due to IHD, The ten-year risk of hospitalization for IHD among UCEP patients was increased 1.6-fold compared with controls. The highest increase in risk was observed within the first two years following the upper endoscopy, but the risk remained elevated even after five years. All-cause mortality for UCEP patients was 16% over ten years, 1.1 times higher than the all-cause mortality in the general population. In the first year after the upper endoscopy, all-cause mortality among UCEP patients was nearly 2.5-fold higher than that of controls, but the difference faded away with time. The increased mortality among UCEP patients stemmed from alcohol dependence, pneumonia, and lung cancer, but not IHD. The main strengths of our study are its relatively large size, a well-defined patient sample drawn from a universal-access health care system, and complete follow-up over ten years. In Denmark, nearly all patients with IHD are hospitalized during the cause of the disease (by admission to hospital either directly or through out-patient clinics), and this ensured us to registry virtually all IHD diagnoses among our cohort members. Data used to assess outcomes and potential confounders were obtained from routinely recorded discharge diagnoses and causes of death. While their quality may be variable, the positive predictive value of heart-related discharge diagnoses has been reported to be high, Diagnoses recorded on death certificates are less reliable, This increases the likelihood of misclassification, though most likely non-differential. To reduce variation in definition of diagnoses and symptoms, a single physician coded and entered the information from the medical records into a research database. Though some misclassification of UCEP cannot be ruled out, it is unlikely to be related to the outcomes measured. Despite the limited level of clinical detail available in administrative data, we were able to adjust for alcohol- and smoking-related diseases and for comorbidity. However, adjusting for these potential confounders did not change our relative estimates. The Charlson Index has been shown to have high specificity, but its sensitivity is diagnosis-dependent, so that residual confounding by comorbidity cannot be ruled out. Further, since discharge diagnoses are proxy measurements for alcohol abuse and smoking, misclassification of these factors may have also produced residual confounding. The UCEP patients in our study may resemble patients with upper FGIDs in characteristics such as functional chest pain of presumed esophageal origin, functional dyspepsia (epigastric pain only), or the epigastric pain syndrome, In order to exclude patients with organic upper gastrointestinal diseases, we restricted our study to patients with a normal upper endoscopy and chest and/or epigastric pain as the sole symptom. Therefore, patients with reflux-like symptoms or dyspepsia-like symptoms described in the medical record were excluded. Likewise, we excluded UCEP patients who had received an IHD diagnosis before enrollment in the study. However, it is possible that some UCEP patients had undiagnosed IHD. Exclusion of underlying IHD is very difficult, and, as has been recently shown, even coronary angiography is not guaranteed to rule out this condition, It is also possible that normal endoscopy and absence of reflux-like symptoms do not eliminate the possibility of GERD in small proportion of UCEP patients, However, even the addition of pH monitoring data or documentation of response to anti-reflux therapy would not suffice to exclude GERD, because of the variable quality of such information, Finally, it could be argued that patients with chest pain should be considered separately from patients with pain in the epigastrium. However, a clear differentiation of the two pain locations based on medical records was not feasible. It is well known that pain from viscera is often difficult to localize and that there is a major overlap of symptoms of pain emanating from the esophagus and related organs, This has been also demonstrated in experimental studies, Hence, the combination of pain from the chest and epigastrium appears to be a valid approach to a common clinical problem. The increase in the risk of IHD could reflect the presence of undiagnosed IHD at the time of upper endoscopy. However, the risk remained elevated more than 5 years after the procedure. This is a strong indication that UCEP is an early marker of IHD, a finding that until now has not been reported. The finding of increased cardiac and overall mortality among UCEP patients conforms with a previous cohort study among NCCP patients and another among patients with non-ulcer dyspepsia (subgroup of FGID), both using comparison groups drawn from the general population. In contrast, our results disagree with those reported in two other cohort studies among NCCP patients, both of which used asymptomatic persons as a control group, All four cohort studies have important limitations that were avoided in our study. Three studies did not include results of upper endoscopy examinations, which could lead to inclusion of a large proportion of patients with a known underlying gastrointestinal cause of pain (up to 30% of NCCP patients ). In addition, the study of patients with non-ulcer dyspepsia included patients with ‘discomfort’ and reflux-like symptoms, which are explicitly excluded from the FGIDs in the recently defined Rome III criteria in order to avoid overlap with organic disease (mainly GERD), Two studies were restricted to men aged 40–59 years, One study examined a combined outcome (major IHD events ), complicating the interpretation of the result, Finally, none of the studies estimated short- or long-term risks, and thus could not detect potential trends in risk. The short-term increase in all-cause mortality among UCEP patients found in our study might be explained by the presence of severe underlying disease undiagnosed at the time of upper endoscopy, which could raise the risk of death shortly after the procedure. However, our data may indicate a truly increased risk of death from alcohol dependence, pneumonia (>31 days after procedure), and lung cancer, despite the low statistical precision of our relative mortality estimates. Pneumonia has been reported as a complication of upper endoscopy predominantly within 7 days after the procedure, Therefore the risk increase observed in this study cannot be explained by the endoscopy procedure itself. No obvious pathophysiological mechanism can explain the increase in cause-specific deaths found in our study. The findings could be due to chance or to unmeasured confounding. Our main study findings suggest that UCEP patients have substantially increased risk of hospitalization for IHD and all-cause mortality during 10-years of follow-up. CI: Confidence interval; FGIDs: Functional gastrointestinal disorders; GERD: Gastro-esophageal reflux; HDR: Hospital Discharge Registry; ICD: International Classification of Diseases; IHD: Ischemic heart disease; MRR: Mortality rate ratio; NCCP: Non-cardiac chest pain; UCEP: Unexplained chest/epigastric pain The authors declare that they have no competing interests. EMM collected and analyzed the data used in the study and wrote the manuscript with contribution from BN, CD, HG, AD, PFJ, and HTS. All authors have read and approved the final manuscript. Ischemic heart disease (IHD): Myocardial infarction: ICD-8 code 410 and ICD-10 codes I21-23. Angina: ICD-8 codes 411.09, 411.99 and ICD-10 code I20. Heart failure: ICD-8 codes 402.99, 403.99, 425.99, 427.09, 427.19 and ICD-10 codes I13.0, I25.5, I42.0, I42.6-9, I50.0, I50.1, I50.9. Pneumonia: ICD-8 code 486 and ICD-10 codes J18.0, J18.9. Arteriosclerosis: ICD-8 code 412.9 and ICD-10 codes I25.1, I70.9. Stroke: ICD-10 codes I61.9, I64.9, I69.4. Lung cancer: ICD-8 code 162.1 and ICD-10 code C34.9. Alcohol dependence: ICD-10 code F10.2. Chronic obstructive pulmonary disease: ICD-10 codes J42.9, J43.9, J44.8, J44.9, I27.9. Alcohol-related diseases: ICD-8 codes 303.09, 303.19, 303.20, 303.28, 303.29, 303.90, 303.99, 979, 980, 570.0, 570.9, 571, 571.09, 571.10, 573.00, 573.01, 577.10 and ICD-10 codes F10.0-9, K70.0-9, K71.1-2, K86.0-9, Z72.1, R78.0, T51. Smoking-related diseases: ICD-8 codes 491, 492 and ICD-10 codes J40-44, J98.2, J98.3. Additional file 1: Table 1: Quality, psychosocial variables, participants and settings of the included reviews. This table summarises the 31 psychosocial risk factor reviews identified through the literature search. The authors thank the Department of Surgical Gastroenterology L, Aarhus University Hospital and the Department of Medicine V, Aarhus University Hospital for giving access to the Aarhus University Hospital Endoscopy Registry. This study received financial support from the Research Initiative of Aarhus University Hospital, the Memorial Foundation of Eva and Henry Frænkel, the Clinical Epidemiological Research Foundation, and the Western Danish Research Forum for Health Sciences.
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: Unexplained chest/epigastric pain in patients with normal endoscopy as a predictor for ischemic heart disease and mortality: A Danish 10-year cohort study
