By Dr. Faisal Ali
Pain is a euphemism for distress that brings the mellowness and maturity level of an individual to a standstill. Epigastric pain is one of those medical auguries which can be elicited by several disorders.
Myocardial infarction (MI) can mimic pain at epigastric surface which by definition is pathologically irreversible death of myocardial cells caused by Ischemia. Due to high quality measures of Cardio-protection and emergence of novel cardio protective strategies in experimental arena like that of Stem Cell therapy, Ischemic post conditioning, Remote Ischemic Preconditioning (RIPC), Activation of RISK pathway & Mitochondrial Permeability Transition Pore (mPTP), this pathology has been curtailed to a great extent in Europe and USA.1
In the amphitheatre of Gastro-enterology, Alcohol consumption, GERD, PUD, H-pylori induced Gastritis, Hepatitis, Acute and Chronic Pancreatitis, Pancreatic calculi, Pancreatic Tuberculosis, Cholelithiasis, Cholecystitis, Abdominal Angina & SMA Syndrome are some of the aberrant conditions that can present with an epigastric pain. Abdominal angina is defined as the postprandial pain that occurs in individuals who have Mesenteric Vascular Occlusive Disease that has advanced to the point where blood flow cannot increase enough to meet visceral demands. While Superior Mesenteric Artery (SMA) Syndrome is a digestive condition that occurs when the duodenum is compressed between Abdominal Aorta posteriorly and Superior Mesenteric Artery anteriorly.
In the surgical sphere, Duodenal perforation and Hiatus Hernia are the scenarios that also mimic pain epigastrium. The classical presentation of duodenal perforation is painful and tender epigastrium along with a linear radiolucent shadow of air under diaphragm on right side of Abdominal X-Ray.
In the field of Oncology, Carcinoma of Pancreas and Gastric Adenocarcinoma are the two foremost neoplasms that induce Epigastric pain.2,3 The risk factors for Pancreatic cancer include age, tobacco use, heavy Alcohol use, obesity, chronic pancreatitis, DM, prior abdominal radiation, family history, CKDN2A or PRSS1 mutation, Peutz-Jeghers Syndrome and exposure to Arsenic and Cadmium.4 Diarrhea, weight loss, depression, nausea, vomiting, ↓ oral intake, jaundice due to biliary obstruction, Courvoisier sign & Sister Mary Joseph’s nodule are other presenting signs and symptoms of pancreatic carcinoma.5
Contrast-Enhanced Endoscopic Ultrasound (EUS) and Multiphase thin-cut helical CT are the imaging techniques of choice for the detection of Pancreatic carcinoma.6 Whipple resection is strictly indicated for cancers that are limited to the head of pancreas, peri-ampullary area & Duodenum (T1, NO, MO).7 Metastatic Pancreatic cancers are treated with FOLFIRINOX in combination with Gemcitabine & nab-paclitaxel.8 Celiac plexus nerve block under CT or Endoscopic Ultrasound guidance or Thoracoscopic splanchnicectomy may improve pain control.9 Metformin may improve survival in DM patients with Pancreatic Adeno-carcinoma.10
During my survival as a medical practitioner in the COVID-19 pandemic, I pitched upon a 40 years old patient with Metastatic Adenocarcinoma of Pancreas by the name of Sadiq S/O Alam Gul. His area of residence was Mardan, KPK. The patient suffered from postprandial epigastric pain about one year ago. Upon his complaint, He was taken by his relatives to the medical unit of a hospital where he was diagnosed as a case of Acute pancreatitis. His initial investigations revealed stool +ve H-Pylori, ↑ Serum Lipase (71µ/L), ↑ serum IgG-4 (907), ↑ serum TG (325mg/dL). EGD showed antral erosions while MRCP was normal. He was treated for acute pancreatitis for a period of 6 months but his pain did not subside. After a lapse of one year, a gastroenterologist advised contrast enhanced CT-Abdomen for him. On 4-8-2021, His CT Abdomen was performed and it revealed mildly swollen pancreas with irregular margins in body region. A mass was observed in the body of pancreas measuring 2.2×40mm. Furthermore, some hypo attenuating areas were noted in the liver. His Liver Biopsy was carried out on 13-08-2021 whose results exhibited Metastatic Adenocarcinoma & later on, he died on 23rd January, 2022.
It is therefore concluded that the community of medical practitioners should shape a broad spectrum portrait of a patient with pain epigastrium which is the hallmark of my essay. A patient with pain epigastrium may suffer from a simple disease but it is also possible that he may be experiencing an agonizing situation like that of Metastatic Adenocarcinoma patient who belonged to District Mardan which I observed. In short, the clinicians should not procrastinate the matter of chronic pain epigastrium.
The writer is a postgraduate of Community Child Health from Khyber Medical University (KMU) and currently serves as medical officer at Type-D hospital, Tehsil Banda Daud Shah, District Karak, Pakistan.
