The upper abdomen is a part of the trunk between the lower ribs and the navel. Epigastrium is the medical term for the upper middle region which lies high up in the abdomen. It is approximately where the breastbone ends, although some of the abdomen is tucked under the ribcage and behind the breastbone.
Causes of Upper Middle Abdominal Pain
1. Esophageal (Gullet) Disorders
- Upper central abdominal pain during swallowing may appear in esophageal varices (mainly in chronic alcoholics) or in esophageal ulcers due to prolonged gastric acid reflux
- Strong painful cramps in the esophagus that may be felt behind and below the breastbone may be due to:
- Dry food
- Hard passage of the food because of the dry esophageal mucosa (in dehydration), overgrown fibrous tissue (strictures) in prolonged GERD or, rarely, in systemic sclerosis
- Improper relaxation of the muscles that embrace the stomach entrance (cardia) due to damaged nerves (mostly during surgery)
Diagnosis is made from history or by upper endoscopy (esophagoscopy).
Gastro-esophageal reflux disease (GERD) refers to back-flow of gastric acid into esophagus. Burning pain below and behind the breastbone and/or in the throat and acidic taste in mouth are main symptoms. The cause is inadequate closure of the stomach entrance from various reasons, like herniation of the upper part of the stomach through a widened opening in the diaphragm (hiatus hernia). Diagnosis is made from symptoms, upper endoscopy and measuring of pressures and pH in the esophagus.
Gastritis (Latin gaster = stomach; -itis denotes inflammation) is inflammation of the inner layer (mucosa) of the stomach with one or more of the following symptoms:
- Burning pain below the breastbone, worsening during or after the meal
- Nausea and vomiting
- Early satiety
- Excessive belching (burping)
- Heartburn, burning feeling behind the breastbone and/or in the throat
- Abdominal cramps
- Black stools
The causes of acute (sudden) gastritis include infection with rotavirus (stomach flu) , mainly in children, food poisoning, excessive secretion of gastric acid, painkillers like aspirin or ibuprofen, acidic foods, spices and so on.
The causes of chronic (prolonged or recurrent) gastritis include infection by bacterium Helycobacter pylori, rare autoimmune gastritis (with vit B12 deficiency and anemia), chronic poisoning and so on.
In most cases, diagnosis of gastritis may be made from symptoms. In doubtful cases, X-ray with contrast (barium swallow) and upper endoscopy (gastroscopy) may be performed. White blood cells in the blood may (not necessary) be elevated and stool test for occult blood may be positive.
Gastroparesis refers to slow stomach emptying due to inadequate relaxation of muscles that embrace the stomach exit (pylorus) because of damaged nerves (mostly in long term atherosclerosis or diabetes), hormonal disorders, psychological reasons or fibrous tissue after healing of chronic gastric ulcer or after stomach surgery . Pain or cramping during or shortly after the meal in the upper middle abdomen, early satiety, heartburn, upper abdominal bloating and excessive belching (burping) are main symptoms. Diagnosis is made by gastric emptying tests.
5. Peptic Ulcer
- Stomach ulcer is an open sore appearing in the inner layer (mucosa) of the stomach, which causes dull or burning pain in the upper middle abdomen during or shortly after the meal; avoiding eating and losing weight may follow.
- Duodenal ulcer appears in the duodenum (the first part of the small intestine) and may cause dull or burning pain between meals and typically at night. Black stool from bleeding may appear in both gastric and duodenal ulcers.
Diagnosis of a peptic ulcer is made by upper endoscopy (gastroduodenoscopy).
6. Gastric Carcinoma (Stomach Cancer)
Stomach cancer may appear at any age but mostly in people after 50. Beside upper middle abdominal pain, nausea, poor appetite, losing weight and black stools are common. Diagnosis is confirmed by gastroscopy and examination of the sample of the gastric mucosa under the microscope.
7. Pancreatic Disorders
- Inflamed pancreas. Acute pancreatitis is inflammation of the pancreas, mainly due to long term alcohol abuse or gallstones and may cause central or left side upper abdominal pain and nausea. Chronic pancreatitis usually results from repeating attacks of acute pancreatitis.
- Pancreatic cancer may be preceded by long term chronic pancreatitis, but it may arise from the healthy pancreas. Main symptoms are upper middle abdominal pain, poor appetite, losing weight and white diarrhea or floating stools.
Diagnosis. In acute pancreatitis, pancreatic enzymes in the blood are elevated. Diagnosis of chronic pancreatitis is usually made by CT; pancreatic enzymes in the blood are not typically changed. In pancreatic cancer, pancreatic amylase and CA-19-9 marker (not always) are elevated.
Video on Upper Middle Abdominal Pain
8. Muscle Tear
Muscle tear is usually due to injury (hit with a hard object, stitch with a sharp object or rupture during exercise). The injured spot is tender to the touch. Hematoma (blood collection) may build within the muscle and can cause a small visible (bluish) and palpable (soft) bulge. Diagnosis is made by physical examination and ultrasound.
9. Intestinal Hernia
A part of small intestine may protrude through a cleft in upper abdominal muscles. Pain and a soft bulge of a golf ball size are main symptoms. Doctor can usually give diagnosis after physical examination.
10. Broken Breastbone
- Broken xiphoid (the lower part of the breastbone) may cause upper middle abdominal pain. Diagnosis is made by X-ray.
- Costohondritis – inflammation of the connection between the bony and cartilaginous parts of the lower ribs (about an inch from the breastbone on each side) may appear as chest and upper middle abdominal pain. Lower rib(s) may be tender to the touch. Diagnosis is made by physical examination.
11. Spinal Disorders
Bulging or herniated disc, spondylitis (spinal arthritis), broken vertebra or other disorder in the chest or lumbar part of the spine may cause upper middle abdominal pain and middle or lower back pain. Pain usually changes with moving or body position, aggravates with sitting and is relieved by walking. Diagnosis is made by CT or MRI.
12. Aneurysm or Dissection of Abdominal Aorta
In patients over 50 years of age, the wall of the aorta may be weakened due to atherosclerosis or other disorder leading to aortic wall bulging (aneurysm) or splitting of its layers (dissection). Constant dull upper abdominal pain that worsens during or after the meal is the main symptom. Diagnosis is made by the ultrasound, CT or MRI.
13. Heart Attack
Heart attack may appear with upper middle or left upper abdominal pain and is rare before 40 years of age. Smoking and high blood cholesterol are two important risk factors. Diagnosis is made on the basis of symptoms, ECG and elevation of certain enzymes in the blood.
Enlarged lymph nodes near the stomach, appearing in gastric lymphoma may be painful. Low grade fever, paleness, fatigue and losing weight are other symptoms of lymphoma. Diagnosis is made by CT or MRI.