Epigastric pain is pain in the area defined as epigastrium. The epigastric region is the area medial to the nipples, above the umbilicus and beneath the ribs. Most commonly, epigastric pain is experienced in a fist sized area beneath the notch of the ribs. The pain may radiate to the hypochondriac region or back, and may associate with symptoms such as intergestion, flatulence, nausea, vomiting, acid reflux, indeterminate gnawing hunger, coldness in the body, black sticky stools or constipation and diarrhoea.
The epigastric region is under the control of the Stomach, Spleen and Liver. Most epigastric pain is associated with Stomach and/or Liver pathology. The most common patterns clinically are Liver and Stomach disharmony, stomach qi or yang deficiency, and Stomach Heat or yin deficiency.
Epigastric pain can be acute or chronic, or chronic with acute exacerbations. When acute and severe, possible surgical emergencies, such as perforated peptic ulcer, should be kept in mind. In general, it is chronic or recurrent epigastric pain that brings patients to seek Traditional Chinese Medicine treatment, and for which is usually quite successful.
Aetiology
Cold
External Cold: External cold can be introduced into the body in association with Wind, or directly, by ingestion of large quantities of cold natured or physically cold foods, drinks or medications. Enviromental Cold can invade the gastro-intestinal system directly through the mouth, bypassing the surface altogether. Invasion of external Cold is facilitated by pre-existing weakness of Spleen and Stomach qi and/or yang. Cold invasion usually causes acute epigastric pain.
Internal Cold: Internal Cold is the product of a deficiency of Spleen and/or Kidney yang, whereby yin Cold becomes predominant relative to warming active yang. Depending on the degree of deficiency and the degree of Cold, the pain produced can vary. When the deficiency elements are primary, the pain tends to be mild and dull, relieved by both warmth and pressure. When yin Cold excess is predominant, the pain tends to be fairly severe and cramping, relieved by warmth but made worse by pressure.
Heat
External Heat: External Heat can invade the gastro-intestinal system directly, or follow a virulent, or unresolved, acute exterior disorder. Heat, or Cold which transforms into Heat as it penetrates deeper into the body, pushes through the surface, the shao yang level, and lodges in the yang ming level, the Stomach and Intestines. Occasionally, febrile illness can leave a residue of phlegm Heat in the Stomach, causing pain and discomfort. External Heat type epigastric pain is mostly acute.
Internal Heat: Consumption of heating foods introduces Heat directly into the Stomach. Internally generated Heat that affects the Stomach may also be the product of chronic Liver qi stagnation that generates stagnant Heat or Fire. Once stagnant Heat is present in the Liver system, it can be introduced into the Stomach via the controlling cycles, similarly, but less commonly, prolonged worry, anxiety and depression, or a sudden shock can retard the movement of Heart qi. The resulting accumulation of qi creates a focus of pressure in the chest, which can result in Heart Fire. Heart Fire can be transmitted via the generating cycle to influence and heat the Stomach. Internal Heat can also be created by yin deficiency. The Stomach needs a degree of moisture for efficient operation, and is thus easily dried out and heated up by a systemic increase in Heat from yin deficiency.
Diet
The type of food consumed and the way it is consumed are important factors in the genesis of epigastric pain. Eating spoiled or contaminated food can produce acute pain, which in TCM terms may resemble an attack of Cold or Damp Heat.
To much cold natured food can introduce Cold and weaken Spleen and Stomach qi and yang. Some drugs weaken the middle jiao and deplete Spleen and Stomach qi and yang. Reduced food intake as a result of strict dieting, or prolonged starvation or digestive insult, such as occurs in patients with a history of anorexia nervosa, bulimia or during famine, serious damages Spleen yang.
Over consumption in general, and excessive consumption of rich, heating or supplementing foods in particular, can lead to the accumulation of stagnant food and Heat or Damp in the Stomach. Food stagnation is a common precursor to a host of pathologies that may give rise to epigastric pain. Eating large quantities of foods that heat the Stomach and Liver, specifically substances like chilli and spices, alcohol, coffee and chocolate cause Heat to accumulate. Once Heat is resident in the Stomach it easily damages Stomach yin. The natural tendency of Heat to rise can contribute to acid reflux which may damage the lining of the oesophagus and cause pain. Some specific foods are notorious for being indigestible to some people, and easily cause acid and pain. These include acid foods like the citrus family, tomatoes, uncooked peppers and capsicums, radishes, onions and garlic. Sugar and dairy products create Dampness and Phlegm.
Drugs
Numerous therapeutic agents, both herbal and pharmaceutical, legal or illicit, can cause epigastric pain. Probably most common are those that are cold in nature, such as non steroidal anti-inflammatory agents (NSAIDs), purgative laxatives and occasionally antibiotics. Non steroidal anti-inflammatory agents are well known for physically damaging the lining of the Stomach. Drugs that are heating can also damage the Stomach, consume yin and cause pain. These include corticosteroids, alcohol, inappropriate yang supplementing medicines, and stimulants such as cocaine and speed.
Emotion
Emotional factors, particularly those that contribute to stagnant Liver qi, are a major factor in the development of epigastric pain. Liver qi stagnation is most commonly produced by repression of emotions, the buried frustrations of everyday life, the suppressed anger and resentments. It also arises from exposure to ongoing stress or emotional tension, whether at work, at home or at school.
Prolonged qi stagnation can contribute to several complications which also cause pain, such as Blood stagnation, stagnant Heat and Spleen deficiency with the eventual generation of internal Cold or Dampness. In addition, qi stagnation leads to a generalised hypertonicity of both skeletal and smooth muscle, further restricting the circulation of qi and Blood to the tissues.
In addition to the emotional factors that upset the Liver, worry, obsessive thinking and prolonged concentration in combination with a sedentary or studious lifestyle and poor diet, will weaken Spleen and Stomach qi. When weak, the Stomach is predisposed to invasion by Liver qi resulting in further damage.
Some Biomedical Causes of Epigastric Pain
Gastro-intestional
> Acute and chronic gastritis
> Peptic ulcers
> Acute and chronic pancreatitis
> Oesophagitis/reflux
> Cholecystitis
> Chloelithiasis
> Gastrospasm
> Carcinoma – stomach oesophagus, pancreas
> ‘Nervous’ stomach
> Irritable bowel syndrome
> Dyspepsia
Cardiac
> Referred myocardial infarction
Respiratory
> Referred lower lobe pneumonia
Medications
> Aspirin/NSAIDS
> Cortisone
> Alcohol abuse
Other
> Poisoning
Treatment
Treatment of epigastric pain is generally quite successful with TCM, especially when combined with dietary and life habit modifications. Acupuncture is effective for relieving acute pain and for gradual removal of the stagnation which contributes to chronic epigastric pain. Herbs are usually required to replenish Blood and yin.