Upper Middle Abdominal Pain (Epigastric) Causes and Symptoms

Abdominal pain can be one of the most difficult symptoms to diagnose due to the host of different organs in the abdominal cavity. Identifying the cause of the pain depends on the nature of the pain, exact region within the abdomen, other symptoms that are present alongside the pain, and factors that worsen and ease the pain. If this is insufficient to diagnose the pain then diagnostic investigations like an x-ray or ultrasound may be necessary.

What is epigastric pain?

Epigastric pain is pain in the upper middle part of the abdomen. This area is known as the epigastrium. Most of the abdomen is occupied by the digestive organs, like the stomach, intestines (small and large) andthe liver. We tend to assume that abdominal pain is due to a problem with the digestive system but there may be a host of other possible causes. First it is important to understand which organs lie in the region of the abdomen where the pain is being experienced. Second the associated symptoms need to be considered.

Upper middle abdominal pain may also be linked to problems in the chest cavity since the region lies right next to the thorax. This may also cause some degree of confusion. For example, a heart attack can cause epigastric pain and there may be nausea or vomiting which most people will assume to be a digestive rather than a heart problem. As a general rule, epigrastic pain that is severe and unabating, worsening over time, accompanied by symptoms like dizziness or difficulty in breathing should always be investigated by a medical professional immediately.

Organs in the Upper Middle Abdomen

Before delving into the organs in this region it is important to understand where the upper middle abdomen (epigastrium) lies. Contrary to popular belief, the abdomen does not begin at the bottom edge of the lowest ribs. A flat muscular sheet known as the diaphragm separates the thorax (chest cavity) from the abdomen. This sheet lies a short distance below the nipples. Therefore the upper abdomen lies underneath the ribcage to a certain degree.

Given the V-shape formed by the lower ribcage towards the center, the upper middle abdominal area is not shielded by the ribcage to the extent as the upper right or upper left region of the abdomen. The epigastrium is also sometimes referred to as the pit of the stomach or as the solar plexus or celiac plexus, named according to the the nerve network that lies in this region. There are several organs that lie partly in the upper middle abdominal region or cross through it, including the:

  • Stomach
  • Pancreas
  • Gallbladder and bile ducts
  • Liver
  • Small intestine (first portion known as the duodenum)
  • Colon (transverse portion)
  • Abdominal aorta

Since the diaphragm flattens during inhalation, the thoracic (chest) and abdominal organs can move slightly downwards for short periods. Similarly, there may be a slight shift in position when a person is lying down or standing up due to the action of gravity.

Causes of Upper Middle Abdominal Pain

The symptoms associated with upper abdominal pain may overlap with the various causes. This may be continuous with pain and other symptoms of:

 Abdominal Wall

Abdominal wall pain is one of the leading causes of abdominal pain but is often overlooked for deeper lying conditions. The abdominal wall is composed of skin, muscles, fascia and fat. It is easily injured by blunt and sharp force. Furthermore there are various skin diseases that could result in pain or muscular problems as is the case with muscle strain among other conditions. Similarly, diseases of the superficial nerves can also cause abdominal pain as is seen in shingles.


Most of the stomach lies in the left upper quadrant (LUQ) of the abdomen but it also extends into the epigastrium. Stomach pain in the epigastric region may be due to conditions like gastritis and peptic ulcers which are relatively common problems. Gastroenteritis may also affect the stomach. Less common stomach diseases include gastroparesis and stomach cancer.

Symptoms related to stomach causes may include:

  • Nausea
  • Vomiting
  • Pain when hungry or after eating
  • Bloating
  • Acid reflux

Small Intestine

The first part of the small intestine known as the duodenum is connected to the stomach. A host of conditions can affect the duodenum but the most common is peptic ulcers. It may develop for the same reasons as gastritis and stomach ulcers. It may also become inflamed with infections. Small intestine cancer is uncommon but can also account for epigastric pain especially when The symptoms of small intestine inflammation are similar to stomach inflammation:

  • Nausea
  • Vomiting
  • Pain after eating
  • Loss of appetite
  • Diarrhea


The pancreas is responsible for secreting hormones into the bloodstream and digestive enzymes into the duodenum. It can be injured with trauma to the abdomen but the more common pancreatic condition is acute pancreatitis. This is often related to excessive alcohol consumption. Chronic pancreatitis is another possibility and is largely asymptomatic except when there are acute flareups. Pancreatic cancer is one of the more common types of cancers and is very aggressive. Less common pancreatic conditions include pancreatic cysts and pseudocysts.

The symptoms of pancreas problems include:

  • Nausea
  • Vomiting
  • Severe pain extending to the back
  • Diarrhea
  • Unintentional weight loss

Gallbladder and Bile Duct

The gallbladder is located under the liver and bile from the livers is stored in it. This bile is then passed out through the bile ducts into the duodenum. One of the more common gallbladder problems is gallstones. Small gallstones be passed out unnoticed but larger stones can become lodged in the neck of the gallbladder or the bile duct. Gallbladder inflammation is known as cholecystitis which can occur with gallstones and infections. The bile ducts may beceom infected or narrowed (strictures). Gallbladder cancer is another possible cause as is bile duct cancer.

Symptoms include:

  • Nausea
  • Vomiting
  • Colicky pain
  • Diarrhea
  • Jaundice


Most of the liver lies in the right upper quadrant but crosses the midle to extend into the left upper quadrant. A host of liver diseases can cause upper abdominal pain including hepatitis which is more commonly due to viruses, autoimmune diseases, excessive alcohol consumption or with exposure to toxins. It may lead to cirrhosis which is usually not painful. Liver cancer is another possible cause of pain. The symptoms include:

  • Jaundice
  • Nausea
  • Vomiting
  • Diarrhea
  • Weight loss


The transverse colon crosses the epigastric region. Therefore colon conditions can lead to pain in the upper middle abdominal region. This may be seen with conditions like colitis, diverticulitis, inflammatory bowel disease, irritable bowel syndrome, colonic polyps and colon cancer. Symptoms may include:

  • Diarrhea or sometimes constipation
  • Abdominal cramps
  • Excessive flatulence
  • Blood or mucus in he stool

Abdominal Aorta

The aorta enters the abdomen towards the left of the midline. Conditions of the aorta like aortitis or aortic dissection can cause upper middle abdominal pain. An abdominal aneurysm is usually not painful but there may be a pulsating sensation felt in the abdomen.

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