Table 18

Investigation and management of chronic epigastric pain

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Neuropathic postoperative pain	Refer to the pain team.
First line
Routine and additional blood tests	Abnormal results	Follow treatment for abnormal blood results (p. 2).
OGD and SI aspirate (p. 25)	Inflammation/ulceration	See management of acid or bile related inflammation (p. 25).
OGD and SI aspirate (p. 25)	Local fungal infection	Consider treatment with nystatin or fluconazole.
	Oesophageal or pyloric stricture	Consider dilatation (p. 25) with careful biopsy only after discussion with cancer MDT.
	Spasm	Start PPI or H2 antagonist. Calcium antagonist. Low dose antidepressant.
	Malignancy/tumour recurrence	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Benign peptic ulceration	Treat with PPI. Arrange follow-up endoscopy if oesophageal or gastric in 6 weeks. Consider Helicobacter pylori eradication.
US	Biliary tree obstruction	This is an emergency if any fever. Otherwise discuss with the supervising clinician within 24 hours.
	Gallstones Pancreatic duct problems Renal stones	Discuss with the supervising clinician within 24 hours.
	Ascites	Discuss with the supervising clinician and the oncology team within 24 hours.
	Mesenteric ischaemia	This is an emergency. Discuss with the on-call surgical team immediately.
	Malignancy/tumour recurrence/lymphadenopathy	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Pancreatitis	Refer to the appropriate MDT
ECG	Acute cardiac ischaemia	This is an emergency. Discuss with cardiology.
	Normal resting ECG but cardiac aetiology suspected	Urgent referral to cardiology.
Glucose hydrogen methane breath test	SIBO	Management of SIBO (p. 27).
Second line
AXR	Faecal loading	See management of constipation (p. 26).
	Ileus/obstruction	This is an emergency. Discuss immediately with the on-call surgical team and arrange urgent CT scan.
CXR	Infection	Discuss with the supervising clinician within 24 hours and treat appropriately.
CT/MRI/PET	Malignancy/tumour recurrence/lymphadenopathy	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Consider also Internal hernia (if Roux-en-Y) Jejunal tube complication, eg, volvulus (if still in situ) Pancreatitis	These are emergencies. Refer to the upper GI surgical team
	Mesenteric ischaemia	This is an emergency. Discuss with the on-call surgical team immediately.
	Ascites	Discuss with the supervising clinician and the oncology team within 24 hours.
Third line
If normal investigations/no response to intervention		Reassure.

AXR, abdominal X-ray; CT, computerised tomography; CXR, chest X-ray; GI, gastrointestinal; H2, histamine receptor 2; MDT, multidisciplinary team; MRI, magnetic resonance imaging; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PET, positron emission tomography; PPI, proton pump inhibitor; SIBO, small intestinal bacterial overgrowth; US, ultrasound.