Upper Abdominal Pain: Causes, Symptoms and When to Worry

Where is the upper abdomen?

Doctors divide the abdomen into regions. The upper abdomen has three:

• Epigastric area (center): just below the breastbone. The stomach, the first part of the small intestine (duodenum), the pancreas and the lower esophagus sit here. "Central upper abdominal pain" means pain here.
• Right upper quadrant: under the right ribs. The liver, gallbladder and bile ducts.
• Left upper quadrant: under the left ribs. The stomach, spleen, tail of the pancreas and part of the colon.

Pain from inside organs is often poorly localized at first, and some pain comes from outside the abdomen. A heart attack, pneumonia at the base of a lung or a rib injury can all be felt as upper abdominal pain.

Upper abdominal pain causes by location

Common causes of upper abdominal pain

Indigestion (dyspepsia)

Functional dyspepsia is the most common cause of recurring central upper abdominal pain. It feels like burning, gnawing or early fullness after eating, often with bloating and nausea. Tests are normal. Stress, large meals, fatty food, alcohol and smoking make it worse.

Gastritis and peptic ulcers

Gastritis is inflammation of the stomach lining. A peptic ulcer is an open sore in the stomach or duodenum. The two main causes are infection with Helicobacter pylori bacteria and anti-inflammatory painkillers (NSAIDs) such as ibuprofen, naproxen and aspirin. Ulcer pain is burning and central. Duodenal ulcer pain often improves with food and returns 2 to 3 hours later or at night. Ulcers can bleed (black stools, vomiting blood) or perforate.

Acid reflux

Gastroesophageal reflux disease causes heartburn behind the breastbone that can spread into the upper abdomen, with sour regurgitation. It is worse after meals, bending over and lying flat. A hiatal hernia makes it more likely.

Gallstones

Gallstones cause biliary colic: steady, severe pain under the right ribs or in the center, often starting 30 to 60 minutes after a fatty meal or at night. It lasts from 30 minutes to several hours and may spread to the right shoulder blade. Pain lasting longer than about 6 hours, or with fever, suggests an inflamed gallbladder (cholecystitis).

Gas, bloating and constipation

Trapped gas in the colon, especially where it bends under the left ribs, causes sharp, shifting pain with abdominal bloating that eases after passing gas or a bowel movement.

Serious causes not to miss

• Acute pancreatitis: severe, constant central pain that spreads through to the back, with vomiting. Sitting forward eases it slightly. Gallstones and alcohol are the main causes. See acute pancreatitis.
• Heart attack: especially in women, older adults and people with diabetes, a heart attack can feel like indigestion or epigastric pressure, with sweating, nausea and breathlessness. Never assume new "indigestion" with exertion is your stomach. See heart attack.
• Perforated ulcer: sudden severe pain that spreads across the abdomen with a rigid belly.
• Hepatitis and liver disease: a dull ache under the right ribs with jaundice, dark urine, tiredness and loss of appetite.
• Abdominal aortic aneurysm: in older smokers, sudden pain in the abdomen or back with dizziness or fainting.
• Stomach, pancreatic or esophageal cancer: persistent pain with weight loss, difficulty swallowing, vomiting or anemia, mostly after age 55.
• Preeclampsia and HELLP syndrome: pain under the right ribs late in pregnancy.
• Lower lung pneumonia: upper abdominal pain with cough, fever and pain on breathing in.

Upper abdominal pain symptoms and what they suggest

How doctors find the cause

A doctor will ask exactly where the pain is, how it started, how long it lasts, what it feels like, and whether it relates to meals, alcohol, NSAIDs or exertion. They will press on your abdomen to find tenderness and check for a positive Murphy's sign (pain and a catch in breath when pressing under the right ribs, typical of cholecystitis).

Tests depend on the clues:

• Blood tests: blood count, liver tests, lipase (raised in pancreatitis), kidney function, and troponin if a heart cause is possible.
• ECG: for anyone with pain that could be cardiac.
• Ultrasound: the first test for gallstones and liver problems.
• H. pylori test: a breath or stool test for people with dyspepsia.
• Upper endoscopy: a camera into the stomach for ulcers, persistent symptoms, or alarm features such as weight loss, bleeding or trouble swallowing.
• CT scan: for severe pain, suspected pancreatitis complications, perforation or aneurysm.
• Pregnancy test in women of childbearing age.

Treatment and relief

Treatment depends on the cause.

Home care for mild upper stomach pain

• Eat smaller meals and stop eating 3 hours before bed.
• Cut back on alcohol, fatty and spicy food, coffee and fizzy drinks if they trigger pain.
• Stop smoking.
• Raise the head of your bed if pain comes with reflux at night.
• Use an antacid or an over-the-counter acid reducer (an H2 blocker or a proton pump inhibitor), following the label. See a doctor if you need them for more than 2 weeks.
• For pain relief, use acetaminophen (paracetamol) rather than ibuprofen, naproxen or aspirin, which irritate the stomach.

Medical treatments

• Acid suppression with proton pump inhibitors for reflux, gastritis and ulcers.
• H. pylori eradication: a 2-week course of antibiotics with acid suppression, followed by a test to confirm the infection has cleared.
• Gallbladder removal (cholecystectomy) for recurrent biliary colic or cholecystitis, usually keyhole surgery.
• Hospital care for pancreatitis: fluids, pain relief and treating the cause.
• Treatment of the heart if the pain is cardiac.

Frequently asked questions

What causes central upper abdominal pain?

Central upper (epigastric) pain most often comes from indigestion, gastritis, acid reflux or a peptic ulcer. Gallstones and pancreatitis can also cause it. Because a heart attack can feel like epigastric pain, pressure-like pain with sweating, breathlessness or exertion needs emergency assessment.

When should I worry about upper abdominal pain?

Seek emergency care for sudden severe pain, pain spreading to your back, a rigid belly, vomiting blood, black stools, or pain with sweating and breathlessness. See a doctor soon for jaundice, fever, persistent vomiting, weight loss or pain lasting more than 2 weeks.

What does pain in the upper abdomen between the ribs mean?

Pain high in the center, just below where the ribs meet, usually comes from the stomach or lower esophagus, such as reflux, gastritis or an ulcer. It can also come from the heart or a hiatal hernia. Pain that comes on with exercise and eases with rest should be checked for heart disease.

Can stress cause upper abdominal pain?

Yes. Stress and anxiety can trigger functional dyspepsia, worsen reflux and increase sensitivity of the gut. The pain is real, not imagined. Still, new or changing pain, especially after age 55 or with weight loss, should be tested before it is put down to stress.

Is upper abdominal pain after eating a gallbladder problem?

It can be. Gallstone pain typically starts 30 to 60 minutes after a fatty meal, sits under the right ribs or center, and lasts from 30 minutes to a few hours. Burning pain soon after eating is more typical of gastritis or reflux. An ultrasound tells them apart.

What is the fastest way to relieve upper stomach pain?

For mild indigestion or heartburn, an antacid works within minutes, and sitting upright helps. Sip water and avoid lying down or eating more. Avoid ibuprofen and aspirin. If pain is severe, persistent or comes with red-flag symptoms, seek medical care rather than waiting.