Most of the times, the pain in the epigastrium is due to peptic ulcer, non-ulcer dyspepsia or gall bladder disease. Often if the history is elicited properly, the patient will agree with you when suggested that the pain is felt superficially and not deep inside the tummy. The same thing applies to the pain due to congested or infected liver, where the pain and the tenderness are felt superficially, rather than deep.

I am writing this article to stress the fact that some times the patient complains that the pain, which he has experienced, is ‘deep’ in the epigastrium or in the upper abdomen. Often he shows this with a gesture by pressing tightly in the epigastrium towards the spine. Such deep epigastric pains should be given due importance because quite often, they point to a disease of deep-seated organ, like the pancreas.

During more than 40 years of practice, I have often appreciated the intelligence of many uneducated patients, who have diagnosed a sudden rupture of the blood vessel in the brain (subarachnoid haemorrhage) or sudden rupture of the viscera in the abdomen (perforation of the duodenal ulcer).

Remember that the observations of the patient are more accurate and informative than the physical signs.