Epigastralgia, abbreviated as epigastralgia, refers to pain occurring in the upper abdomen near the pit of the stomach.

This condition is referred to as "stomach pain at the heart" in Suwen; Jingyue Quanshu calls it "heart abdominal pain"; Shoushi Baoyuan refers to it as "heart epigastralgia". According to its disease cause and mechanism of disease, it can be divided into deficiency pain, qi pain, heat pain, cold pain, stasis pain, food pain, and worm pain.

The heart pain and pain below the heart mentioned in ancient literature often include stomach pain, but this condition should be differentiated from real heart pain. The latter pain often occurs suddenly in the left chest, is severe, like a stabbing or suffocating pain, and is unbearable. The pain may radiate to the left shoulder, back, or the inner side of the left arm, which is known as "heart pain penetrating the back". In severe cases, as described in Lingshu．syncope: "real heart pain, cold hands and feet to the joints, severe heart pain, morning onset leading to death by evening, evening onset leading to death by morning". Its prognosis and treatment are completely different from epigastralgia and should not be confused.

The heart pain in the major chest bind pattern in the "Cold-Damage Disease Treatise" is similar to this condition in location but differs in the nature of the pathogenic factors and the size of the affected area. The pain in major thoracic accumulation extends from below the heart to the lower abdomen, while this condition is limited to the upper abdomen. The former is caused by the internal transmission and transformation of wind-cold into heat, resulting in the binding of water and heat, while the latter is commonly seen in internal damage Zabing.

1. Spleen and Stomach Yang Deficiency︰The epigastrium has dull pain that lingers continuously, with poor appetite and anorexia, regurgitation of clear fluid, preference for pressure and warmth, severe pain when hungry, slight relief after eating, worsening upon exposure to cold, fear of cold, cold limbs, loose stools, and clear, profuse urine. The pain fluctuates in intensity but persists for years without healing. In severe cases, it may be accompanied by hematemesis or bloody stool. Those with qi deficiency may exhibit a dull complexion, emaciation, fatigue and lack of strength, poor appetite and anorexia, or even lower abdominal distension and sagging, chronic diarrhea without control, and prolapse of the rectum. The tongue texture is pale and tender with tooth marks on the edges, thin white and slippery coating, and a deep, slow or soggy, weak pulse. This is often caused by constitutional qi deficiency or prolonged illness leading to spleen-stomach weakness, middle yang deficiency, internal cold generation, and failure of the stomach to receive warmth and nourishment. The pain is characterized by dull stomachache, alleviated by pressure, with tongue and pulse signs indicating deficiency-cold. Treatment should focus on warming and nourishing the spleen and stomach, using Astragalus Center-Fortifying Decoction with modifications; for sinking of middle qi, use Middle-Tonifying Qi-Replenishing Decoction; for severe cold, use Aconite Middle-Regulating Decoction; for hematemesis and bloody stool, use Returning to Spleen Decoction or Oven Yellow Earth Decoction with modifications.
2. Stomach Yin Deficiency︰Dull and burning pain in the epigastrium, dry mouth and lips, epigastric upset resembling hunger, or hunger with anorexia. Retching and hiccups may be observed, and in severe cases, dysphagia and regurgitation. Dry stool. The tongue is red with scant moisture, little or no coating, and the pulse is wiry and thin or rapid. This condition is mostly caused by prolonged stomach disease damaging yin-blood, or Rebing depleting stomach yin. The key points of differentiation lie in the deficiency of yin-fluid, leading to the stomach losing its nourishment and the vessels becoming tense and uncomfortable. Hence, the stomachache is dull and the pain is relatively mild. It is often accompanied by symptoms of yin deficiency such as dry mouth without desire to drink, feverish feeling in palms and soles, a red tongue with scant coating or a glossy red tongue without coating, and a thin pulse. The treatment should harmonize the stomach and nourish yin, assisted by regulating qi. The recommended formula is Ophiopogon Decoction combined with All-Along Decoction with modifications.
3. Liver Qi Depression︰The main clinical manifestations include distension and throbbing pain in the gastric region, extending to both hypochondriac regions, chest tightness and stuffiness, frequent sighing, reduced appetite (anorexia), belching and acid regurgitation, or vomiting. Bowel movements are irregular. The tongue coating is thin white or thin yellow, and the pulse is wiry. The primary causes of qi stagnation are internal damage from the seven emotions, liver qi depression, transverse rebellion affecting the stomach, impaired stomach harmony and descent, obstruction of qi movement, leading to pain (where there is obstruction, there is pain), and migratory pain. The characteristic symptoms include pain accompanied by distension, along with hypochondriac fullness and belching. If qi stagnation persists, it will eventually affect the blood, or prolonged stomachache may injure the collaterals, resulting in static blood retention. For liver depression and qi stagnation, the treatment principle is to soothe the liver and regulate qi while harmonizing the stomach. The recommended formula is Bupleurum Liver-Soothing Powder with modifications.
4. Food Stagnation︰Abdominal distension and fullness, pain that refuses pressure, belching with foul and sour odor, aversion to the smell of food, nausea and vomiting, pain relieved after vomiting. Unsmooth bowel movements. Thick and greasy tongue coating, slippery pulse. This also belongs to an excess pattern, with the main clinical manifestations being epigastric distending pain, belching and vomiting, epigastric upset with acid regurgitation, often with a history of overeating. The key points for differentiating between food stagnation and qi stagnation stomachache: the former presents with epigastric distending pain that refuses pressure, accompanied by aversion to food, belching with foul or sour and rotten odor, thick and greasy tongue coating, and other symptoms of food injury (dyspepsia). The latter involves stomachache radiating to both flanks, or accompanied by chest and hypochondriac distension and discomfort, symptoms of disorder of qi movement. Moreover, the stomachache often occurs or worsens with emotional distress, with belching and acid regurgitation but without foul odor, and no thick and greasy tongue coating. For food stagnation stomachache, the treatment should focus on promoting digestion and removing food stagnation. The recommended formula is Harmony-Preserving Pill with modifications, or Minor Purgative Decoction supplemented with Aucklandia Root and Cyperus to unblock and purge the stomach.
5. Up-flaming of Liver Fire︰Burning and scorching pain in the epigastrium, with a sudden and intense onset, aggravated by pressure and alleviated by cold, aversion to heat, heartburn, acid regurgitation, dry mouth, bitter taste in the mouth, or even vomiting of bitter fluid, sometimes accompanied by hematemesis or bloody stools. Dysphoria, irritability, constipation, and dark urine. The tongue is red with a yellow coating, and the pulse is wiry and rapid. This condition may develop from liver depression and qi stagnation leading to stomachache, often due to emotional distress causing liver qi stagnation, which over time transforms into fire, resulting in liver fire attacking the stomach. Alternatively, it may arise from excessive consumption of spicy, greasy, or rich foods, or the overuse of warming medications, leading to internal heat accumulation. It can also result from exposure to the six excesses, which transform into heat and invade the stomach, causing heat obstruction in the collaterals and disharmony of qi and blood, manifesting as stomachache. Due to the urgent nature of fire, the onset of stomachache is sudden and the pain is severe, often accompanied by thirst with a desire to drink, red face and eyes, and coarse breathing—signs of excess heat. Treatment should focus on clearing heat and resolving stagnation, using modified Qingre Jieyu Tang (Heat-Clearing and Stagnation-Resolving Decoction).
6. Static Blood︰Stomach pain is like being pricked by needles or cut by a knife, with a fixed location and tenderness, possibly accompanied by hematemesis and black stools. The tongue texture is purplish-dark or with ecchymosis, and the pulse is choppy. It belongs to an excess pattern. If qi stagnation persists, it will eventually affect the blood, or stomachache may linger and injure the collaterals, leading to static blood obstruction. As a result, the pain is fixed and immovable, characterized by stabbing pain, along with symptoms such as hematemesis, black stools, and a purplish tongue. The treatment should focus on invigorating blood and resolving stasis to unblock the collaterals. The recommended formulas are Sudden Smile Powder or Infradiaphragmatic Stasis-Expelling Decoction with modifications.
7. Cold Evil Invading the Stomach︰The epigastric pain is severe, alleviated by warmth, and often accompanied by aversion to cold or vomiting of white froth, with no thirst or a preference for hot drinks. The tongue coating is white, and the pulse is tight. This condition is mostly caused by cold invading from the exterior and affecting the spleen and stomach, with a history of exposure to cold or excessive consumption of raw and cold foods. The stomachache occurs suddenly, and the course of the illness is relatively short. The pain is characterized by colicky pain in the epigastrium, with intense severity, a white tongue coating, and a tight pulse, presenting signs of cold excess. The treatment should focus on warming the stomach and dissipating cold. The recommended formula is Lesser Galangal and Cyperus Pill with modifications.

bubble_chart Documentation

1. Yixue Zhengzhuan．epigastralgia: "In ancient prescriptions, there are nine types of heart pain... Upon detailed investigation, their origin lies in the stomach cavity, and not actually in the heart."
2. Shoushi Baoyuan: "Those with epigastralgia mostly indulge in spicy and sour foods, drink hot decoctions with wine, and then consume cold and raw foods, damaging themselves from morning to night, accumulating over time, leading to stagnation and phlegm. The phlegm fire torments, causing blood to flow recklessly, mixing with phlegm and blood, obstructing the rise and fall, hence stomach cavity pain, acid regurgitation, belching, epigastric upset, nausea, all are gradual symptoms of dysphagia and stomach reflux."
3. Zabing Yuanliu Xizhu．Stomach Disease: "Epigastralgia is a disease caused by evil invading the stomach cavity. The stomach is endowed with a harmonious qi, rich in both qi and blood. In the strong, evil cannot invade, but in the weak, it settles and causes disease, whether biased towards cold or heat, water retention, or food accumulation, all clash with vital qi and cause pain. However, the multiplication of liver qi is particularly severe, as the nature of wood is violent, and it directly overcomes."