What evaluation would you do for a patient presenting with abdominal pain, bloating, burping, nausea, vomiting, and heartburn?

Evaluation of Abdominal Pain with Bloating, Burping, Nausea, Vomiting, and Heartburn

The initial evaluation for a patient with abdominal pain, bloating, burping, nausea, vomiting, and heartburn should include a focused history, physical examination, basic laboratory tests, and upper endoscopy for patients with alarm features, with additional testing guided by predominant symptoms.

Initial Assessment

History

• Characterize predominant symptoms (nausea/vomiting vs. abdominal pain/discomfort)
• Document onset, duration, and progression of symptoms
• Identify alarm features:
  • Weight loss
  • Dysphagia
  • Hematemesis
  • Melena
  • Family history of GI malignancy
  • Age >60 years with new-onset symptoms
  • Anemia
  • Persistent vomiting

Physical Examination

• Vital signs (tachycardia, hypotension may indicate volume depletion)
• Abdominal examination focusing on:
  • Tenderness and location
  • Distention
  • Succussion splash (suggests delayed gastric emptying)
  • Right upper quadrant bruit (suggests celiac artery compression syndrome)
  • Peritoneal signs (suggests perforation or severe inflammation)
  • Masses or enlarged lymph nodes

Laboratory Testing

• Complete blood count (CBC) - elevated WBC >10,000/mm³ may suggest inflammation 1
• Basic metabolic panel - assess electrolytes and renal function
• Liver function tests
• Amylase/lipase if pancreatitis suspected
• Pregnancy test for women of childbearing age
• H. pylori testing (stool antigen, breath test, or during endoscopy)
• Celiac disease serologies for patients with bloating 1

Diagnostic Imaging and Procedures

For All Patients with Persistent Symptoms

• Upper endoscopy should be performed in patients with:
  • Alarm features
  • Recent worsening of symptoms
  • Abnormal physical examination findings
  • Age >60 with new-onset symptoms
  • Symptoms that persist despite empiric therapy 1

For Patients with Predominant Nausea and Vomiting

• Gastric emptying study if gastroparesis is suspected (especially with diabetes, post-surgical changes) 1
• Consider impedance pH monitoring to differentiate between gastric and supragastric belching 1

For Patients with Predominant Bloating and Distention

• Carbohydrate breath testing if carbohydrate enzyme deficiencies or SIBO suspected 1
• Anorectal physiology testing if bloating is related to constipation or difficult evacuation 1

For Patients with Suspected Mechanical Obstruction

• CT abdomen and pelvis with IV contrast is the preferred initial imaging modality (>90% diagnostic accuracy) 2
• Plain radiography has limited diagnostic value but may identify perforation 1

Differential Diagnosis Based on Symptom Clusters

Gastroesophageal Reflux Disease (GERD)

• Primary symptoms: heartburn, regurgitation
• Atypical symptoms may include nausea, chest pain, cough, wheezing 3
• Diagnosis: typically clinical, may require endoscopy or pH monitoring

Functional Dyspepsia

• Symptoms: epigastric pain, early satiety, postprandial fullness
• Diagnosis: Rome IV criteria after excluding organic disease

Gastroparesis

• Symptoms: nausea, vomiting, early satiety, bloating
• Risk factors: diabetes, post-surgical, medications
• Diagnosis: gastric emptying study 1

Small Intestinal Bacterial Overgrowth (SIBO)

• Symptoms: bloating, flatulence, diarrhea
• Diagnosis: glucose or lactulose breath testing 1

Celiac Disease

• Symptoms: bloating, diarrhea, abdominal pain
• Diagnosis: serologic testing followed by duodenal biopsy if positive 1

Peptic Ulcer Disease

• Symptoms: epigastric pain, nausea, vomiting
• Risk factors: H. pylori, NSAIDs
• Diagnosis: upper endoscopy

Biliary Disease

• Symptoms: right upper quadrant pain, nausea, vomiting
• Diagnosis: ultrasound, liver function tests

Special Considerations

When to Consider Acute Mesenteric Ischemia

• Severe abdominal pain out of proportion to physical exam findings
• Risk factors: atrial fibrillation, heart failure, hypercoagulable states
• Requires immediate CT angiography if suspected 1

When to Consider Intra-abdominal Infection

• Fever, tachycardia, peritoneal signs
• Elevated WBC count
• May require CT imaging and early surgical consultation 1

When to Consider Small Bowel Ileus

• Abdominal distention, absence of bowel sounds, lack of passage of stool/flatus
• Review medication history (opioids, anticholinergics)
• May require abdominal imaging 2

Common Pitfalls to Avoid

1. Failing to identify alarm features that warrant urgent evaluation
2. Not considering atypical presentations of GERD (such as isolated nausea) 3
3. Attributing symptoms to GERD without considering other diagnoses
4. Ordering gastric emptying studies in patients with bloating without nausea/vomiting 1
5. Not testing for H. pylori in patients with dyspeptic symptoms
6. Overlooking medication side effects (especially NSAIDs, opioids)
7. Missing celiac disease in patients with chronic bloating

By following this systematic approach to evaluation, clinicians can efficiently identify the underlying cause of abdominal pain, bloating, burping, nausea, vomiting, and heartburn, allowing for appropriate targeted therapy.