What is the differential diagnosis and initial management for a patient presenting with epigastric fullness and tightness?

Differential Diagnosis of Epigastric Fullness and Tightness

The differential diagnosis for epigastric fullness and tightness includes functional dyspepsia (most common, accounting for 80% of cases), gastroesophageal reflux disease, peptic ulcer disease, gastritis, gastric cancer, and life-threatening conditions including myocardial infarction, perforated peptic ulcer, and acute pancreatitis that must be excluded first. 1, 2

Life-Threatening Causes to Rule Out Immediately

• Myocardial infarction presents atypically with epigastric pain as the primary manifestation in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 2, 3
• Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours—never rely on a single troponin measurement 2, 3
• Perforated peptic ulcer manifests with sudden, severe epigastric pain becoming generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed 2, 3
• CT with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 2, 3
• Acute pancreatitis characteristically presents with epigastric pain radiating to the back, diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 2, 3

Common Gastrointestinal Causes

Functional Dyspepsia (Most Common)

• Functional dyspepsia accounts for approximately 80% of patients with epigastric symptoms in the community and is defined by bothersome epigastric pain, burning, postprandial fullness, or early satiation without structural disease on endoscopy 1
• Rome IV criteria require symptom onset at least 6 months prior to diagnosis with symptoms active within the past 3 months 1
• Two subtypes exist: Epigastric Pain Syndrome (EPS) requires bothersome epigastric pain or burning at least 1 day per week, while Postprandial Distress Syndrome (PDS) requires bothersome postprandial fullness or early satiation at least 3 days per week 1
• Epigastric fullness may result from delayed gastric emptying or paradoxically from rapid emptying leading to proximal small intestine distention 4

Gastroesophageal Reflux Disease (GERD)

• GERD affects 42% of Americans monthly and 7% daily, presenting with heartburn, regurgitation, and epigastric pain 1, 2
• Distal esophageal wall thickening (≥5 mm) on CT has moderate association with reflux esophagitis with sensitivity of 56% and specificity of 88% 1
• Reflux esophagitis manifests as fine nodularity or granularity of mucosa, erosions, ulcers, thickened longitudinal folds, and inflammatory esophagogastric polyps 1
• Biphasic esophagram using combined single-contrast and double-contrast technique achieves 88% sensitivity for detecting esophagitis 1

Peptic Ulcer Disease and Gastritis

• Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 2
• CT findings suggestive of gastritis or PUD include gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement, fat stranding, fluid along the gastroduodenal region, and focal outpouching from ulcerations 1
• Gastritis appears on fluoroscopy as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 1, 2
• Bleeding is the most common complication, presenting as hematemesis or melena 2, 5

Gastric Cancer

• Gastric adenocarcinoma has a 5-year relative survival rate of only 32% and is now the most common cause of gastric outlet obstruction in adults 1, 2
• CT findings concerning for malignancy include ulcer associated with nodularity of adjacent mucosa, mass effect, or coarse, lobulated, or irregular radiating folds 1
• Scirrhous gastric carcinoma may manifest as diffuse narrowing with rigid, nondistensible wall and obliterated peristalsis on fluoroscopy, which endoscopy and biopsy may miss 1

Initial Management Algorithm

Step 1: Assess for Emergency Conditions

• Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis 2
• Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation requiring immediate surgical consultation 2, 3
• Obtain ECG within 10 minutes to exclude myocardial ischemia 2, 3

Step 2: Identify Alarm Features Requiring Urgent Endoscopy

• Request 2-week wait endoscopy for dyspepsia with weight loss if age ≥55 years, or dyspepsia and age >40 years from an area at increased risk of gastric cancer or with family history of gastroesophageal malignancy 1
• Consider urgent CT scan for abdominal pain and weight loss if age ≥60 years 1
• Other alarm features include dysphagia, hematemesis, persistent vomiting, and anemia 1, 2

Step 3: Baseline Investigations

• Full blood count in patients aged ≥55 years 1
• Coeliac serology in patients with overlap of IBS-type symptoms 1
• Breath or stool testing for H. pylori in patients younger than 60 years before initiating acid suppression therapy 1, 6
• Serum amylase or lipase to exclude acute pancreatitis 2
• Cardiac troponins at 0 and 6 hours if any concern for cardiac etiology 2, 3

Step 4: Imaging When Diagnosis Unclear

• CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 1, 2, 3
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 1
• Biphasic esophagram provides anatomic and functional information on esophageal length, hiatal hernia, diverticulum, stricture, and gastroesophageal reflux events 1
• Fluoroscopy upper GI series evaluates structural and functional abnormalities of esophagus, stomach, and duodenum, particularly useful for scirrhous gastric carcinoma 1, 2

Step 5: Empiric Management for Non-Emergent Cases

• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2, 7
• For active duodenal ulcer, omeprazole 20 mg once daily for 4 weeks; most patients heal within 4 weeks, some require additional 4 weeks 7
• For active benign gastric ulcer, omeprazole 40 mg once daily for 4-8 weeks 7
• H. pylori eradication using triple therapy (omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all twice daily for 10 days) reduces duodenal ulcer recurrence 7, 6
• Advise patients to limit foods associated with increased symptoms; a diet low in FODMAPs is suggested 6
• Avoid NSAIDs as they worsen PUD and bleeding risk 2

Step 6: Treatment for Functional Dyspepsia

• Eight weeks of acid suppression therapy is recommended for patients who test negative for H. pylori or who continue to have symptoms after H. pylori eradication 6
• If acid suppression does not alleviate symptoms, treat with tricyclic antidepressants followed by prokinetics and psychological therapy 6
• Establish an effective and empathic doctor-patient relationship and explain the diagnosis of functional dyspepsia in the context of the gut-brain axis 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age—myocardial infarction can present with epigastric symptoms as the primary manifestation 2, 3
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 2, 3
• Never rely on single troponin measurement; serial measurements at least 6 hours apart are required to exclude NSTEMI 2, 3
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 2
• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease such as peptic ulcer or acute coronary syndrome 1, 2
• Clinical impression based on symptoms alone is unreliable and cannot distinguish functional disorders from severe conditions 4
• Individual alarm symptoms do not correlate with malignancy for patients younger than 60 years, but severe or multiple alarm symptoms warrant endoscopy 6