What is the differential diagnosis (Dx) and workup for a patient of Asian descent with months of intermittent nausea and epigastric pain?

Differential Diagnosis and Workup for Asian Patient with Months of Intermittent Nausea and Epigastric Pain

In an Asian patient with months of intermittent nausea and epigastric pain, the most critical priority is ruling out gastric cancer and peptic ulcer disease through urgent upper endoscopy if age >40 years or with any alarm features, while simultaneously excluding cardiac causes with an ECG, as Asian populations have higher gastric cancer risk and approximately 4-fold higher omeprazole exposure requiring dose adjustments. 1, 2, 3

Immediate Life-Threatening Causes to Exclude First

Cardiac Evaluation

• Obtain an ECG within 10 minutes of presentation to exclude myocardial infarction, which can present atypically with epigastric pain as the primary manifestation, especially in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 1, 2
• Order serial troponins at 0 and 6 hours—never rely on a single troponin measurement 2
• The American Heart Association emphasizes heightened awareness that epigastric symptoms may represent acute coronary syndrome 4

Assess for Perforation

• Check vital signs immediately for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation or sepsis 1
• Examine for peritoneal signs including rigidity, rebound tenderness, and absent bowel sounds 2
• Perforated peptic ulcer has mortality reaching 30% if treatment is delayed 2

Critical Consideration: Asian Ethnicity and Gastric Cancer Risk

Urgent Endoscopy Indications

• Request 2-week wait endoscopy for dyspepsia if age >40 years from an area at increased risk of gastric cancer or with family history of gastroesophageal malignancy 5
• Gastric adenocarcinoma has only a 32% 5-year survival rate and is now the most common cause of gastric outlet obstruction in adults 5
• Other alarm features requiring urgent endoscopy include: 1, 2, 5
  • Weight loss (especially if age ≥55 years)
  • Dysphagia
  • Persistent vomiting (Rome IV criteria state this excludes functional dyspepsia and mandates investigation)
  • Anemia
  • Hematemesis

Most Likely Differential Diagnoses

1. Functional Dyspepsia (Most Common Overall)

• Accounts for approximately 80% of patients with epigastric symptoms in the community 5
• In Asia specifically, 8-23% of the population suffers from functional dyspepsia 6
• Rome IV criteria require symptom onset at least 6 months prior with symptoms active within past 3 months 5
• Two subtypes exist: 5
  • Epigastric Pain Syndrome (EPS): Bothersome epigastric pain or burning at least 1 day per week
  • Postprandial Distress Syndrome (PDS): Bothersome postprandial fullness or early satiation at least 3 days per week
• Critical caveat: Persistent vomiting excludes functional dyspepsia diagnosis and mandates investigation for structural disease 1

2. Peptic Ulcer Disease

• Incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 1, 2
• Presents with epigastric pain not relieved by antacids 1
• Bleeding is the most common complication and can present as hematemesis 1

3. Gastroesophageal Reflux Disease (GERD)

• Affects 42% of Americans monthly and 7% daily 1, 2
• Presents with epigastric pain often accompanied by heartburn and regurgitation 1

4. Gastric Cancer

• Higher risk in Asian populations 5
• May present with ulcer associated with nodularity of adjacent mucosa 1, 2
• CT findings concerning for malignancy include mass effect or irregular radiating folds 5

5. Helicobacter pylori Gastritis

• H. pylori infection is common in Asia and characterized by high levels of pepsinogen II and IgG against H. pylori 7
• Can cause chronic gastritis leading to dyspeptic symptoms 7

Diagnostic Workup Algorithm

Step 1: Baseline Laboratory Tests

• Complete blood count (check for anemia) 1, 5
• Serum electrolytes and glucose 1
• Liver function tests 1
• Serum amylase (≥4x normal) or lipase (≥2x normal) to exclude acute pancreatitis with 80-90% sensitivity and specificity 1, 2
• C-reactive protein and serum lactate levels 1
• Cardiac troponins at 0 and 6 hours if any cardiac concern 2, 5

Step 2: H. pylori Testing

• Breath or stool testing for H. pylori in patients younger than 60 years before initiating acid suppression therapy 5
• Serological determination of serum pepsinogens, gastrin 17, and IgG against H. pylori can help diagnose chronic atrophic gastritis and H. pylori infection 7

Step 3: 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 2, 5
• CT findings for peptic ulcer disease include: 1
  • Extraluminal gas (97% of perforations)
  • Fluid or fat stranding along gastroduodenal region (89%)
  • Ascites (89%)
  • Focal wall defect and/or ulcer (84%)
  • Wall thickening (72%)

Step 4: Upper Endoscopy

• Definitive for peptic ulcer disease, gastritis, gastric cancer, and esophagitis when patient is stable 2
• Mandatory if age >40 years in Asian patients or any alarm features present 5
• Delaying endoscopy in patients with alarm features can lead to poor outcomes 1

Empiric Management While Awaiting Workup

Proton Pump Inhibitor Therapy

• Start high-dose PPI therapy immediately: omeprazole 20-40 mg once daily before meals 1, 3
• Healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• Critical Asian-specific dosing: Asian patients have approximately 4-fold higher omeprazole exposure than Caucasians; dosage reduction to 10 mg once daily is recommended for maintenance of healing of erosive esophagitis 3
• Take before meals; antacids may be used concomitantly 3

Symptomatic Relief for Nausea

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 1
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 1
• Prochlorperazine 5-10 mg every 6-8 hours 1

Avoid NSAIDs

• NSAIDs worsen peptic ulcer disease and bleeding risk 5

Common Pitfalls to Avoid

• Never dismiss cardiac causes in patients with "atypical" epigastric pain, regardless of age 2, 5
• Do not delay endoscopy in Asian patients >40 years with chronic dyspepsia due to higher gastric cancer risk 5
• Do not attribute persistent vomiting to functional dyspepsia—this mandates investigation for structural disease 1
• Remember to adjust PPI dosing in Asian patients due to 4-fold higher drug exposure 3
• Do not miss H. pylori testing before starting acid suppression, as this can affect test accuracy 5
• Cultural competency and formal translation services are essential for accurate history-taking in diverse populations 4