What is the diagnosis and management for a patient presenting with epigastric pain, abdominal tenderness, weight loss, early satiety, postprandial pain, and difficulty breathing?

Diagnosis and Management of a 26-Year-Old Male with Epigastric Pain, Weight Loss, and Bilateral Foot Pain

Most Likely Diagnosis

This clinical presentation most strongly suggests functional dyspepsia with postprandial distress syndrome (PDS), but you must immediately rule out life-threatening cardiac and perforated viscus etiologies before settling on this diagnosis. 1, 2

Immediate Life-Threatening Conditions to Exclude

Step 1: Rule Out Cardiac Etiology (Within 10 Minutes)

• Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours—myocardial infarction presents atypically with epigastric pain in young patients, particularly with dyspnea, and carries 10-20% mortality if missed 1, 2
• Never rely on a single troponin measurement; serial measurements at least 6 hours apart are required to exclude NSTEMI 2
• The combination of epigastric pain with difficulty breathing mandates cardiac evaluation regardless of age 1, 2

Step 2: Assess for Perforated Peptic Ulcer

• Examine specifically for peritoneal signs: abdominal rigidity, rebound tenderness, and absent bowel sounds 1, 2
• Check vital signs for fever ≥38°C, tachycardia ≥110 bpm, or hypotension, which predict perforation with mortality reaching 30% if treatment is delayed 1, 2
• If peritoneal signs are present, obtain CT abdomen/pelvis with IV contrast immediately—this shows extraluminal gas in 97% of perforations, fluid or fat stranding in 89%, and focal wall defect in 84% 3, 1

Step 3: Exclude Acute Pancreatitis

• Obtain serum amylase and lipase immediately—acute pancreatitis characteristically presents with epigastric pain and is diagnosed by amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 1, 2
• The 1kg weight loss and early satiety make chronic pancreatitis less likely but do not exclude acute-on-chronic disease 1

Differential Diagnosis Based on Clinical Features

Most Likely: Functional Dyspepsia (Postprandial Distress Syndrome)

• Functional dyspepsia accounts for approximately 80% of patients with epigastric symptoms in the community and is defined by bothersome epigastric pain, postprandial fullness, or early satiation without structural disease on endoscopy 1
• This patient meets Rome IV criteria for Postprandial Distress Syndrome (PDS): bothersome postprandial fullness and early satiation present for at least 3 days per week, with symptom onset at least 6 months prior 1
• The 1-month history is too short for definitive Rome IV diagnosis, but the clinical picture is consistent 1

Consider: Peptic Ulcer Disease or Gastritis

• Postprandial epigastric pain and early satiety are classic for PUD, which has complications in 2-10% of cases 1, 2
• The abdominal tenderness to palpation supports organic pathology over purely functional disease 1
• CT findings suggestive of gastritis or PUD include gastric or duodenal wall thickening, mucosal hyperenhancement, fat stranding, and focal outpouching from ulcerations 1

Consider: Gastric Cancer (Alarm Feature Present)

• Weight loss in a patient with epigastric symptoms is an alarm feature requiring urgent investigation 1, 2, 4
• Gastric adenocarcinoma now causes most gastric outlet obstruction in adults with only 32% 5-year survival 1, 2
• Early satiety and weight loss are concerning features that mandate endoscopy 1, 4

Unusual Feature: Bilateral Sole of Feet Pain

• This symptom does not fit typical gastrointestinal pathology and suggests either a systemic inflammatory process or a separate musculoskeletal issue 1
• The fact that foot pain improves with exercise suggests plantar fasciitis or mechanical etiology rather than inflammatory arthropathy 1
• Consider celiac disease with associated dermatitis herpetiformis or peripheral neuropathy, though foot sole involvement would be atypical 1

Diagnostic Algorithm

Baseline Laboratory Investigations (Obtain Immediately)

• Complete blood count to assess for anemia (alarm feature) 1, 2
• Cardiac troponins at 0 and 6 hours to exclude NSTEMI 1, 2
• Serum amylase or lipase to exclude acute pancreatitis 1, 2
• C-reactive protein and serum lactate if sepsis or perforation suspected 2
• Coeliac serology (tissue transglutaminase IgA with total IgA) given the systemic nature of symptoms 1
• H. pylori breath or stool testing before initiating acid suppression therapy 1, 2

Imaging Strategy

If peritoneal signs, hemodynamic instability, or severe pain:

• CT abdomen/pelvis with IV contrast is the gold standard for identifying perforation, pancreatitis, and vascular emergencies 1, 2, 4
• Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 1

If stable with alarm features (weight loss):

• Upper endoscopy is definitive for PUD, gastritis, esophagitis, and gastric cancer when patient is stable 2, 4
• Request 2-week wait endoscopy for dyspepsia with weight loss given the patient's age and alarm feature 1
• Obtain at least 5 esophageal mucosal biopsy specimens to evaluate for eosinophilic esophagitis if dysphagia develops 3

If no alarm features and stable:

• Consider fluoroscopic upper GI series to evaluate structural and functional abnormalities of esophagus, stomach, and duodenum 1, 2, 4
• Biphasic esophagram provides anatomic and functional information with 88% sensitivity for detecting esophagitis 1, 2

Initial Management While Awaiting Definitive Diagnosis

If Life-Threatening Conditions Excluded

Empiric PPI Therapy:

• Start high-dose PPI therapy (omeprazole 40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 1, 2
• Continue for 4-8 weeks while awaiting endoscopy 1

Dietary and Lifestyle Modifications:

• Advise small, frequent meals to address early satiety 1
• Avoid NSAIDs as they worsen PUD and bleeding risk 1, 2
• Eliminate alcohol and smoking if present 1

Address Foot Pain Separately:

• Recommend supportive footwear and stretching exercises for presumed plantar fasciitis 1
• If foot pain persists or worsens, consider rheumatologic evaluation for systemic inflammatory conditions 1

If Functional Dyspepsia Confirmed After Negative Workup

• Establish an effective and empathic doctor-patient relationship and explain the diagnosis of functional dyspepsia in the context of the gut-brain axis 1
• Continue PPI therapy or consider tricyclic antidepressants (amitriptyline 10-25 mg at bedtime) for visceral hypersensitivity 1
• Consider prokinetic agents for postprandial distress syndrome if available 1

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on young age alone—myocardial infarction presents atypically with epigastric pain, especially with dyspnea 1, 2
• Do not delay imaging in patients with peritoneal signs, as perforated ulcer mortality increases significantly with delayed diagnosis 1, 2
• Never assume GERD or functional dyspepsia without excluding life-threatening causes first, even in young patients 1, 2
• Weight loss is an alarm feature that mandates endoscopy—do not treat empirically with PPIs alone without investigation 1, 2, 4
• Do not rely on single troponin measurement; serial measurements are required to exclude NSTEMI 2
• Persistent vomiting with epigastric pain excludes functional dyspepsia and mandates investigation for structural disease 2

Follow-Up Strategy

• If empiric PPI therapy fails after 4-8 weeks, proceed to upper endoscopy regardless of age 3, 1
• If endoscopy is normal, consider esophageal manometry to exclude atypical achalasia or distal esophageal spasm 3
• If all testing is negative, diagnose functional dyspepsia and initiate neuromodulator therapy 1
• Monitor weight closely—any further weight loss mandates repeat endoscopy and cross-sectional imaging 1, 2