What is the most appropriate method of investigation for a patient with upper abdominal pain, shortness of breath, and palpitations after meals, with relief by vomiting?

Diagnostic Approach for Upper Abdominal Pain with Post-Prandial Symptoms and Relief by Vomiting

The most appropriate initial investigation is an upper GI barium study (fluoroscopy upper GI series), which can diagnose hiatal hernia—particularly paraesophageal hernia—that explains this classic triad of post-prandial upper abdominal pain, shortness of breath, palpitations, and relief by vomiting. 1

Clinical Reasoning

This patient's symptom complex strongly suggests a paraesophageal hiatal hernia or large hiatal hernia causing gastric volvulus. The key diagnostic clues are:

• Post-prandial symptoms (pain, shortness of breath, palpitations after meals) suggest mechanical gastric outlet obstruction or compression 1
• Relief by vomiting indicates the stomach empties and decompresses, resolving the obstruction 2
• Shortness of breath and palpitations occur when a distended, herniated stomach compresses the heart and lungs in the chest 1

Why Upper GI Barium Study is Superior

Barium studies are specifically better than endoscopy for differentiating sliding hiatal hernias from paraesophageal hernias, which is critical because the surgical approach differs significantly between these two conditions. 1 The American College of Surgeons Esophageal Diagnostic Advisory Panel explicitly states that all patients considered for antireflux surgery require a barium esophagram. 1

Specific Advantages of Barium Study

• Detects presence and size of hiatal hernia with high sensitivity 1
• Provides anatomic and functional information on esophageal length, gastric position, and gastric emptying 1
• Reveals gastric volvulus which can occur with paraesophageal hernias and causes the exact symptoms described 1
• Demonstrates gastric peristalsis (or lack thereof in gastroparesis/volvulus) 2
• Shows delayed gastric emptying and retained gastric contents 2

The double-contrast upper GI series specifically evaluates structural and functional abnormalities of the esophagus, stomach, and duodenum, making it ideal for this presentation. 1

Why Not the Other Options

Upper GI Endoscopy (Option B)

While endoscopy is excellent for mucosal disease (ulcers, gastritis, malignancy), it cannot adequately assess hiatal hernia anatomy, gastric volvulus, or functional gastric emptying disorders. 1 Endoscopy is the wrong test when mechanical obstruction from a large hiatal hernia is suspected. 1

CT Scan Abdomen (Option A)

CT is appropriate for acute abdominal pain with fever or suspected complications (perforation, abscess), but not for evaluating functional gastric disorders or hiatal hernia anatomy. 1 CT would miss the dynamic, positional nature of a paraesophageal hernia. 1

Plain Abdominal X-ray (Option C)

Plain films have limited sensitivity for upper GI pathology and would likely be normal or show only nonspecific gastric distension. 1 They cannot provide the anatomic detail needed to diagnose hiatal hernia or assess gastric function. 1

Important Clinical Caveats

If barium study reveals a large paraesophageal hernia, surgical referral is urgent because these hernias carry risk of gastric volvulus, strangulation, and perforation. 1

Gastroparesis can present similarly (post-prandial symptoms, vomiting relief), and barium studies can diagnose this by showing decreased/absent gastric peristalsis, gastric dilatation, and delayed barium emptying. 2 In one study, 92% of patients with gastroparesis on barium studies had decreased gastric peristalsis, and 83% improved with appropriate treatment. 2

Dumping syndrome should be considered if the patient has prior gastric or bariatric surgery, though this was not mentioned in the history. 1