What could cause a sensation of food stuck in the epigastric area with tenderness?

Sensation of Food Stuck in Epigastric Area with Tenderness

This 42-year-old woman with 11 days of epigastric discomfort and tenderness most likely has peptic ulcer disease, gastritis, or functional dyspepsia, and requires urgent upper endoscopy given the persistent symptoms and epigastric tenderness. 1

Immediate Assessment Required

Check for alarm features that mandate urgent endoscopy:

• Weight loss (objective evidence required) 1
• Persistent vomiting (excludes functional dyspepsia) 1, 2
• Dysphagia or sensation of food sticking at a specific level 1
• Hematemesis or evidence of bleeding 2
• Anemia on complete blood count 1

At age 42 years, this patient falls into a gray zone for endoscopy recommendations. The British Society of Gastroenterology recommends non-urgent endoscopy for treatment-resistant dyspepsia in patients ≥55 years 1, but the presence of epigastric tenderness on examination and 11-day symptom duration warrants consideration of earlier endoscopy. 1

Most Likely Diagnoses

Peptic Ulcer Disease (PUD):

• Presents with epigastric discomfort, often with tenderness on examination 3
• Incidence of 0.1-0.3% in general population 2
• Pain may be relieved by food intake or antacids, or occur between meals 3
• Complications occur in 2-10% of cases, with bleeding being most common 2
• Caused by H. pylori infection (42% of cases) or NSAID use (36% of cases) 4

Gastritis:

• Manifests as enlarged areae gastricae, thickened gastric folds, or erosions 1, 2
• Often coexists with PUD and shares similar risk factors 4
• Associated with NSAID use, alcohol, or H. pylori infection 5

Functional Dyspepsia:

• Accounts for 70% of dyspepsia cases 6
• Requires exclusion of organic disease via endoscopy 6
• Symptoms include postprandial fullness, early satiety, and epigastric pain or burning 6
• However, the presence of epigastric tenderness suggests organic pathology rather than functional disease 1

Critical Conditions to Exclude

Life-threatening causes that can present with epigastric pain:

• Myocardial infarction - especially in women, can present atypically with epigastric pain; obtain ECG within 10 minutes and serial troponins at 0 and 6 hours 5
• Perforated peptic ulcer - sudden severe pain with fever, abdominal rigidity, absent bowel sounds; mortality reaches 30% if delayed 2, 5
• Acute pancreatitis - pain radiating to back; check serum amylase ≥4x normal or lipase ≥2x normal 2, 5

Diagnostic Workup

Immediate laboratory tests:

• Complete blood count (to assess for anemia) 1
• Serum electrolytes and glucose 2
• Liver function tests 2
• C-reactive protein and serum lactate 2
• Serum amylase or lipase (to exclude pancreatitis) 2

Imaging considerations:

• Upper endoscopy is the gold standard for diagnosing PUD, gastritis, and excluding malignancy 4, 3
• CT abdomen/pelvis with IV contrast if perforation suspected (shows extraluminal gas in 97% of cases, fluid/fat stranding in 89%, focal wall defect in 84%) 2, 5
• Fluoroscopy upper GI series can detect ulcers, gastritis, and hiatal hernias but is less sensitive than endoscopy 1

H. pylori testing strategy:

• For patients <60 years without alarm features, test-and-treat for H. pylori before endoscopy is acceptable 3, 6
• However, given 11-day symptom duration with tenderness, proceeding directly to endoscopy is reasonable 1
• If endoscopy performed, obtain at least two biopsy samples from antrum and body for H. pylori testing 4

Initial Management

Start empiric therapy while awaiting diagnostic workup:

• High-dose proton pump inhibitor (omeprazole 20-40 mg once daily before meals) 2, 5
• Healing rates: 80-90% for duodenal ulcers, 70-80% for gastric ulcers 5

Discontinue aggravating factors:

• Stop NSAIDs immediately if being used 3
• Avoid alcohol 5
• Limit foods that worsen symptoms 6

Symptomatic relief if nausea present:

• Ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG due to QTc prolongation risk) 2
• Promethazine 12.5-25 mg orally/rectally every 4-6 hours 2
• Prochlorperazine 5-10 mg every 6-8 hours 2

Common Pitfalls to Avoid

• Missing cardiac causes: Always obtain ECG in patients with epigastric pain, especially women and those with risk factors; mortality is 10-20% if acute coronary syndrome is missed 5
• Delaying endoscopy in high-risk patients: Persistent symptoms beyond 8 weeks with tenderness warrant endoscopy regardless of age 1
• Attributing symptoms to functional dyspepsia without excluding organic disease: Epigastric tenderness on examination suggests organic pathology 1
• Missing perforation: Sudden worsening of pain with fever and rigidity requires immediate CT and surgical consultation 2, 5