What could be causing fluttery feelings from the left upper abdomen to the epigastric and right chest under the breast?

Fluttery Sensations from Left Upper Abdomen to Epigastric and Right Chest

This symptom pattern requires immediate cardiac evaluation with ECG and serial troponins to exclude myocardial ischemia, as atypical cardiac presentations—particularly in women, diabetics, and elderly patients—can manifest as epigastric sensations and chest discomfort without classic pain. 1, 2, 3

Immediate Life-Threatening Causes to Exclude First

Cardiac Ischemia

• Obtain an ECG within 10 minutes of presentation, as myocardial infarction can present atypically with epigastric sensations, "fluttery" feelings, or indigestion-like symptoms rather than classic chest pain 1, 2
• Measure serial cardiac troponins at 0 and 6 hours—never rely on a single troponin measurement, as this is mandatory to exclude NSTEMI 2, 4, 3
• The absence of pain does not exclude cardiac disease; atypical presentations include epigastric sensations, isolated dyspnea, and chest discomfort that patients describe as "fluttering" 1, 2, 3
• Women, diabetics, and elderly patients are particularly prone to atypical presentations with mortality rates of 10-20% if cardiac causes are missed 2, 4

Other Emergent Conditions

• Acute aortic dissection can present with epigastric sensations radiating across the chest, especially in patients over 50 with vascular risk factors 2, 4
• Pulmonary embolism may cause chest sensations with tachycardia and dyspnea 1, 5

Common Benign Causes After Cardiac Exclusion

High-Frequency Diaphragmatic Flutter

• This rare disorder presents with fluttering sensations in the upper abdomen and lower chest, often accompanied by belching, hiccups, or retching 6
• Diagnosis is confirmed by electromyography showing repetitive discharges of 9-15 Hz in the diaphragm and intercostal muscles 6
• Spirographic tracings show high-frequency oscillations (9-15 Hz) superimposed on normal respiratory movements 6
• Treatment with carbamazepine 200-400 mg three times daily leads to disappearance or significant improvement in all documented cases 6

Gastrointestinal Causes

• Gastroesophageal reflux disease affects 42% of Americans monthly and can cause epigastric sensations that radiate to the chest 2, 4
• Gastric volvulus (chronic form) can present with recurrent chest symptoms and epigastric sensations, though more common in infants 7
• Peptic ulcer disease has an incidence of 0.1-0.3% and may cause epigastric discomfort radiating across the upper abdomen 2, 4

Musculoskeletal Causes

• Costochondritis (Tietze syndrome) causes chest wall tenderness and sensations that can be reproduced by palpation 1
• Intercostal nerve irritation from T3-T5 can cause sensations perceived as originating from the chest or upper abdomen 1

Diagnostic Algorithm

Initial Assessment

1. Check vital signs immediately: tachycardia ≥110 bpm, fever ≥38°C, or hypotension predict serious pathology 2, 3
2. Perform focused cardiovascular examination looking for irregular pulse, cardiac murmurs, jugular venous distension, or friction rub 1
3. Assess chest wall: palpate costochondral joints to reproduce symptoms, which suggests musculoskeletal origin 1

Laboratory Testing

• Complete blood count, C-reactive protein, serum lactate, liver and renal function tests 2, 3
• Serum amylase or lipase to exclude pancreatitis 2, 3
• Serial cardiac troponins at 0 and 6 hours (mandatory) 2, 4, 3

Imaging Strategy

• ECG within 10 minutes for all patients with upper abdominal or chest sensations 1, 3
• CT abdomen/pelvis with IV contrast is the gold standard when diagnosis remains unclear after initial workup, identifying pancreatitis, perforation, and vascular emergencies 2, 4, 3
• Upper endoscopy if GERD or peptic ulcer disease is suspected after cardiac causes are excluded 4

Initial Management While Awaiting Diagnosis

• Maintain NPO status until surgical emergency is excluded 2, 4
• Provide IV access and fluid resuscitation if hemodynamically unstable 2, 4
• Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% 2, 4, 3
• Avoid NSAIDs as they worsen peptic ulcer disease and bleeding risk 2, 4
• For symptomatic nausea, use ondansetron 8 mg sublingual every 4-6 hours (obtain baseline ECG first due to QTc prolongation risk) 2

Critical Pitfalls to Avoid

• Never dismiss cardiac causes based on absence of classic chest pain or "atypical" presentation—fleeting sensations lasting only seconds are unlikely to be ischemic, but this requires objective confirmation with ECG and troponins 1, 2, 3
• Do not rely on a single troponin measurement; serial measurements at least 6 hours apart are mandatory to exclude NSTEMI 2, 4, 3
• Do not assume GERD without excluding life-threatening causes first, even in patients with known reflux disease 4, 3
• Positional chest sensations are usually nonischemic (musculoskeletal), but cardiac evaluation is still required initially 1