What is the cause and appropriate management of epigastric fullness, fluttering, and abdominal distension?

Epigastric Fullness, Fluttering, and Abdominal Distension: Diagnostic and Management Approach

Obtain an ECG within 10 minutes and serial troponins to exclude myocardial infarction first, as epigastric pain with dyspnea carries 10-20% mortality if missed, then proceed with CT abdomen/pelvis with IV contrast to evaluate for gastric volvulus, perforation, or other surgical emergencies. 1

Immediate Risk Stratification

Life-threatening conditions must be excluded first:

• Cardiac evaluation is mandatory regardless of age when epigastric symptoms are present, particularly if accompanied by any respiratory symptoms or "fluttering" sensations that could represent palpitations 1
• Obtain ECG within 10 minutes and serial troponins at 0 and 6 hours 1
• Examine specifically for peritoneal signs: abdominal rigidity, rebound tenderness, and absent bowel sounds to assess for perforated peptic ulcer 1
• Check vital signs for tachycardia, hypotension, or fever requiring immediate surgical consultation 1

Diagnostic Imaging Strategy

CT abdomen/pelvis with IV contrast is the gold standard initial imaging study for this presentation 2, 1:

• This evaluates for gastric volvulus (which presents with sudden epigastric pain, fullness, vomiting, and abdominal distension), perforation, pancreatitis, and vascular emergencies 1, 3
• CT has moderate sensitivity (56%) but high specificity (88%) for reflux esophagitis when showing distal esophageal wall thickening ≥5 mm 2
• Signs of gastrointestinal perforation include extraluminal gas, intra-abdominal fluid, and air pockets around the stomach 2
• Gastric volvulus appears as markedly enlarged stomach filled with gas and fluid, with displacement of the antrum above the gastroesophageal junction 3

A critical pitfall: Plain radiography has limited diagnostic value and should not be relied upon 4

Essential Laboratory Workup

Obtain the following tests immediately:

• Serum amylase and lipase to exclude acute pancreatitis (lipase ≥2x normal has 80-90% sensitivity and specificity) 1
• Complete blood count 5, 1
• Liver function tests to evaluate hepatobiliary pathology 4
• Consider H. pylori breath or stool testing if dyspeptic symptoms predominate 4, 1

Differential Diagnosis Framework

The combination of epigastric fullness, fluttering sensation, and abdominal distension suggests several possibilities:

Gastric Volvulus (Surgical Emergency)

• Presents with sudden epigastric pain, fullness, vomiting, and abdominal distension 3
• May be associated with wandering spleen 3
• Requires endoscopic reduction followed by laparoscopic gastropexy 3
• Delay in treatment can result in lethal complications 3

Peptic Ulcer Disease with Perforation

• Severe, sudden-onset epigastric pain that can become generalized 2
• Abdominal distension, tenderness, and rigidity with masked liver dullness and absent bowel sounds 2
• Requires laparoscopic/open repair with omental patch for small perforations or distal gastrectomy for large perforations 2

Functional Dyspepsia/Gastroparesis

• Postprandial fullness and early satiation present for at least 3 days per week 1
• Approximately 40% of gastroparesis patients report bloating correlating with nausea and abdominal fullness 2
• Gastric scintigraphy is not advocated for bloating alone but should be considered with severe nausea or vomiting 2

GERD/Esophagitis

• Affects 7% of Americans daily and 42% monthly 2
• Presence of air in the esophagus, especially middle and lower parts, suggests GERD on CT 2

Management Algorithm

If Peritoneal Signs or Hemodynamic Instability Present:

Immediate surgical consultation without delay 1

For perforated peptic ulcer:

• Laparoscopic/open simple or double-layer suture with omental patch for small perforations 2
• Antibiotic therapy: Amoxicillin/Clavulanate 2 g/0.2 g q8h for immunocompetent patients with adequate source control 2
• If critically ill: Piperacillin/tazobactam 6 g/0.75 g loading dose then 4 g/0.5 g q6h 2
• If septic shock: Meropenem 1 g q6h by extended infusion 2
• Duration: 4 days if immunocompetent with adequate source control, up to 7 days if immunocompromised or critically ill 2

If Stable Without Peritoneal Signs:

Start high-dose PPI therapy (omeprazole 40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers 1

Upper endoscopy is definitive for PUD, gastritis, esophagitis, and gastric cancer when patient is stable 1:

• Proceed to endoscopy if empiric PPI therapy fails after 4-8 weeks 1
• Consider endoscopy earlier if age ≥40 years with dyspeptic symptoms, especially in regions with high H. pylori prevalence 2

Test and treat H. pylori with antibiotic eradication therapy if positive 4, 1

Dietary and Lifestyle Modifications:

• Inquire about lactose, fructose, and gluten consumption and correlation with symptoms 2, 5
• Assess relationship between bloating and meals, as symptoms may worsen after eating 5
• Avoid trigger foods and encourage regular exercise 4
• Avoid restrictive diets that can lead to malnutrition 4

Second-Line Pharmacotherapy:

If PPI therapy fails:

• Consider tricyclic antidepressants to modulate gut-brain axis pain perception 4
• Prokinetic agents may be considered for documented motility disorders 2

Follow-Up Monitoring

• Monitor weight closely—any weight loss mandates repeat endoscopy and cross-sectional imaging 1
• If symptoms persist beyond initial treatment, consider celiac serology if overlapping IBS-type symptoms present 4
• Patients with ongoing signs beyond 7 days of treatment warrant diagnostic investigation 2

Key caveat: The "fluttering" sensation requires careful characterization—if it represents palpitations rather than intestinal sensations, cardiac workup takes absolute priority over gastrointestinal evaluation 1