What is the diagnosis and treatment for a patient with epigastric fullness, loss of appetite, abdominal distention, and upper abdominal fluttering, without pain or dyspnea?

Differential Diagnosis and Management

Most Likely Diagnosis

This symptom constellation—epigastric fullness, loss of appetite, abdominal distention, and upper abdominal fluttering without pain or dyspnea—most strongly suggests functional dyspepsia (FD) with postprandial distress syndrome subtype, though gastroparesis and carbohydrate malabsorption must be systematically excluded. 1

Diagnostic Approach

Initial Clinical Assessment

The absence of pain distinguishes this presentation from typical peptic ulcer disease or biliary pathology. 1 Key features to evaluate include:

• Relationship to meals: Postprandial symptoms (fullness, early satiety) felt at the lower epigastrium suggest FD postprandial distress subtype or possible pancreatic exocrine dysfunction 2
• Timing and character: Upper abdominal "fluttering" may represent aerophagia, supragastric belching, or visceral hypersensitivity 1
• Associated symptoms: Loss of appetite with bloating occurs in 40% of gastroparesis patients but correlates poorly with actual gastric emptying delay 1

Red Flags Requiring Urgent Evaluation

Before proceeding with functional disorder workup, exclude:

• Age ≥40-55 years with new-onset symptoms warrants upper endoscopy, particularly in high H. pylori prevalence regions 1, 3
• Weight loss >10% suggests malabsorption, malignancy, or gastroparesis 1, 3
• Iron-deficiency anemia or GI bleeding requires celiac testing and endoscopy 3
• Family history of IBD or GI malignancy increases risk 4
• Women ≥50 years: Consider ovarian cancer, as bloating and fullness are common presenting symptoms 3

Targeted Laboratory Testing

Do not perform extensive testing without red flags—the yield is extremely low. 1, 3 When indicated:

• Tissue transglutaminase IgA with total IgA for celiac disease screening 4, 3
• Complete blood count only if anemia suspected 3
• Fecal elastase if symptoms persist despite pancreatic enzyme replacement, suggesting chronic pancreatitis 1
• Abdominal X-ray only if severe constipation suspected to reveal stool burden 1, 3

Specialized Testing (Selective Use Only)

Gastric scintigraphy is NOT recommended for bloating and fullness alone, as symptoms correlate poorly with emptying delay. 1 Consider only if:

• Severe nausea/vomiting present suggesting true gastroparesis 1
• Postprandial FD subtype with treatment failure 1

Upper endoscopy is appropriate if patient >40 years with dyspeptic symptoms in high H. pylori regions 1

Treatment Algorithm

First-Line: Dietary Modifications (2-Week Trial)

Begin with a 2-week elimination diet targeting the most likely culprit based on symptoms—this is the simplest and most effective initial approach. 4

• Carbohydrate malabsorption (lactose, fructose, FODMAPs) affects 51-60% of patients with digestive symptoms 4
• Artificial sweeteners (sugar alcohols, sorbitol) are common triggers 1
• Symptom resolution during restriction serves as diagnostic confirmation 4
• Dietitian consultation recommended to prevent malnutrition from prolonged restrictions 3

Second-Line: Pharmacologic Management

If dietary modifications fail after 2 weeks:

For Predominant Fullness/Bloating with Constipation:

• Secretagogues (linaclotide, lubiprostone, plecanatide) are superior to placebo for bloating when constipation present 4, 3

For Visceral Hypersensitivity:

• Central neuromodulators (tricyclic antidepressants like amitriptyline or SNRIs like duloxetine) reduce visceral sensations and bloating 4, 3

For Suspected SIBO:

• Rifaximin for confirmed SIBO (test first rather than empiric treatment for antibiotic stewardship) 1, 4
• High-risk patients: chronic watery diarrhea, malnutrition, weight loss, systemic diseases causing dysmotility 4

For GERD-Associated Symptoms:

• PPI therapy (omeprazole 20 mg daily) only if gastric belching or reflux symptoms present 1, 5
• PPIs are NOT effective for functional bloating without GERD 5

Third-Line: Behavioral Interventions

Brain-gut behavioral therapies have robust evidence for improving bloating and quality of life when symptoms significantly impact function. 1, 4

• Diaphragmatic breathing immediately effective for acute bloating by reducing vagal tone 4
• Cognitive behavioral therapy or gut-directed hypnotherapy for refractory symptoms 1, 4

Critical Pitfalls to Avoid

• Do not assume gastroparesis based on symptoms alone: Bloating, nausea, and fullness do not correlate with gastric emptying delay on scintigraphy 1, 3
• Do not over-test in functional bloating: Extensive imaging, endoscopy, and motility testing are unnecessary without alarm symptoms 3
• Do not prescribe PPIs empirically for all bloating: They are only effective when gastric belching is associated with proven GERD 5
• Do not use opioid analgesics: They worsen gastric emptying and gas symptoms 4
• Do not ignore pelvic floor dysfunction: Straining with soft stool or need for manual assistance suggests dyssynergia, not just constipation 1, 3

When to Escalate

• Persistent symptoms after 4 weeks of optimized therapy: Refer to GI psychology for formal CBT or esophageal-directed hypnotherapy 5
• Severe symptoms with weight loss: Consider small bowel motility evaluation with antroduodenal manometry or wireless motility capsule 1
• Early gastroenterology consultation if ongoing severe toxicity or diagnostic uncertainty 1