Differential Diagnosis of Epigastric Fullness and Tightness

Life-Threatening Causes to Rule Out Immediately

Myocardial infarction presents atypically with epigastric pain as the primary manifestation in women, diabetics, and elderly patients, with mortality rates of 10-20% if missed 2, 3
Obtain an ECG within 10 minutes of presentation and serial troponins at 0 and 6 hours—never rely on a single troponin measurement 2, 3
Perforated peptic ulcer manifests with sudden, severe epigastric pain becoming generalized, accompanied by fever, abdominal rigidity, and absent bowel sounds, with mortality reaching 30% if treatment is delayed 2, 3
CT with IV contrast shows extraluminal gas in 97% of cases, fluid or fat stranding in 89%, ascites in 89%, and focal wall defect in 84% 2, 3
Acute pancreatitis characteristically presents with epigastric pain radiating to the back, diagnosed by serum amylase ≥4x normal or lipase ≥2x normal with 80-90% sensitivity and specificity 2, 3

Functional dyspepsia accounts for approximately 80% of patients with epigastric symptoms in the community and is defined by bothersome epigastric pain, burning, postprandial fullness, or early satiation without structural disease on endoscopy 1
Rome IV criteria require symptom onset at least 6 months prior to diagnosis with symptoms active within the past 3 months 1
Two subtypes exist: Epigastric Pain Syndrome (EPS) requires bothersome epigastric pain or burning at least 1 day per week, while Postprandial Distress Syndrome (PDS) requires bothersome postprandial fullness or early satiation at least 3 days per week 1

GERD affects 42% of Americans monthly and 7% daily, presenting with heartburn, regurgitation, and epigastric pain 4, 2
Distal esophageal wall thickening (≥5 mm) on CT has moderate association with reflux esophagitis with sensitivity of 56% and specificity of 88% 4
Reflux esophagitis manifests as fine nodularity or granularity of mucosa, erosions, ulcers, thickened longitudinal folds, and inflammatory esophagogastric polyps 4, 5

Peptic ulcer disease has an incidence of 0.1-0.3%, with complications occurring in 2-10% of cases 4, 2
CT findings suggestive of gastritis or PUD include gastric or duodenal wall thickening due to submucosal edema, mucosal hyperenhancement, fat stranding, fluid along the gastroduodenal region, and focal outpouching from ulcerations 4
Gastritis appears on fluoroscopy as enlarged areae gastricae, disrupted polygonal pattern, thickened gastric folds, or erosions 5, 2

Gastric adenocarcinoma has a 5-year relative survival rate of only 32% and is now the most common cause of gastric outlet obstruction in adults 5, 2
CT findings concerning for malignancy include ulcer associated with nodularity of adjacent mucosa, mass effect, or coarse, lobulated, or irregular radiating folds 4, 5

Check vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, which predict perforation, anastomotic leak, or sepsis 2
Examine for peritoneal signs (rigidity, rebound tenderness, absent bowel sounds) indicating perforation requiring immediate surgical consultation 2, 3
Obtain ECG within 10 minutes to exclude myocardial ischemia 2, 3

Request 2-week wait endoscopy for dyspepsia with weight loss if age ≥55 years, or dyspepsia and age >40 years from an area at increased risk of gastric cancer or with family history of gastroesophageal malignancy 8
Consider urgent CT scan for abdominal pain and weight loss if age ≥60 years 8
Other alarm features include dysphagia, hematemesis, persistent vomiting, and anemia 1, 8, 2

Full blood count in patients aged ≥55 years 8
Coeliac serology in patients with overlap of IBS-type symptoms 8
Breath or stool testing for H. pylori in patients younger than 60 years before initiating acid suppression therapy 8, 2
Serum amylase or lipase to exclude acute pancreatitis 2
Cardiac troponins at 0 and 6 hours if any concern for cardiac etiology 2, 3

CT abdomen and pelvis with IV contrast is the gold standard when diagnosis is unclear, identifying pancreatitis, perforation, and vascular emergencies 4, 2, 3
Use neutral oral contrast (water or dilute barium) when gastric disease is suspected to delineate intraluminal space 4, 7
Biphasic esophagram provides anatomic and functional information on esophageal length, hiatal hernia, diverticulum, stricture, and gastroesophageal reflux events 5, 7
Fluoroscopy upper GI series evaluates structural and functional abnormalities of esophagus, stomach, and duodenum, particularly useful for scirrhous gastric carcinoma 5, 7, 2

Start high-dose PPI therapy (omeprazole 20-40 mg once daily) for suspected acid-related pathology, with healing rates of 80-90% for duodenal ulcers and 70-80% for gastric ulcers 2
Avoid NSAIDs as they worsen PUD and bleeding risk 2

Establish an effective and empathic doctor-patient relationship and explain the diagnosis of functional dyspepsia in the context of the gut-brain axis 8