Differential Diagnosis for Sudden Onset Epigastric Fullness and Decreased Appetite

Immediate Life-Threatening Causes to Exclude First

The American College of Cardiology recommends excluding myocardial infarction, which can present atypically with isolated epigastric symptoms, particularly in women, diabetics, and elderly patients, with a mortality rate of 10-20% if missed, and obtaining an ECG within 10 minutes and serial troponins at 0 and 6 hours 1, 2
The American College of Radiology suggests that acute pancreatitis is characterized by epigastric pain radiating to the back, diagnosed by serum lipase ≥2x normal or amylase ≥4x normal with 80-90% sensitivity and specificity 1
The American College of Radiology recommends identifying perforated peptic ulcer by peritoneal signs, such as rigidity, rebound tenderness, and absent bowel sounds, on physical examination, with a 30% mortality rate if treatment is delayed 1
The American College of Radiology states that gastric outlet obstruction from malignancy is now the most common cause in adults due to decreased peptic ulcer disease incidence with widespread H2 blocker use 3

The Rome IV criteria, as supported by the American Gastroenterological Association, define functional dyspepsia with postprandial distress syndrome as bothersome postprandial fullness present at least 3 days a week, which is the cardinal symptom of postprandial distress syndrome 4
The American Gastroenterological Association recommends that decreased appetite or early satiation, preventing the completion of regular meals, is the second defining feature of postprandial distress syndrome 4
The American Gastroenterological Association suggests that symptom onset several hours after waking, not immediately meal-related, is consistent with functional dyspepsia, where symptoms may occur with or without direct food triggers 4
The Rome IV criteria, as supported by the American Gastroenterological Association, require a 10-day duration to meet the clinical criteria for routine practice, which is less restrictive than research criteria requiring 6 months 4

The American College of Radiology recommends that gastric or duodenal ulcers can present with epigastric fullness, typically accompanied by epigastric pain or burning 5, 3
The American College of Radiology states that H. pylori infection is a major causative factor requiring testing via breath or stool antigen, not serology 1, 2
The American College of Radiology suggests that gastric malignancy, such as gastric adenocarcinoma, has a 32% 5-year survival rate and often presents with nonspecific symptoms, including early satiety and decreased appetite 3
The American College of Radiology recommends that age ≥55 years with early satiety or limited appetite qualifies as an alarm symptom requiring urgent 2-week wait endoscopy 6
The American College of Radiology states that if the patient's age is ≥55 years, urgent endoscopy is mandatory; if <55 years without alarm features, empirical management is appropriate 1, 6

The American College of Cardiology recommends an ECG within 10 minutes to exclude myocardial infarction 1, 2
The American College of Radiology suggests checking vital signs for tachycardia ≥110 bpm, fever ≥38°C, or hypotension, suggesting perforation or sepsis 1
The American College of Radiology recommends assessing for peritoneal signs, such as rigidity, rebound, or absent bowel sounds, indicating perforation 1
The American College of Radiology states that serum lipase or amylase should be tested if there is any suspicion of pancreatitis 1

The American College of Cardiology warns against dismissing cardiac causes, regardless of age, as atypical presentations are common, and missing MI has a 10-20% mortality rate 1, 2
The American Gastroenterological Association advises against attributing persistent vomiting to functional dyspepsia, as Rome IV criteria suggest this indicates another disorder and mandates investigation 4, 1
The American College of Radiology recommends against delaying endoscopy in patients with alarm features, such as weight loss, anemia, dysphagia, or age ≥55 years, as missing gastric cancer or a perforated ulcer leads to poor outcomes 1, 6