Differentials
Oesophageal cancer
SIGNS / SYMPTOMS
Presence of alarm features (e.g., weight loss, bleeding, anaemia, vomiting, early satiety, or dysphagia, or if the patient develops dyspeptic symptoms after age 55 years), or family history of upper gastrointestinal tract cancer, jaundice, a palpable mass, or lymphadenopathy may be indicative of a gastro-oesophageal neoplasm.
INVESTIGATIONS
Distinguished from peptic ulcer disease by endoscopy: shows mass or irregular ulcer.
Diagnosis should be confirmed by endoscopic biopsy.
May require additional imaging to diagnose and stage (e.g., endoscopic ultrasound, CT, MRI).
Stomach cancer
SIGNS / SYMPTOMS
Presence of alarm features (e.g., weight loss, bleeding, anaemia, vomiting, early satiety, or dysphagia, or if the patient develops dyspeptic symptoms after age 55 years), or family history of upper gastrointestinal cancer, jaundice, a palpable mass, or lymphadenopathy may be indicative of a gastro-oesophageal neoplasm.
INVESTIGATIONS
Distinguished from peptic ulcer disease by endoscopy: shows mass or irregular ulcer.
Diagnosis should be confirmed by endoscopic biopsy.
May require additional imaging to diagnose and stage (e.g., endoscopic ultrasound, CT, MRI).
Gastro-oesophageal reflux disease (GORD)
SIGNS / SYMPTOMS
History of heartburn or pain rising from the lower chest to the throat is typical although not invariable.
May have associated laryngitis, cough, and atypical chest pain.
INVESTIGATIONS
Endoscopy shows absence of gastric/duodenal ulcers and, often, erosions in oesophagus. In most patients with pathological acid reflux, the endoscopy is normal.
May require additional testing with ambulatory pH testing to aid in diagnosis.
Gastroparesis
SIGNS / SYMPTOMS
Early satiety prominent.
A history of longstanding diabetes with evidence of peripheral neuropathy and other end-organ damage.
INVESTIGATIONS
Endoscopy may show food stasis.
Definitive diagnosis by gastric emptying study (nuclear medicine imaging).
Biliary colic
SIGNS / SYMPTOMS
Pain typically in right upper quadrant, about 30 minutes after meals, waxing and waning over minutes or hours.
INVESTIGATIONS
Ultrasound or CT scan shows stones in gallbladder and/or bile ducts.
Acute pancreatitis
SIGNS / SYMPTOMS
History of gallstones or alcohol use.
Pain typically radiates to back.
INVESTIGATIONS
Elevated serum amylase and lipase levels.
CT scan shows inflammation of pancreas.
Non-ulcer dyspepsia (functional dyspepsia)
SIGNS / SYMPTOMS
Dyspepsia is defined as a discomfort centred in the upper abdomen, commonly related to meals.
INVESTIGATIONS
A diagnosis of exclusion after finding no relevant abnormality on appropriate testing.
Coeliac disease
SIGNS / SYMPTOMS
Diarrhoea and evidence of malabsorption are typical.
INVESTIGATIONS
Laboratory testing may show microcytic anaemia, iron deficiency, and low calcium and albumin.
Anti-tissue transglutaminase antibody has sensitivity and specificity of about 95% for the diagnosis.
Endoscopy with duodenal biopsy is the gold standard diagnostic test. Biopsy shows flattening of the villi.
Irritable bowel syndrome
SIGNS / SYMPTOMS
Pain may be indistinguishable from that of peptic ulcer disease, but alteration of bowel habit separates this syndrome.
Bloating is a common complaint.
INVESTIGATIONS
A diagnosis of exclusion after finding no relevant abnormality on appropriate testing.
Pleuritic pain
SIGNS / SYMPTOMS
Chest pain altered by respiration.
INVESTIGATIONS
Chest x-ray may reveal pneumonia or effusion.
Pericarditis
SIGNS / SYMPTOMS
Constant pleuritic central chest pain that is worse in the recumbent position and radiates to one or both trapezius ridges.
History of transmural myocardial infarction, cardiac surgery, neoplasm, viral and bacterial infection, uraemia, dialysis treatment, or systemic autoimmune disorders may be present.
A prodrome of myalgias and malaise may be present with any cause of acute pericarditis, particularly in young adults. High or spiking fever may also be present.
Pericardial friction rub heard on examination. The rub, when present, is described as high-pitched or squeaky. It is heard best at the left sternal edge with the patient leaning forwards at end-expiration.
INVESTIGATIONS
ECG shows upwards concave ST-segment elevation globally with PR depressions.
Serum troponin is mildly elevated.
Chest x-ray may be normal or show a water bottle-shaped enlarged cardiac silhouette.
C-reactive protein, erythrocyte sedimentation rate (ESR), and white blood cells are usually elevated.
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