Differentials
Common
Functional dyspepsia
History
symptoms of dyspepsia; psychosocial factors may be present
Exam
physical exam is expected to be normal
1st investigation
- hemoglobin:
normal
- urea breath test:
negative
Other investigations
Helicobacter pylori infection
History
history of previous peptic ulcer disease, a family history of peptic ulcer disease, and early years spent outside North America and Western Europe are risk factors
Exam
physical exam cannot detect the presence or absence of H pylori infection
1st investigation
Other investigations
GERD and esophagitis
History
family history of GERD, hiatal hernia, heartburn, acid regurgitation, dysphagia, globus
Exam
bloating, laryngitis, enamel erosion, halitosis
1st investigation
- proton pump inhibitor (PPI) trial:
symptoms improve
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Peptic ulcer disease
History
history of nonsteroidal anti-inflammatory use (often with concomitant use of corticosteroids) or past ulcers is common; smoking; ingestion of food often transiently improves abdominal pain
Exam
midepigastric tenderness to palpation (pointing sign)
1st investigation
Other investigations
Gastroparesis
History
diabetes mellitus and previous abdominal surgery that may result in vagal nerve injury; postprandial nausea, vomiting, early satiety, epigastric pain, fullness, bloating, weight loss
Exam
succussion splash; no other specific physical findings
1st investigation
- CBC:
lymphocytosis
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Other investigations
- glucose:
elevated
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Gastritis and duodenitis with and without erosions
History
history of nonsteroidal anti-inflammatory use or Helicobacter pyloriinfection
Exam
normal or mild epigastric tenderness
1st investigation
Other investigations
Lactose intolerance
History
bloating, abdominal distress, and loose stool after ingestion of lactose
Exam
normal exam is expected
1st investigation
- lactose breath test:
positive
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Other investigations
Cholelithiasis
History
pain is typically in the right upper quadrant (RUQ), but may occasionally present with epigastric pain
Exam
positive Murphy sign, tender RUQ or epigastrium, jaundice
1st investigation
- abdominal ultrasound:
gallstones and/or dilation of bile ducts due to obstruction by gallstone
Other investigations
Cholecystitis
History
epigastric or right upper quadrant (RUQ) pain radiating to the right scapula, nausea and pain lasting 3-6 hours
Exam
positive Murphy sign, tender RUQ or epigastrium, jaundice; fever is a serious sign of complicated gallbladder disease
1st investigation
- abdominal ultrasound:
inflammation of the gallbladder
Other investigations
Drug-induced dyspepsia
History
a complete drug history (including prescription, over-the-counter, and herbal) must be taken for all patients who have dyspepsia; certain medications such as nonsteroidal anti-inflammatories, alendronate, cisapride, acarbose, codeine, iron, metformin, certain oral antibiotics (especially macrolides), orlistat, corticosteroids, and theophylline are more likely to cause dyspepsia; a link between starting a medication and onset of dyspepsia symptoms is critical to making the diagnosis
Exam
normal or at most mild epigastric tenderness
1st investigation
- none:
diagnosis is clinical
Other investigations
Celiac disease
History
abnormal quality or frequency of bowel movements, bloating, distension or excessive flatus
Exam
the physical exam is typically unremarkable in adults
1st investigation
Other investigations
Uncommon
Upper gastrointestinal malignancy
History
new onset of progressively worsening dyspepsia in an older individual (refer to local guidance for age threshold) and the presence of any alarm features (V: vomiting; B: bleeding or anemia; A: abdominal mass or unintended weight loss; D: dysphagia) suggest the need for investigation to exclude malignancy; upper gastrointestinal (UGI) malignancies (esophagus, stomach, and pancreas) are rare under age 50 years, although some cases do occur in younger individuals
Exam
abdominal mass, cachexia, lymphadenopathy (particularly left supraclavicular area), hepatomegaly, or hepatic mass
1st investigation
- CT of thorax and abdomen:
site and size of primary tumor, and presence or absence of local invasion and/or metastases
- UGI endoscopy and biopsy:
ulcer or mass or mucosal change
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Other investigations
Intestinal parasites: Giardia, Cryptosporidium
History
typically causes persistent diarrhea after travel or exposure to contaminated water, but can be associated with upper abdominal symptoms
Exam
usually normal but may reveal dehydration, active bowel sounds, and evidence of increased abdominal gas
1st investigation
- stool antigen detection; enzyme-linked immunosorbent assay; and direct fluorescence antibody:
positive
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Other investigations
Coronary artery disease
History
history of coronary artery disease (CAD) (most important in making this diagnosis); risk factors of CAD (increasing age, male, hypertension, diabetes, obesity, hyperlipidemia); chest pain, palpitations, dyspnea, weakness, and lightheadedness; women, patients with diabetes mellitus, and elderly patients are more likely to present with atypical symptoms that sometimes may suggest dyspepsia
Exam
evidence of stress response such as diaphoresis, tachycardia, or tachypnea may lead a clinician to suspect a cardiac cause for the symptoms; signs of acute congestive cardiac failure with pulmonary congestion and elevation of jugular venous pulsations
1st investigation
Other investigations
- chest x-ray:
cardiomegaly, pulmonary venous congestion, effusions, widened mediastinum, or aortic shadow (aneurysm)
Chronic pancreatitis
History
chronic epigastric pain with subsequent development of steatorrhea, weight loss, and diabetes; history of excess alcohol use, cystic fibrosis, or severe acute pancreatitis
Exam
no specific exam findings for chronic pancreatitis, but may have features of the underlying disease such as palmar erythema, leukonychia, hepatomegaly, splenomegaly, or ascites in patients with alcoholic cirrhosis, or finger clubbing and respiratory exam abnormalities (e.g., dull lung bases and coarse crepitations when bronchiectasis develops) in patients with cystic fibrosis
1st investigation
Acute pancreatitis
History
acute-onset, constant, severe mid-abdominal/epigastric pain that often radiates to the back; nausea, vomiting; anorexia; history of biliary colic, alcohol misuse, use of specific medications (e.g., sulfonamides, tetracycline, estrogens, corticosteroids), trauma, or surgery
Exam
varying degrees of abdominal tenderness, usually worse in the epigastric region; guarding, abdominal distension, and reduced or absent bowel sounds; ecchymoses in the skin of one or both flanks (Grey-Turner's sign) and/or the periumbilical area (Cullen's sign)
1st investigation
- serum lipase or amylase:
elevated (3 times the upper limit of normal)
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Other investigations
- abdominal ultrasound:
may see ascites, gallstones, dilated common bile duct, and enlarged pancreas
More - CT scan of abdomen with oral and intravenous contrast:
may show pancreatic inflammation, peripancreatic stranding, calcifications, or fluid collections; confirms or excludes gallstones
More - MRI/MRCP:
findings may include stones, tumors, diffuse, or segmental enlargement of the pancreas with irregular contour and obliteration of the peripancreatic fat, necrosis, or pseudocysts
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Pancreatic tumors/cancers
History
tobacco use, family history of pancreatic cancer
Exam
hepatomegaly, epigastric abdominal mass, positive Courvoisier sign, petechiae, purpura, bruising, Trousseau sign
1st investigation
Obstruction of the hepatobiliary tract from stricture or tumor
History
Nonspecific epigastric or right upper quadrant pain
Exam
may be normal; may have jaundice, muscle wasting, gynecomastia, palmar erythema, spider angiomata, petechiae, ascites, distended abdominal veins, signs of hemochromatosis or other liver diseases, hepatosplenomegaly, signs of encephalopathy (e.g., memory, attention, and concentration deficits; confusion, asterixis, nystagmus, clonus, rigidity, coma)
1st investigation
- serum liver tests:
elevated alkaline phosphatase; bilirubin, aspartate aminotransferase and alanine aminotransferase may be normal or elevated
- abdominal ultrasound:
may show dilated bile ducts or mass
Other investigations
Hypercalcemia
History
vague abdominal pains simulating dyspepsia, polyuria
Exam
physical findings are usually related to the underlying cause of hypercalcemia (e.g., malignancy)
1st investigation
- calcium:
elevated
- phosphate:
high or low
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Other investigations
Abdominal wall pain
History
pain emanating from the abdominal wall; relationship to movement and posture
Exam
herpes zoster rash, consistent tender spot on palpation
1st investigation
- none:
diagnosis is clinical
Other investigations
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