Stomach Problems – Causes, Symptoms, Diagnosis, Treatment

Stomach Problems – Causes, Symptoms, Diagnosis, Treatment

Stomach problems that are severe or that do not improve within a day or two can be symptoms of serious medical conditions for severe pain that comes on suddenly, an inability to have bowel movements, bloody stool, vomiting blood, abdominal rigidity, breathing difficulties, or pain in the neck, chest, shoulders, or between the shoulders. You should also seek immediate care if you have stomach problems and have cancer or might be pregnant and experience vaginal bleeding or abdominal cramps.

Causes of  Stomach Problems

Stomach problems often originate in the digestive tract, although they can be due to disorders of the circulatory system, urinary tract, reproductive system, respiratory system, nervous system, or body wall.

The digestive tract causes stomach problems

Stomach problems may be caused by conditions of the digestive tract including:

  • Bacterial, parasitic, or viral infection of the gastrointestinal tract
  • Celiac disease (severe sensitivity to gluten from wheat and other grains that causes intestinal damage)
  • Diverticulitis (inflammation of an abnormal pocket in the colon)
  • Food intolerance such as lactose intolerance (inability to digest lactose, the sugar in dairy products)
  • Gallbladder disease or stones
  • Gastritis (inflammation of the stomach lining)
  • Gastroesophageal reflux disease (GERD)
  • Inflammatory bowel disease (includes Crohn’s disease, ulcerative colitis)
  • Irritable bowel syndrome (IBS; digestive discomfort that does not cause intestinal damage or serious disease)
  • Liver disease, including hepatitis (inflammation of the liver)
  • Pancreatitis (inflammation of the pancreas)
  • Ulcers of the stomach or duodenum (first section of the small intestine)

Other causes of stomach problems

Stomach problems can also be caused by conditions involving other body systems including:

  • Abdominal or hiatal hernia (weakening in the abdominal wall or diaphragm, through which internal organs can pass)
  • Cancer of an abdominal or pelvic organ
  • Endometriosis (a condition where tissues resembling the uterine lining grow in other areas of the body)
  • Kidney stones
  • Menstrual cramps
  • Pelvic inflammatory disease (PID; infection of a woman’s reproductive organs)
  • Pleurisy (inflammation of the lining around the lungs)
  • Pneumonia
  • Shingles (painful, blistering rash that results from a reactivation of the varicella-zoster, or chickenpox, virus)
  • Urinary tract infection

Serious or life-threatening causes of stomach problems

In some cases, stomach problems may be a symptom of a serious or life-threatening condition that should be immediately evaluated in an emergency setting. These include:

  • Abdominal abscess
  • Abdominal, pelvic or testicular trauma
  • Aneurysm of the abdominal aorta (life-threatening bulging and weakening of the wall of the abdominal aorta that can burst and cause severe hemorrhage)
  • Appendicitis
  • Bowel obstruction or perforation
  • Chemical or heavy metal poisoning
  • Colonic volvulus (twisting of the colon) or intussusception (telescoping of the intestines into themselves)
  • Ectopic pregnancy (life-threatening pregnancy growing outside the uterus)
  • Intestinal ischemia (loss of blood supply to the intestines leading to the death of intestinal tissue)
  • Myocardial infarction (heart attack)
  • Peritonitis (infection of the lining that surrounds the abdomen)
  • Torsion of an ovary or a testicle (twisting of an ovary or spermatic cord)

Symptoms of Stomach Problems

Stomach problems may accompany other symptoms, which vary depending on the underlying disease, disorder or condition. Stomach problems are often related to the digestive system, but may also be related to other body systems.

Stomach problems may accompany other symptoms affecting the digestive system including:

  • Abdominal pain or cramping
  • Abdominal swelling, distension, or bloating
  • Belching
  • Bloody stool (blood may be red, black, or tarry in texture)
  • Changes in bowel movements
  • Constipation
  • Cramping
  • Diarrhea
  • Gas
  • Indigestion
  • Nausea with or without vomiting
  • Urgent need to pass stool

Other symptoms that may occur along with stomach problems

Stomach problems may accompany symptoms related to other body systems including:

  • Cough
  • Enlarged liver and glands such as the spleen and lymph nodes
  • Fever
  • Pain during sexual intercourse
  • Pain or burning with urination
  • Pain, numbness or tingling
  • Palpable mass in the abdomen or pelvic area
  • Rash
  • Unexplained weight loss

Serious symptoms that might indicate a life-threatening condition

In some cases, stomach problems may be a symptom of a life-threatening condition that should be immediately evaluated in an emergency setting. Seek immediate medical care (call 911) if you, or someone you are with, have any of these life-threatening symptoms including:

  • Bleeding while pregnant
  • Change in level of consciousness or alertness such as passing out or unresponsiveness
  • Chest pain, chest tightness, chest pressure, or palpitations
  • High fever (higher than 101 degrees Fahrenheit)
  • Inability to have bowel movements, especially if accompanied by vomiting
  • Rapid heart rate (tachycardia)
  • Respiratory or breathing problems such as shortness of breath, difficulty breathing, labored breathing, wheezing, not breathing, or choking
  • The rigidity of the abdomen
  • Seizure
  • Severe abdominal pain or sharp abdominal pain that comes on suddenly
  • Trauma to the abdomen, pelvis, or testicles
  • Vomiting blood, rectal bleeding, or bloody stool
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Diagnosis of Stomach Problems

To diagnose your condition, your doctor or licensed health care practitioner will ask you several questions related to your stomach problems including:

  • How long have you had stomach problems?
  • How would you describe your problems?
  • Does anything make them go away or get worse?
  • Have you had stomach problems like this before?
  • Do you have any other symptoms?
  • What medications are you taking?
  • Is there any possibility you are pregnant?

History and Physical

The typical clinical presentation of stomach problems is heartburn and regurgitation. However, stomach problems can also present with various other symptoms that include dysphagia, odynophagia, belching, epigastric pain, and nausea . Heartburn is defined as a retrosternal burning sensation or discomfort that may radiate into the neck and typically occurs after the ingestion of meals or when in a reclined position. Regurgitation is a retrograde migration of acidic gastric contents into the mouth or hypopharynx. GERD/ stomach problems presentation is considered to be atypical when patients present with extraesophageal symptoms such as chest pain, chronic cough, asthma, laryngitis, dental erosions, dysphonia, and hoarseness and globus sensation.

Lab Test

The diagnosis of stomach problems is imprecise as there is no gold standard test available. The diagnosis of stomach problems is made solely based on presenting symptoms or in combination with other factors such as responsiveness to antisecretory therapy, esophagogastroduodenoscopy, and ambulatory reflux monitoring.

  • Proton pump inhibitor (PPI) trial – Stomach problems can be presumptively diagnosed in most patients presenting with typical symptoms of heartburn and regurgitation . Unless there are no associated alarm symptoms that include dysphagia, odynophagia, anemia, weight loss, and hematemesis, most patients can be initiated on empiric medical therapy with proton pump inhibitors(PPIs) without further investigations with a response to treatment confirming the diagnosis of stomach problems . However, a meta-analysis published literature by Numans et al. refuted the accuracy of this empiric PPI trial diagnostic strategy.
  • Esophagogastroduodenoscopy (EGD) – Patients presenting with typical stomach problems symptoms associated with any one of the alarm symptoms should be evaluated with stomach problems to rule out complications of stomach problems. These include erosive esophagitis, Barrett’s esophagus, esophageal stricture, and esophageal adenocarcinoma or rule out peptic ulcer disease. Distal esophageal biopsies are not routinely recommended to make a diagnosis of stomach problems as per the current American College of Gastroenterology (ACG) guidelines. Patients with a high index of suspicion for coronary artery disease presenting with stomach problems symptoms should undergo evaluation for underlying cardiovascular disease. In contrast, patients presenting with noncardiac chest pain suspected due to stomach problems should have a diagnostic assessment with stomach problems and pH monitoring before initiation of PPIs. Current ACG guidelines recommend against screening for Helicobacter pylori infection in patients with GERD symptoms.
  • Radiographic studies – Radiographic studies like barium radiographs can detect moderate to severe esophagitis, esophageal strictures, hiatal hernia, and tumors. However, their role in the evaluation of stomach problems is limited and should not be performed to diagnose stomach problems .
  • Ambulatory esophageal reflux monitoring – Medically refractory stomach problems are increasingly common, and patients often have normal endoscopy evaluation as PPIs are incredibly effective in healing esophagitis caused by the refluxate. Ambulatory esophageal reflux monitoring can assess the correlation of symptoms with abnormal acid exposure. It is indicated in medically refractory stomach problems and in patients with extraesophageal symptoms suspicious of stomach problems. Ambulatory reflux (pH or in combination with impedance) monitoring employs the utility of a telemetry pH capsule or a transnasal catheter. It is the only available test that detects pathological acid exposure, frequency of reflux episodes, and correlation of symptoms with reflux episodes. Current practice guidelines recommend mandatory preoperative ambulatory pH monitoring in patients without evidence of erosive esophagitis.

Treatment of

The goals of managing stomach problems are to address the resolution of symptoms and prevent complications such as esophagitis, BE, and esophageal adenocarcinoma. Treatment options include lifestyle modifications, medical management with antacids and antisecretory agents, surgical therapies, and endoluminal therapies.

Lifestyle modifications

Lifestyle modifications are considered to be the cornerstone of any stomach problems therapy. Counseling should be provided about the importance of weight loss given that underlying obesity is a significant risk factor for the development of stomach problems, and studies have shown that weight gain in individuals with a normal BMI has been associated with the development of stomach problem symptoms . Individuals should also be counseled about avoiding meals at least 3 hours before bedtime and maintaining good sleep hygiene as it has been shown that minimal disturbances in sleep are associated with suppression of TLESRs, resulting in decreased reflux episodes . Studies have also shown improvement in stomach problems symptoms and pH monitoring studies with the elevation of the head end of the bed. Diet modification with the elimination of chocolate, caffeine, and spicy foods, citrus, and carbonated beverages in stomach problems is controversial and is not routinely recommended as per current ACG guidelines.

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Medical Therapy

Medical therapy is indicated in patients who do not respond to lifestyle modifications. Medical therapy is comprised of antacids antisecretory agents like histamine (H2) receptor antagonists (H2RAs) or PPI therapy and prokinetic agents. Currently, there are two US Food and Drug Administration (FDA) approved H2RAs (famotidine and cimetidine) available in the US and are available over-the-counter. The other commonly used H2RA known as ranitidine has been recalled as a potential health hazard or safety risk due to an unexpected impurity in the active ingredient. The less commonly known prescription-only H2RA nizatidine has also been recalled as well due to similar concerns. In the US, there are six PPIs that are currently available, of which three (omeprazole, lansoprazole, and esomeprazole) are available over-the-counter, and the remaining three (pantoprazole, dexlansoprazole, and rabeprazole) are prescription-only medications. Of the available medical options, PPI therapy is considered to be the most effective for both erosive and non-erosive stomach problems based on multiple large-scale studies. These studies have also shown improved symptom control, healing of underlying esophagitis, and decreased relapse rates compared to H2RAs . ACG guidelines recommend PPI therapy to be initiated at once a day dosing before the first meal of the day. Patients with incomplete responses to once-daily dosing can be treated with twice-daily dosing or adjustment of dose timing, specifically in patients with nighttime symptoms . As needed, bedtime administration of H2RAs is recommended for individuals with nighttime symptoms not optimized with maximal PPI therapy. The role of prokinetic agents such as metoclopramide and domperidone in stomach problems is limited due to lack of data and also due to their profound adverse effects on the central nervous system and cardiovascular system.

Antibiotic therapy

Not every patient, even with a known bacterial etiology, should be given antibiotic therapy, especially with Shiga toxin-producing E. coli. Empiric antibiotic therapy with azithromycin or fluoroquinolones can be indicated in severe illness (e.g., greater than 6 stools in a day, fever, need for hospitalization), specific host factors (e.g., age greater than 70 years, immunocompromised host, having co-morbidities), and features suggesting of the invasive organisms (e.g., blood or mucus in stool) but should be discontinued if EHEC is isolated. Tetracyclines have the greatest efficacy for Vibrio. For pregnant patients with the suspicion of Listeria, ampicillin is the drug of choice. For C. difficile infection (CDI), discontinuation of the causative antibiotic and antibiotic therapy should be initiated. It should be noted that recent Centers for Disease Control and Prevention guidelines changed in March 2018 and now recommend either oral vancomycin or fidaxomicin for nonsevere over oral metronidazole for severe CDI. Combination therapy of oral vancomycin with IV metronidazole should be used for fulminant CDI.

Symptomatic therapy

Loperamide can be given carefully in patients who are afebrile and have non-bloody diarrhea.

Surgical therapy

Patients who present with either medically refractory stomach problems, noncompliance, or experience side effects with medical therapy, underlying large hiatal hernia, or individuals who desire to discontinue long-term medical treatment can be considered for surgical management. The available surgical options for stomach problems are laparoscopic Nissen fundoplication, Laparoscopic anterior 180° fundoplication (180° LAF), or bariatric surgery in obese patients. Laparoscopic Nissen fundoplication has been the gold standard surgical treatment in the management of stomach problems patients. However, given the rapid prevalence of obesity in the United States, gastric bypass surgery is becoming the most common surgical treatment for stomach problems . It should be considered in obese patients with symptoms of stomach problems who prefer surgical therapy. Current ACG guidelines recommend performing preoperative ambulatory pH monitoring in patients without erosive esophagitis and esophageal manometry to rule out achalasia or undiagnosed scleroderma-like esophagus prior to surgical therapy . Two large meta-analyses comparing medical therapy with surgical therapy reported contrary conclusions with one reporting improvement of symptoms of stomach problems after surgery compared with medical therapy and others reporting considerable uncertainty in the benefits of surgical therapy compared to medical therapy . However, patients undergoing fundoplication are at risk for developing postoperative adverse events that include bloating, which is seen in 15 to 20% of patients, dysphagia, and belching. The most common bariatric surgeries performed are Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banded plication (LAGP), and sleeve gastrectomy. Studies have shown that the resulting weight loss from surgical management of obesity has had positive effects on stomach problems. Of all the bariatric surgeries available, RYGB has proven to be the most effective bariatric surgery for reducing stomach problems symptoms. It is recommended as the bariatric procedure of choice in patients with severe stomach problems npreoperatively.

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Endoluminal Therapy

In the era of minimally invasive surgery techniques, many different types of endoscopic therapies have been developed for stomach problem management. Most of them were discontinued after failing to demonstrate long-term efficacy. The current available endoluminal therapies include magnetic sphincter augmentation (MSA) and transoral incision-less fundoplication using the EsophyX (EndoGastric Solutions, Redmond, WA, United States).  A recent meta-analysis by Gerson et al. that included data from 233 patients demonstrated that subjects who underwent TIF 2.0 procedure had improved esophageal pH, decreased need for PPIs, and significant improvement in the quality of life at three years after the TIF 2.0 procedure . Another prospective study by Testoni et al. demonstrated TIF with EsophyX as an effective long-term treatment option for patients with symptomatic stomach problems with associated hiatal hernia less than 2 cm. A meta-analysis comparing Nissen fundoplication and magnetic sphincter augmentation that included data from patients who underwent MSA and the rest who were treated with Nissen fundoplication concluded that MSA was an effective therapeutic option for stomach problems as short-term outcomes with magnetic sphincter augmentation appeared to be comparable to Nissen fundoplication.

Avoid the Following Foods

There are certain foods that can worsen bloating and cause gassiness. These include the following:

  • Lentils and beans contain indigestible sugars which are broken down by bacteria, resulting in the generation of gas
  • Fruits and vegetables like carrots, cabbage, Brussel sprouts,  prunes, and apricots also cause gassiness
  • Artificial sweeteners like sorbitol are not easy to digest and hence are broken down by bacteria to produce gas.
  • Patients with meteorism should avoid dairy products, as they can worsen the bloating sensation.
  • Wheat contains a protein called gluten which may cause bloating. Gluten should be included in the elimination diet to rule out gluten sensitivity.
  • Finally, people prone to meteorism should become physically active as this can also lead to increased peristalsis and emptying of gas from the intestine.

What are the potential complications of stomach problems?

Because stomach problems can be due to serious diseases, failure to seek treatment can result in serious complications and permanent damage. Once the underlying cause is diagnosed, it is important for you to follow the treatment plan that you and your health care professional design specifically for you to reduce the risk of potential complications including:

  • Bowel infarction (severe injury to an area of the bowel due to decreased blood supply)
  • Infertility
  • Internal hemorrhage
  • Intestinal obstruction and rupture of the intestinal wall
  • Organ failure or dysfunction
  • Ruptured appendix
  • Spread of cancer
  • Spread of infection

References

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