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So ... what bought you here today > 12. Epigastric Pain > Flashcards

12. Epigastric Pain Flashcards

1
Q

List some differential diagnoses of epigastric pain.

A 
Acute pancreatitis 
Perforated peptic ulcer 
Gastritis/duodenitis
Peptic ulcer disease 
Biliary colic 
Acute cholecystitis 
Ascending cholangitis 
MI
Ruptured AAA
Mesenteric ischaemia 
Basal pneumonia
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2
Q

Describe the pattern of pain that would be caused by a perforated peptic ulcer.

A

There would initially be an intense pain in the epigastrium

This would spread across the whole abdomen as the patient becomes peritonitic

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3
Q

What does sudden-onset pain suggest?

A

Perforated viscus

MI

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4
Q

How long does pain from acute pancreatitis or biliary colic take to reach maximum intensity?

A

10-20 mins

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5
Q

How long do inflammatory processes such as pneumonia and cholecystitis take to reach their peak in terms of pain?

A

A matter of hours

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6
Q

Which diseases cause epigastric pain that radiates to the back?

A

Acute pancreatitis

Leaking AAA

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7
Q

What can cause shoulder-tip pain?

A

Diaphragmatic irritation (e.g. by basal pneumonia, subphrenic abscess)

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8
Q

Which diseases cause retrosternal pain?

A

Oesophagitis

Myocardial ischaemia

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9
Q

What can relieve the pain caused by pancreatitis?

A

Sitting forward

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10
Q

Describe how gastric ulcers and duodenal ulcers can be differentiated based on when the pain is worst.

A

Gastric Ulcers – pain is worse when eating

Duodenal Ulcers – pain is relieved by eating

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11
Q

What does pain triggered by fatty meals suggest?

A

Biliary colic

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12
Q

Which of the causes of epigastric pain cause particularly severe pain?

A

Severe pancreatitis
MI
Perforated peptic ulcer

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13
Q

List some important associated symptoms that should be enquired about when taking a history.

A 
Nausea and vomiting 
Fever
Dyspepsia and waterbrash
Changes in stool
Cough
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14
Q

List some diseases that cause epigastric pain and nausea and vomiting.

A

Small bowel obstruction
Inferior MI
Boerhaave’s perforation (vomiting precedes the epigastric pain)

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15
Q

Which pathology is associated with causing pale stools?

A

Obstruction of bile outflow

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16
Q

Which diseases cause steatorrhoea?

A

Long-standing biliary disease

Pancreatic exocrine insufficiency

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17
Q

Why is it important to ask a patient with epigastric pain whether they’ve had a cough?

A

Basal pneumonia can cause epigastric pain and it will also cause an acute, productive cough

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18
Q

List the four main diseases in the past medical history that are important to ask a patient with epigastric pain about.

A

GORD
Peptid ulcer disease
Biliary disease (e.g. gallstones)
Vascular disease

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19
Q

Why is it important to ask about previous vascular disease and cardiovascular risk factors?

A

A history of vascular disease increases the risk of mesenteric ischaemia and myocardial infarction

20
Q

Which two diseases that cause epigastric pain can be caused by drugs?

A

Peptic Ulcer Disease

Acute Pancreatitis

21
Q

Which drugs are associated with Peptic Ulcer Disease?

A

NSAIDs
Aspirin
Bisphosphonates
Steroids

22
Q

Which drugs are associated with Acute Pancreatitis?

A

Sodium valproate
Thiazides
Steroids
Azathioprine

23
Q

List some significant features of the social history.

A

Alcohol – excess can cause acute pancreatitis

Smoking – associated with peptic ulcer disease, MI and mesenteric ischaemia

24
Q

Describe the appearance of a peritonitic patient.

A

Patients lie completely still
Taking shallow breaths
Movement is painful

25
Q

How can acute pancreatitis lead to jaundice in the absence of gallstones?

A

Oedema of the head of an inflamed pancreas can obstruct the common bile duct

26
Q

Describe Grey-Turner’s and Cullen’s Signs. What are they signs of?

A

They are signs of severe pancreatitis
Cullen’s Sign – bruising/discolouration around the umbilicus
Grey-Turner’s Sign – bruising/discolouration on the flanks

27
Q

List signs of small bowel obstruction.

A

Abdominal distension
Tinkling bowel sounds
Absolute constipation

28
Q

What is Murphy’s sign?

A

A finger is placed just below the tip of the right 9th costal cartilage and the patient is asked to breathe in deeply
Inspiration is arrested when the inflamed gallbladder strikes the finger of the examiner
This is indicative of cholecystitis

29
Q

Which masses might you palpate for in the abdomen of a patient with epigastric pain?

A

AAA – central expansile and pulsatile mass

Check hernia orifices because a strangulated hernia could cause bowel obstruction

30
Q

List some important blood tests that you would perform in a patient with epigastric pain.

A 
FBC – check for raised WCC, anaemia, neutrophilia
CRP
Pancreatic Amylase and Lipase
Liver enzymes 
Albumin 
U&Es
Calcium
Glucose 
ABG
31
Q

Describe different patterns of derangement of liver enzymes and state what they indicate.

A

High AST + ALT (transaminitis) = liver pathology (e.g. hepatitis)
High ALP + GGT = biliary disease
Isolated raised GGT = alcoholic liver disease
High AST: ALT ratio (> 2:1) = alcoholic liver disease

32
Q

List some prognostic indicators in pancreatitis.

A

Neutrophilia
Albumin
Blood glucose

33
Q

Describe the time taken for serum amylase to rise and fall in a case of pancreatitis.

A

Rises within hours

Returns to normal after 3-5 days

34
Q

Why is it important to measure serum calcium in a patient with pancreatitis?

A

Hypercalcaemia – can cause pancreatiits
Hypocalcaemia – can result from severe pancreatitis (a process called saponification occurs where calcium binds to digested lipids)

35
Q

Why is it important to perform a VBG in a patient with epigastric pain?

A

Allows assessment of pH and lactate
pH will decrease and lactate will increase in conditions causing a severe inflammatory response (e.g. acute pancreatitic, peritonitis)
NOTE: this is because a systemic inflammatory response -> vasodilation -> hypoperfusion of tissues -> increase in anaerobic respiration -> lactic acidosis

36
Q

Which forms of imaging are useful in patients with epigastric pain?

A

Erect CXR
AXR
Ultrasound

37
Q

Which sign on erect CXR suggests that there has been a GI perforation?

A

Air under the diaphragm (pneumoperitoneum)

38
Q

Why might ultrasound be useful in investigating a patient with epigastric pain?

A

Allows visualisation of AAA

Allows visualisation of gallstone disease

39
Q

What is the downfall with the use of ultrasound to investigate AAAs?

A

It does not show whether the AAA is leaking/ruptured

A CT aortogram is required to confirm a leak

40
Q

List the causes of acute pancreatitis.

A 
GALLSTONES
ETHANOL
Trauma
Steroids
Mumps/HIV/Coxsackie
Autoimmune
Scorpion venom
Hypercalcaemia/hyperlipidaemia/hypothermia
ERCP
Drugs (e.g. sodium valproate, thiazides)
41
Q

What are the two main scoring systems for pancreatitis?

A

Glasgow

Ranson

42
Q

With regards to the Glasgow scoring system, what score is considered severe pancreatitis?

A

3 and above

43
Q

Outline the management of acute pancreatitis.

A 
Assess ABC (NOTE: pancreatitis can cause ARDS)
IV fluids 
Oxygen 
Analgesia
Anti-emetics 
DVT prophylaxis 
Low-fat diet
44
Q

How can you reduce the recurrence of pancreatitis?

A

Cholecystectomy

Stop drinking alcohol

45
Q

Describe the two main tests for Helicobacter pylori.

A

Urease Breath Test – pt swallows sample of urea containing radio-labelled carbon. After 10-30 mins, breath tested -> if the radio-labelled carbon is identified in the patient’s breath, it suggests that urease, produced by H. pylori, is present in the patient’s stomach

Campylobacter-like Organism (CLO) Test – biopsy from patient’s stomach and placed on a medium containing urea and an indicator. If urease (produced by H. pylori) is present in the patient’s stomach, it will convert the urea to carbon dioxide (and other by-products) and cause a change in the colour of the indicator

46
Q

Describe the treatment of H. pylori.

A

Triple therapy – 2 x antibiotics + PPI

47
Q

What is non-ulcer dyspepsia?

A

Chronic epigastric pain with normal blood tests, normal OGD and normal biliary ultrasound (there is no organic cause for the pain)

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