12. Epigastric Pain Flashcards
Acute epigastric pain Ddx:
ACUTE PANCREATITIS Perforated PEPTIC ULCER Gastritis/duodenutis Peptic ulcer disease (gastric or duodenal) Biliary colic Acute cholecystitis Ascending Cholangitis MI Ruptured AAA Mesenteric ischaemia Basal pneumonia Oesophagitis (due to GORD) Non ulcer dyspepsia (NUD, aka idiopathic dyspepsia) Chronic pancreatitis Incomplete bowel obstruction Boerhaaves perforation gastric c Pancreatic c (but c in head of pancreas usu painless) Acute hepatitis (usu painless unless hepatomegaly)
SITE of epigastric pain
- Pain that’s spread from epigastrium to involve the rest of the abdo may suggest peritonitis from a perforated GIT (eg. perforated gastric ulcer, which causes epigastric pain as stomach is embryologically a foregut structure)
- Pain that’s spread from the epigastrium to involve the chest may be cardiac
- Biliary disease, although anatomically located in RUQ, may present with epigastric symptoms
ONSET of epigastric pain
- Pain that’s of very sudden onset suggests perforation of a viscus (eg perforated duodenal ulcer or Boerhaave’s perforation) or MI
- Pain from acute pancreatitis and biliary colic develops maximal intensity over 10-20 minutes
- Inflammatory processes such as acute cholecystitis or pneumonia typically take hours to reach their peak
CHARACTER of epigastric pain
- Crushing or tightness qualities are typical of cardiac pathology
- Sharp, burning pain is typical of peptic ulcers, gastritis and duodenitis
- Deep ‘boring’ pain is typical of pancreatitis
RADIATION of epigastric pain
- Back pain is classically associated with pancreatitis, leaking AAA and sometimes seen w peptic ulcers
- Shoulder tip pain due to irritation of the phrenic nerve suggests diaphragmatic involvement (for example by a basal pneumonia or subphrenic abscess)
- Jaw, neck or arm pain suggests cardiac pathology
- Retrosternal chest pain suggests oesophagitis or myocardial ischaemia
ATTENUATING FACTORS of epigastric pain
- Pts with acute pancreatitis may find that sitting forward relieves their pain
- Surgical dogma suggests that eating makes the pain of gastric ulcers worse but relieves the pain from duodenal ulcers (but unreliable way to distinguish them)
TIMING of epigastric pain
- Biliary colic, uncomplicated peptic ulcer disease, gastritis, duodenitis and non ulcer dyspepsia are likely to be self limiting over timescales of <6-8hrs (although in many cases there will be recurrent episodes)
- Bear in mind that biliary colic doesn’t produce truly colicky pain (where pain waxes and wanes during a single episode) but rather the pain is relatively constant for the duration of the attack
- Epigastric pain made worse by exercise must make you consider cardiac pathology
EXACERBATING factors of epigastric pain
- Movement worsens severe pain of intra-abdominal origin and peritonitis
- Deep breathing (pleuritic pain) can worsen epigastric pain when due to basal pneumonia, PE, pneumothorax, pericarditis or any cause of pleural inflammation
- Triggering of self limiting pain by fatty meals is highly suggestive of biliary colic
SEVERITY of epigastric pain
- Uncomplicated peptic ulcer disease, gastritis, duodenitis and non ulcer dyspepsia are usually not severe (and many pts will not present to hospital)
- Severe pancreatitis, perforated peptic ulcers and MI are typically very painful
Associated symptoms to ask about
Nausea +/or vomiting Fever Dyspepsia +/or waterbrash Any change in stool recently Cough
Nausea +/or vomiting ?
Small bowel obstruction can present as colicky epigastric pain associated with N + V. An inferior MI can also cause vomiting by irritation of the diaphragm. Boerhaave’s perforation is precipitated by forceful vomiting. Be clear about when vom was (before or after pain)
Fever?
Could suggest an infection (eg viral hepatitis, pneumonia) or widespread inflammation in the peritoneum (ie. peritonitis)
Dyspepsia +/or waterbrash?
Pts who describe the constellation of symptoms including heartburn, retrosternal discomfort, and a bitter taste in the mouth, likely to have GORD or sequalae eg oesophagitis
Change in stool?
Pale stool = bile not reaching bowel
Foul smelling, floating stools (steatorrhoea) = poor digestion of fat, usu due to pancreatic exocrine insufficiency or long standing biliary disease (as it implies obstruction)
Cough?
In absence of abdo symptoms other than epigastric pain, an acute cough +/or productive sputum raises likelihood of basal pneumonia. A more chronic cough with epigastric pain suggests GORD, where refluxed stomach acid irritates the vocal cords
Hx of biliary disease
Pts with known history of gallstone disease are prone to recurrence of biliary disease and complications eg acute pancreatitis, acute cholecystitis or ascending cholangitis. NB. Even pts who have had a previous cholecystectomy can suffer effects of GS retained in common bile duct
Hx of peptic ulcer disease
A wise maxim is to regard all pts with known peptic ulcer disease, presenting with sudden onset severe epigastric pain, as having a perforated ulcer until proven otherwise
Hx of GORD
Has a high rate of recurrence
Hx of Vascular disease
Pts with widespread arterial disease are at increased risk of both MI and mesenteric ischaemia. Mesenteric ischaemia may occur as an acute presentation, or as chronic ‘mesenteric angina’. The latter is similar to cardiac ischaemia in that it may be preceded by work- related pain which in the gut manifests as colicky post prandial abdo pain. RF for chronic mesenteric ischaemia incl smoking, HTN, DM, hypercholesterolaemia, + FHx of CVD. RF for acute mesenteric ischaemia reflect potential sources of emboli thus include AF, recent MI and cardiac valvular disease
Which drugs induce peptic ulcer disease
NSAIDs, steroids, bisphosphonates, salicylates eg aspiring.
Steroids not only predispose to PUD but also dampen inflammatory response to any subsequent ulcer perforation and hence partially mask signs of peritonism
Which drugs induce acute pancreatitis
Sodium valproate, steroids, thiazides and azathioprine
Hereditary causes of acute pancreatitis
Mutations in PRSS1, SPINK1, and CFTR
Acute pancreatitis O/E
- Position- pts with peritonitis lie still and rigid, pain of pancreatitis is positional so impr when pt sits forward or lies in recovery posn
- Jaundice - seen w posthepatic causes of biliary obstruction eg ascending cholangitis and GS induced Acute Pancreatitis, or acute hepatitis. AP can cause jaundice in absence of GS as oedema of head of pancreas compresses CBD (usu 2-3D after onset)
- Cullen’s or grey turners sign- discolouration due to extravasated bl in retroperitoneum around umbilicus and flank respectively. May be seen in acute haemorrhagic pancreatitis but are rare, non specific and late signs
- Signs of small bowel obstruction - distended abdomen with absent or tinkling bowel sounds
- Tenderness and guarding - may be localised tenderness, as in the case of acute cholecystitis (Murphy’s sign) or mild pancreatitis. Acute mild pancreatitis may produce a degree of local peritonism. If the tenderness is more severe, generalised and seen in combo with guarding and board like rigidity- this is likely to be peritonitis
- Masses - check for central, laterally expansile, pulsatile mass (AAA). Don’t forget to check the inguinal folds and femoral canal for hernias causing bowel obstruction (but unusual)
- Resp exam - pathology of lung based may mask as upper abdo pain. Check for decr expansion, dullness to percussion, decr breath sounds and incr vocal resonance
Acute pancreatitis O/E
- Position
- Jaundice
- Cullen’s or grey turners sign
- Signs of small bowel obstruction
- Tenderness and guarding
- Masses
- Resp exam
