12. Epigastric Pain

Question 1

Acute epigastric pain Ddx:

Answer 1

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)

Question 2

SITE of epigastric pain

Answer 2

1. 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)
2. Pain that’s spread from the epigastrium to involve the chest may be cardiac
3. Biliary disease, although anatomically located in RUQ, may present with epigastric symptoms

Question 3

ONSET of epigastric pain

Answer 3

1. Pain that’s of very sudden onset suggests perforation of a viscus (eg perforated duodenal ulcer or Boerhaave’s perforation) or MI
2. Pain from acute pancreatitis and biliary colic develops maximal intensity over 10-20 minutes
3. Inflammatory processes such as acute cholecystitis or pneumonia typically take hours to reach their peak

Question 4

CHARACTER of epigastric pain

Answer 4

1. Crushing or tightness qualities are typical of cardiac pathology
2. Sharp, burning pain is typical of peptic ulcers, gastritis and duodenitis
3. Deep ‘boring’ pain is typical of pancreatitis

Question 5

RADIATION of epigastric pain

Answer 5

1. Back pain is classically associated with pancreatitis, leaking AAA and sometimes seen w peptic ulcers
2. Shoulder tip pain due to irritation of the phrenic nerve suggests diaphragmatic involvement (for example by a basal pneumonia or subphrenic abscess)
3. Jaw, neck or arm pain suggests cardiac pathology
4. Retrosternal chest pain suggests oesophagitis or myocardial ischaemia

Question 6

ATTENUATING FACTORS of epigastric pain

Answer 6

1. Pts with acute pancreatitis may find that sitting forward relieves their pain
2. 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)

Question 7

TIMING of epigastric pain

Answer 7

1. 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)
2. 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
3. Epigastric pain made worse by exercise must make you consider cardiac pathology

Question 8

EXACERBATING factors of epigastric pain

Answer 8

1. Movement worsens severe pain of intra-abdominal origin and peritonitis
2. Deep breathing (pleuritic pain) can worsen epigastric pain when due to basal pneumonia, PE, pneumothorax, pericarditis or any cause of pleural inflammation
3. Triggering of self limiting pain by fatty meals is highly suggestive of biliary colic

Question 9

SEVERITY of epigastric pain

Answer 9

1. Uncomplicated peptic ulcer disease, gastritis, duodenitis and non ulcer dyspepsia are usually not severe (and many pts will not present to hospital)
2. Severe pancreatitis, perforated peptic ulcers and MI are typically very painful

Question 10

Associated symptoms to ask about

Answer 10

Nausea +/or vomiting
Fever
Dyspepsia +/or waterbrash
Any change in stool recently 
Cough

Question 11

Nausea +/or vomiting ?

Answer 11

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)

Question 12

Fever?

Answer 12

Could suggest an infection (eg viral hepatitis, pneumonia) or widespread inflammation in the peritoneum (ie. peritonitis)

Question 13

Dyspepsia +/or waterbrash?

Answer 13

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

Question 14

Change in stool?

Answer 14

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)

Question 15

Cough?

Answer 15

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

Question 16

Hx of biliary disease

Answer 16

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

Question 17

Hx of peptic ulcer disease

Answer 17

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

Question 18

Hx of GORD

Answer 18

Has a high rate of recurrence

Question 19

Hx of Vascular disease

Answer 19

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

Question 20

Which drugs induce peptic ulcer disease

Answer 20

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

Question 21

Which drugs induce acute pancreatitis

Answer 21

Sodium valproate, steroids, thiazides and azathioprine

Question 22

Hereditary causes of acute pancreatitis

Answer 22

Mutations in PRSS1, SPINK1, and CFTR

Question 23

Acute pancreatitis O/E

Answer 23

1. Position- pts with peritonitis lie still and rigid, pain of pancreatitis is positional so impr when pt sits forward or lies in recovery posn
2. 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)
3. 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
4. Signs of small bowel obstruction - distended abdomen with absent or tinkling bowel sounds
5. 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
6. 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)
7. 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

Question 24

Acute pancreatitis O/E

Answer 24

1. Position
2. Jaundice
3. Cullen’s or grey turners sign
4. Signs of small bowel obstruction
5. Tenderness and guarding
6. Masses
7. Resp exam