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year 3 (term 1) - oxford clinical cases > 12. Epigastric Pain > Flashcards

12. Epigastric Pain Flashcards

1
Q

What are some of the differential diagnoses for epigastric pain?

A
  • Acute pancreatitis
  • Perforated peptic ulcer
  • Gastritis/ duodenitis
  • Peptic ulcer disease
  • Biliary colic
  • Acute cholecystitis
  • Ascending cholangitis
  • Myocardial infarction
  • Ruptured AAA
  • Mesenteric ischaemia
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2
Q

which diagnoses should be excluded as early as possible?

A
  • Acute pancreatitis
  • Perforated peptic ulcer
  • Ascending cholangitis
  • MI
  • Ruptured AAA
  • Mesenteric ischaemia
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3
Q

Whereabouts is the pain from peritonitis?

A

spread from epigastrium to the whole abdomen

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4
Q

Whereabouts is the pain from any biliary diseases?

A

normally right upper quadrant

can sometimes be purely epigastric pain

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5
Q

where does cardiac pain sometimes present?

A
  • spread from the epigastrium to involve the chest
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6
Q

What does epigastric pain of sudden onset suggest?

A
  • Perforation of a viscus (duodenal ulcer or Boerhaave’s perforation )
  • MI
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7
Q

How quickly does pain from acute pancreatitis and biliary colic develop?

A

Usually reaches maximal intensity over 10-20 min

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8
Q

What does ‘burning’ epigastric pain suggest?

A

Peptic ulcers, gastritis and duodenitis

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9
Q

What does ‘deep’/ ‘boring’ epigastric pain suggest?

A

Pancreatitis

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10
Q

what does crushing or tight pain suggest?

A
  • cardiac pathology
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11
Q

what gastro condition might backpain suggest?

A
  • often associated with pancreatitis, leaking AAA or peptic ulcers
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12
Q

What does shoulder tip pain suggest?

A
  • Irritation of the phrenic nerve due to diaphragmatic involvement.
  • This may be due to basal pneumonia/ subphrenic abscess
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13
Q

What kind of pain is relieved by sitting forwards?

A
  • Acute pancreatitis
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14
Q

how does eating affect duodenal and gastric ulcers?

A

this is a bit unreliable but technically

  • eating increases the pain of gastric ulcers
  • eating relieves the pain of duodenal ulcers
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15
Q

how does the timing of biliary colic, peptic disease, gastritis, and non-ulcer dyspepsia present?

A
  • the pain is self limiting over the period of 6-8 hours
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16
Q

what is true colicky pain?

A
  • where the pain waxes and wanes over the period of one episode
17
Q

what conditions might deep breathing worsen?

A
  • basal pneumonia
  • pulmonary embolism
  • pneumothorax
  • pericarditis
  • any cause of pleural inflammation
18
Q

what condition is triggered by fatty meals?

A
  • biliary colic
19
Q

which conditions present with very severe pain?

which conditions present with less severe pain?

A
  • peptic ulcer disease, gastritis, duodenitis and non ulcer dyspepsia are not usually very severe
  • severe pancreatitis, perforated peptic ulcers and MI are very painful
20
Q

What other symptoms should should you ask about once you have characterised epigastric pain?

A
  • Nausea/ vomiting - small bowel obstruction, MI, boerhaaves perforation
  • Fever - infection
  • Dyspepsia - GORD… oesophagitis
  • Changes in stool- steatorrhoea suggests biliary disease
  • Cough (basal pneumonia, GORD)
21
Q

which conditions often present in the past medical history?

A
  • biliary disease
  • peptic ulcer disease
  • GORD
  • vascular disease
22
Q

What drugs may contribute to peptic ulcer disease?

A
  • NSAIDs
  • steroids
  • bisphosphonates
  • salicylates

steriods can mask signs of disease

23
Q

What drugs may contribute to acute pancreatitis?

A
  • Sodium valproate
  • steroids
  • thiazides
  • azathioprine
24
Q

what should be observed on examination?

A
  • position the patient lies in?

patient with peritonitis lie completely still

patient with pancreatitis relieve pain by sitting forwards

  • signs of jaundice?

potentially ascending cholangitis, acute pancreatitis or acute hepatitis

  • Cullens or grey turners sign

this is discolorization due to extravasated blood in the retroperitoneum

  • any signs of bowel obstruction

distended abdomen

  • tenderness or guarding

present in acute cholecystitis or mild pancreatitis

  • masses

check pulsatile mass (AAA)

  • resp examination
25
Q

what bloods should be taken?

A
  • full blood count
  • c-reactive protein
  • pancreatic amylase - acute pancreatitis!
  • liver enzymes
  • albumin
  • urea and electrolytes
  • calcium
  • glucose
  • ABGs
  • troponin
26
Q

why is social history significant?

A
  • acute pancreatitis can be caused by both chronic alcohol consumption and by binge drinking
  • smoking causes vascular issues and also peptic ulcer disease
27
Q

what changes will be seen in the blood in the case of acute pancreatitis?

A
  • high amylase
  • high albumin
  • pancreatitis can cause hypocalcemia
  • hyperglycemia is a marker of severe pancreatitis
  • hypoxia can be a complication of pancreatitis
28
Q

what imaging might be considered for epigastric pain?

A
  • erect chest xray

looking for perforated peptic ulcer, basal pneumonia and pleural effusion

  • abdominal radiograph

only helpful in looking at abdominal dilation and foreign bodies

29
Q

why might an ultrasound be taken?

A
  • when a leaking abdominal aortic aneurysm is suspected
30
Q

why might a CT scan be taken?

A
  • a CT scan might be taken if mesenteric infarction is suspected
  • if AAA is suspected
  • CT scans can also be helpful in diagnosing acute pancreatitis
31
Q

What are the causes of acute pancreatitis?

which causes are the most common

A

I GET SMASHED

  • Idiopathic
  • Gallstones
  • Ethanol
  • Trauma
  • Steroids
  • Mumps/ HIV/ Coxsackie infection
  • Autoimmune
  • Scorpion bites

bold is common

32
Q

What is an easy way to remember the order of an Abdo exam?

A
  • LSB, Shifting D, LSK, Triple A For Percussion and palpation- Percussion- Liver, Spleen, Bladder (LSB) then percuss for shifting dullness Palpation- Liver, spleen, kidneys, abdominal aorta
33
Q

What score is used to assess the severiy and prognosis of pancreatitis?

A

Glasgow score

can be remembered with the pneumonic

P - Pao2< 60mmHg

A- age more than 55

Neutrophilia

Calcium - low

R- renal function - high urea

E - enzymes LDH and AST high

A- albumin is low

S - sugar is high

34
Q

how to prevent a reoccurrence of acute pancreatitis?

A
  • no specific treatment
  • symptoms should subside in a weeks time
  • gallstones need to be dealt with via biliary ultrasound and laparoscopic cholecystectomy
  • in cases of severe pancreatitis patients should have ERCP
  • in cases of alcohol-induced pancreatitis patients should stop drinking
35
Q

how is acute pancreatitis managed?

A
  • first check DRABC
  • IV fluids
  • oxygen
  • analgesia
  • antiemetics
  • DVT prophylaxis
  • low FAT diet

year 3 (term 1) - oxford clinical cases (12 decks)

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