12. Epigastric Pain Flashcards
What are some of the differential diagnoses for epigastric pain?
- Acute pancreatitis
- Perforated peptic ulcer
- Gastritis/ duodenitis
- Peptic ulcer disease
- Biliary colic
- Acute cholecystitis
- Ascending cholangitis
- Myocardial infarction
- Ruptured AAA
- Mesenteric ischaemia
which diagnoses should be excluded as early as possible?
- Acute pancreatitis
- Perforated peptic ulcer
- Ascending cholangitis
- MI
- Ruptured AAA
- Mesenteric ischaemia
Whereabouts is the pain from peritonitis?
spread from epigastrium to the whole abdomen
Whereabouts is the pain from any biliary diseases?
normally right upper quadrant
can sometimes be purely epigastric pain
where does cardiac pain sometimes present?
- spread from the epigastrium to involve the chest
What does epigastric pain of sudden onset suggest?
- Perforation of a viscus (duodenal ulcer or Boerhaave’s perforation )
- MI
How quickly does pain from acute pancreatitis and biliary colic develop?
Usually reaches maximal intensity over 10-20 min
What does ‘burning’ epigastric pain suggest?
Peptic ulcers, gastritis and duodenitis
What does ‘deep’/ ‘boring’ epigastric pain suggest?
Pancreatitis
what does crushing or tight pain suggest?
- cardiac pathology
what gastro condition might backpain suggest?
- often associated with pancreatitis, leaking AAA or peptic ulcers
What does shoulder tip pain suggest?
- Irritation of the phrenic nerve due to diaphragmatic involvement.
- This may be due to basal pneumonia/ subphrenic abscess
What kind of pain is relieved by sitting forwards?
- Acute pancreatitis
how does eating affect duodenal and gastric ulcers?
this is a bit unreliable but technically
- eating increases the pain of gastric ulcers
- eating relieves the pain of duodenal ulcers
how does the timing of biliary colic, peptic disease, gastritis, and non-ulcer dyspepsia present?
- the pain is self limiting over the period of 6-8 hours
what is true colicky pain?
- where the pain waxes and wanes over the period of one episode
what conditions might deep breathing worsen?
- basal pneumonia
- pulmonary embolism
- pneumothorax
- pericarditis
- any cause of pleural inflammation
what condition is triggered by fatty meals?
- biliary colic
which conditions present with very severe pain?
which conditions present with less severe pain?
- peptic ulcer disease, gastritis, duodenitis and non ulcer dyspepsia are not usually very severe
- severe pancreatitis, perforated peptic ulcers and MI are very painful
What other symptoms should should you ask about once you have characterised epigastric pain?
- Nausea/ vomiting - small bowel obstruction, MI, boerhaaves perforation
- Fever - infection
- Dyspepsia - GORD… oesophagitis
- Changes in stool- steatorrhoea suggests biliary disease
- Cough (basal pneumonia, GORD)
which conditions often present in the past medical history?
- biliary disease
- peptic ulcer disease
- GORD
- vascular disease
What drugs may contribute to peptic ulcer disease?
- NSAIDs
- steroids
- bisphosphonates
- salicylates
steriods can mask signs of disease
What drugs may contribute to acute pancreatitis?
- Sodium valproate
- steroids
- thiazides
- azathioprine
what should be observed on examination?
- 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
what bloods should be taken?
- full blood count
- c-reactive protein
- pancreatic amylase - acute pancreatitis!
- liver enzymes
- albumin
- urea and electrolytes
- calcium
- glucose
- ABGs
- troponin
why is social history significant?
- acute pancreatitis can be caused by both chronic alcohol consumption and by binge drinking
- smoking causes vascular issues and also peptic ulcer disease
what changes will be seen in the blood in the case of acute pancreatitis?
- high amylase
- high albumin
- pancreatitis can cause hypocalcemia
- hyperglycemia is a marker of severe pancreatitis
- hypoxia can be a complication of pancreatitis
what imaging might be considered for epigastric pain?
- 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
why might an ultrasound be taken?
- when a leaking abdominal aortic aneurysm is suspected
why might a CT scan be taken?
- 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
What are the causes of acute pancreatitis?
which causes are the most common
I GET SMASHED
- Idiopathic
- Gallstones
- Ethanol
- Trauma
- Steroids
- Mumps/ HIV/ Coxsackie infection
- Autoimmune
- Scorpion bites
bold is common
What is an easy way to remember the order of an Abdo exam?
- 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
What score is used to assess the severiy and prognosis of pancreatitis?
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
how to prevent a reoccurrence of acute pancreatitis?
- 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
how is acute pancreatitis managed?
- first check DRABC
- IV fluids
- oxygen
- analgesia
- antiemetics
- DVT prophylaxis
- low FAT diet
