19- epigastric pain Flashcards by Karin Lavie

cardiac causes of abdominal pain

Myocardial infarction,
angina pectoris,
abdominal aortic aneurysm/ dissection/ rupture.

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psych causes of abdominal pain

anxiety, panic disorder, somatiform disorder, post-traumatic stress disorder.

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pulm causes of abdominal pain

Pleurisy, pneumonia, pulmonary infarction, tumor.

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renal causes of abdominal pain

Nephrolithiasis, pyelonephritis, cystitis, tumor.

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musculoskeletal causes of abdominal pain

Abdominal wall muscle strain,
hernia (e.g., ventral, inguinal, incarcerated),
abscess (e.g., psoas, subphrenic),
trauma (e.g., contusion, hematoma).

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metabolic causes of abdominal pain

Drug overdose, ketoacidosis, iron or lead poisoning, uremia.

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GI causes of abdominal pain

Appendicitis, cholecystitis/cholelithiasis, diverticulitis/diverticulosis, dyspepsia, gastroesophageal reflux disease, gastritis, acute or chronic hepatic failure with resultant complications (e.g., ascites), acute hepatitis (e.g., viral, autoimmune, alcoholic, drug-induced), inflammatory bowel disease, intestinal ischemia, intestinal obstruction, irritable bowel syndrome, pancreatitis, peptic ulcer, perforation/peritonitis (e.g., gastric, colonic, intestinal), gastric outlet obstruction, tumor (e.g., gastric, hepatic, pancreatic, intestinal, colonic).

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are Hematochezia and melena and Hematemesis associated with GERD?

nope! upper GI bleed!

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gastritis

Inflammation or irritation of the stomach lining often causing sharp epigastric pain

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causes of gastritis

H pylori
viruses
NSAIDs, alcohol

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diverticulitis presentation

Commonly presents with acute left lower quadrant abdominal pain, change in bowel movements, and fever.

Most common in patients over 50 years of age.

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acute pancreatitis presentation

Causes severe abdominal pain, associated nausea and vomiting, ill appearance on exam, and clinical signs of dehydration such as tachycardia.

Pain is typically located in the epigastric area with radiation to the back and worsens with eating.

Symptoms often last for many hours without relief.

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Agents that Cause or Contribute to Peptic Ulcer Disease

NSAIDs
Moderate to severe physiologic stress
H pylori
cigarettes

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how does H pylori cause gastritis

by disrupting the mucous layer, liberating enzymes and toxins, and adhering to the gastric epithelium.

In addition, the body’s immune response to H. pylori incites an inflammatory reaction that contributes to tissue injury and leads to chronic gastritis.

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is chronic gastritis typically symptomatic?

no! asx

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how to differentiate between peptic ulcer disease and GERD

PUD:
epigastric ‘aching’, ‘gnawing’, or ‘hunger-like’ pain or discomfort
alleviated by food

GERD:
heartburn, regurgitation
worsened by food

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Do patients with GERD report lower health-related quality of life than patients with heart failure.

yes!

also DM, untreated angina

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what is the most common form of GERD?

Non-erosive reflux disease (NERD)

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what is the primary etiologic factor of GERD?

Transient LES relaxations

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Symptoms of GERD may also be precipitated by:

spicy and fatty foods
chocolate
mint
smoking
alcohol and caffeinated beverages
eating large portions
lying flat after a meal
wearing tight clothing around the waist
some medications (calcium channel blockers, beta-agonists, alpha-adrenergic agonists, theophylline, nitrates, and some sedatives)

what happens when severe reflux reaches the pharynx and mouth or is aspirated?

It can cause atypical signs and symptoms of GERD or laryngopharyngeal reflux (LPR).

atypical signs and symptoms of GERD:

asthma
chronic cough
dental enamel loss
globus sensation
hoarseness
noncardiac chest pain
recurrent laryngitis
recurrent pharyngitis
subglottic stenosis

Complications of GERD

Esophagitis

Peptic strictures from fibrosis and constriction

Replacement of the squamous epithelium of the esophagus by columnar epithelium (Barrett’s esophagus) may result from reflux esophagitis. Two to five percent of cases of Barrett’s esophagus may be further complicated by adenocarcinoma.

complications of PUD

Hemorrhage or perforation into the peritoneal cavity or adjacent organs (causing severe, persistent abdominal pain).

Ulcer scar healing or inflammation can impair gastric emptying leading to gastric outlet obstruction syndrome.

what does dysphagia to solids suggest

possible development of peptic stricture..

Rapidly progressive dysphagia potentially indicates

adenocarcinoma

Dysphagia to liquids suggests

development of a motility disorder.

Initial onset of upper GI symptoms after age 50 can suggest

cancer

Early satiety can suggest

May be associated with gastroparesis or gastric outlet obstruction (stricture or cancer).

Hematemesis | Vomiting blood, which suggests...

``` bleeding ulcer, mucosal erosions (erosive gastritis/esophagitis), esophageal tear (Mallory-Weiss), or esophageal varices. ```

hematochezia can inidicate

indicate a rapidly bleeding ulcer or mucosal erosions.

Odynophagia

Painful swallowing, which is associated with infections (e.g. candida), erosions, or cancer.

Recurrent vomiting can suggest

gastric outlet obstruction.

signs of anemia

Brittle nails and cheilosis (cracks and sores on the lips) are signs of anemia. Pallor of palpebral (eyelid) mucosa or nail beds may also be present with anemia.

how is murphy's sign performed

performed by asking the patient to breathe out and then gently placing the hand in the approximate location of the gallbladder. The patient is then instructed to inspire. If the patient stops inhaling (as the tender gallbladder comes in contact with the examiner's fingers) the test is considered positive.)

what is used when the diagnosis of GERD cannot easily be determined, when patients desire referral for surgical treatment of their GERD/hiatal hernia (Nissen fundoplication) or when patients with classic symptoms of GERD (heartburn, regurgitation) do not improve after appropriate trials of several different PPIs.

24-hour pH probe

what can be useful in determining complications of GERD (e.g. esophageal stricture), but has poor utility in diagnosing GERD and should not be used for this purpose.

upper GI series - barium swallow radiograph

when should patients be referred for upper endoscopy/EGD

setting of alarm or extraesophageal symptoms to rule out significant disease, or in cases that do not respond to the empiric treatment strategy after eight weeks.

when is H. pylori IgG serologic test used

only confirms evidence of past infection and an immunologic response to H. pylori . In a population with a high prevalence of active H. pylori infection, it is a useful first-time test. However, if the prevalence of active infection is low, then the test may yield a high number of false-positive results. It should not be used to confirm eradication of H. pylori after treatment as it can remain positive for years.

when is urea breath test used

accurately detects active infection but is more expensive than serologic testing. patients would need to stop the PPI and bismuth for at least two weeks before a urea breath test when 1st try of H pylori treatment fails

when is stool antigen test for H. pylori used

accurate and widely available, but it is more expensive and less convenient than serologic testing. The stool antigen and urease breath tests may also be used as confirmatory tests after a positive serologic test. or when 1st try of H pylori treatment fails

After H. pylori infection is ruled out, the following therapies have been proposed for functional dyspepsia:

TCAs | some herbs

which alternative remedy decreases lower esophageal sphincter pressure and may worsen GERD symptoms.

peppermint oil

guaiac-based fecal occult blood tests (FOBT), such as Hemoccult II SENSA, are best used to check for

occult upper GI bleeding.

Fecal immunochemical testing (FIT) compared to FOBT

more sensitive and specific than FOBT for detecting occult lower GI bleeding; however, it is not suitable for detecting gastric bleeding, and it should not be used if the suspected source of bleeding is proximal to the ligament of Treitz.

is H pyrlori prevalence increasing or decreasing

decreasing

h pylori transmission

spread through human saliva and feces and via food and water sources.

treatment of H pylori- 2 options

triple therapy: 10-14 days PPI standard dose twice daily Amoxicillin 1 g twice daily Clarithromycin 500 mg twice daily ``` quadruple therapy 10-14 dayS: PPI standard dose once or twice daily Metronidazole 250 mg four times daily Tetracycline 500 mg four times daily Bismuth subsalicylate 525 mg four times daily ```

Indications for testing for proof of H. pylori eradication include:

patients with an H. pylori-associated ulcer, persistent symptoms despite appropriate therapy for H. pylori, patients with H. pylori-associated MALT lymphoma, history of resection for early gastric cancer, and patients planning to resume chronic NSAID therapy