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Tutas Studying > Acute Epigastric Pain > Flashcards

Acute Epigastric Pain Flashcards

1
Q

Where is epigastric ?

A

is the upper central portion of the abdomen.

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2
Q

Epigastric region contains which organs?

A

Stomach,duodenum,part of pancreas,left lobe of liver,and aorta

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3
Q

What are the difference between acute epigastric pain and acute abdominal pain?

A

 Patients are not as seriously ill as acute abdomen.
 Indications for early laparotomy present in acute
abdomen while not for AEP.
 Various diseases are common to both.
 Diseases less severe in patients with AEP
 More time exists for diagnosis.
 Most causes can be managed by conservative non- surgical treatment.

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4
Q

What are the causes of Acute epigastric pain

A
  1. Acute gastritis
  2. Acute exacerbation of duodenal ulcer
  3. Biliary colic and acute cholecystitis
  4. Acute (oedematous)pancreatitis
  5. Non-ulcer dyspepsia
  6. Less common causes
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5
Q

Tell me types of acute gastritis

Or what are causes of gastritis ???

A 
 Bacterial(H.Pylori)
 Viralinfection
 Duodenalrefluxgastritis
 Drugs(NSAID,Aspirin,Steroid.......) 
 Irradiationtherapy
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6
Q

Pt come with AEP ,vomitting and diarrhea ?

A

Viral and bacterial gastroenteritis

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7
Q

H.pylori detected by

A

CLO test also called rapid urease test

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8
Q

Invs for gastritis

A

Endoscopy and biopsy to exclude PU and malignancy

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9
Q

Why its important to take history about drugs and alcohol in AEP

A

damage gastric mucosa and cause acute gastritis(Gastric erosion)

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10
Q

History of cholecystectomy and partial gastric surgery

A

bile reflux gastritis.

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11
Q

Describe biliary pain

A 
Abrupt onset 
Felt in epigastrium 
Or right hypochondrium
Flactuate in severity 
Pain reffered to back
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12
Q

Describe pain of acute pancreatitis

A

80% of cases is modest severity

presents as localized acute upper abdominal pain without systemic effects

Prognosis is good in such cases.

Attacks frequently follow an alcoholic binge or large meal
 The pain abrupt in onset

Severe and persistent and radiating to back
 Persistent vomiting

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13
Q

Cullens sign

A

Hemorrhagic pancreatits with necrosis

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14
Q

oedematous pancreatitis

A

The majority of mild or moderate oedematous pancreatitis settle down rapidly in hospital
 Acute oedematous pancreatitis is often secondary to gall stones
 Past history of biliary pain
 Pain in pancreatitis is central and more severe in compare to biliary pain
 Most attacks resolve as small stones pass the sphincter of Oddi
 Stones in the bile duct are found in only about 10% of patients(when investigated by ERCP)

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15
Q

Examination

Moderate epigastric tendernesss

A

Acute gastritis

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16
Q

Sealed perforation on examination

A

Muscle tenderness and guarding

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17
Q

Detawaaaaa

Examination of cholecystitis

A

RUQ tenderness and guarding
Or Epigastric tenderness
Murphys sign

In about 3rd of patients the inflamed GB is palpable
 Mild fever is common
 Moderate tachycardia and leukocytosis
 In contrast patients with biliary colic have no significant findings on examinations

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18
Q

Examination

Acute pancreatitis

A

Acute pancreatitis
 The signs depend on severity
 Despite severe pain ,examination of the abdomen reveals that guarding is not as marked as would be expected.
 An epigastric mass may be found (due to inflammatory oedema of the pancreas)

Peripheral circulatory and respiratory failure are uncommon
 Temperature normal or slightly elevated
 Moderate degree of leukocytosis
 Clinical evidence of secondary basal atelectasis and pleural effusion on the left side of chest
 Most case with mild disease clinical condition rapidly settles with treatment

19
Q

Diagnostic plan for acute epigastric pain

A

Early endoscopy is contraindicated in the investigation of acute
epigastric pain
 Haematological and biochemical examination:
 Serum lipase:(acute pancreatitis) usually rises to above 100 iu/L
 Serum bilirubin : transient rise is common in gall stone pancreatitis
 Urinary bilirubin: is often present in acute cholecystitis and acute pancreatitis
 Daily review of electrolytes ,calcium, glucose and renal function is essential

20
Q

What is done after biochemical invs and hematological

A

FBC

Normal in most cases.
 Marked leukocytosis suggests sepsis(empyema of GB,paraduodenal abscess)
 Mild to moderate leukocytosis uncomplicated acute cholecystitis or acute pancreatitis
 Hypochromic anaemia suggests blood loss from PU.

21
Q

If the finding on radiology

A

A localized small bowel loop(sentinel loop) or large bowel ileus(colonic cutoff sign)

 Free air under right hemidiaphragm in 50% of cases in perforated ulcer
 Left basal pulmonary atelectasis and effusion in acute pancreatitis
 Plain film of abdomen =radiopaque stone in GB or calcification in
pancreatic region
 20% of gall stones radiopaque
 Ileus pattern localized to right upper quadrant suggests cholecystis or pancreatitis

22
Q

What are indication of US in acute epigastric pain ?

A

 Ultrasound is the best method of detecting gallstones
 In pancreatitis some time difficult to detect gallstones because of distended bowel gas due to ileus
 U/S also valuable in detecting and following a pancreatic mass and the evolution of pseudocysts

23
Q

What we can see in ct

A

Oedema and necrosis is seen in pancreas

24
Q

Types of cholecyctitis

A

Calculous

Acalculous

25
Q

Talk about us findings of pancreas

A

U/S can show increased thickness and oedema of GB wall (feature of acute cholecystitis) and valuable in a calculus cholecystitis
U/S less effective in obese patients with excess bowel gas in such case, CT scan better option.
CT scanning of GB is not as satisfactory as U/S.
CT with contrast very good investigation for pancreas better than U/S.

26
Q

What is suggested in pts with localized perforation of ulcer?

A

Early, water-soluble contrast study of the upper gastrointestinal tract indicated in patient suspected of having localised perforation of an ulcer.

27
Q

Indications include a past history of ulcer in a patient with persistent pain and moderate tenderness with a negative, plain X-ray

A

Nazanm prsyaraka chibe:)

28
Q

When ERCP is indicated?

A

ERCP may be indicated in the patient with postcholecystectomy pain if a stone in the bile duct is suspected, particularly in patients with dilated extrahepatic ducts and altered liver function.

29
Q

What is treatment of localized perforation

A

Elective surgery

Especially in patients with a long history, previous complications or associated stenosis.

30
Q

What is treatment od free perforation

A

Laparascopy and or laparatomy is performed

31
Q

Rx of acute cholecyctitis and biliary colic

A

Intravenous fluids and antibiotics
Acute cholecystitis, pain and tenderness often resolve within 48 hours two thirds of cases.
Clinical trials have show that early operation before discharge from hospital can be performed safely.
Most patients are therefore best operated upon at the first convenient opportunity.

32
Q

Rx of odematous pancreatitis

A

Control pain give pethidine notttt give morphine bcz will cause further spasm of sphincter of oddi

Most patients with oedematous pancreatitis settle down rapidly in
hospital with conservative treatment
 The principles of treatment are:
 control of pain, using pethidine rather than morphine, the latter causing spasm of the sphincter of Oddi
 prevention of renal and respiratory insufficiency by careful replacement of fluids, chest physiotherapy and intranasal oxygen
 nasogastric suction may be used if there is symptomatic ileus (i.e. protracted vomiting)

Antibiotics may be used (respiratory infection)
 More intensive management, such as physiotherapy and ventilatory support, is necessary in severely ill patients
 Gallstone pancreatitis, current opinion favors performing a cholecystectomy during the initial hospital stay so that the risk of another attack is avoided.
 In aged patients, endoscopic sphincterotomy may be a safer alternative initial form of treatment.

33
Q

What are less common causes of epigastric pain

A

These may be gastrointestinal or nongastrointestinal.
 Preicteric hepatitis can be confused with acute cholecystitis.
 Prodromal symptoms of nausea and anorexia and signs of tender hepatomegaly with disordered liver function tests help make the diagnosis.
 Hydronephrosls is often felt in the epigastrium

Nerve root pain (T6-10) can cause acute upper abdominal pain. In most cases the clue to the diagnosis is radiation of the pain from the back. Osteoarthritis with spur formation and shingles are the most common causes of root pain
 Aortic aneurysm
 Presents with acute epigastric or left hypochondrial pain when
rupture is imminent.
 More commonly presents as acute abdomen
 An interval of several hours may exist between the first episode of self-limited bleeding and later retroperitoneal rupture

34
Q

Young ,AEP, guarding, respiratory infection ,respiratory distress,basal crepetation

A

Basallllll pneumoniaa

35
Q

Tumors of the ampulla & head of pancreas usually causes

A

Obstruction

36
Q

More than 85% are ductal adenocarcinoma mostly in the

A

Head

37
Q

Risk factors pf pancreatic cancer

A

Commonest age is 65-75years.

➢Other risk factors include cigarette smoking, family history and male gender.

38
Q

Dark urine,Pale stool, Pruritis: Indicates Obstructive Jaundice

A

Dark urine,Pale stool, Pruritis: Indicates Obstructive Jaundice

39
Q

• Causes of benign biliary stricture

A

Congenital……..Biliary atresia
Bile duct injury at surgery….. Cholecystectomy, Choledochotomy, Gastrectomy Inflammatory…………. Stones, Cholangitis, Parasitic, Sclerosing cholangitis,
Trauma Idiopathic

40
Q

Primary Sclerosing cholangitis :

A

➢Is an idiopathic fibrosing condition that affect both intra & extra hepatic bile ducts.
➢The aetiology is unknown but it has an immunological basis.
➢ Common in 30-60 years age ,more in male and it has an association with
ulcerative colitis.
➢ Symptoms are those of obstructive jaundice with weight loss, anorexia, abdominal pain and fever.

41
Q

Clinical general examination for pt with jaundice

A

• Confusion: diminished mental state.
• Vital signs (fever, hypotension)
• Pallor- hemolytic anemia.
• Fever with jaundice and abdominal pain (RUP) called Charcot’s Triad, a feature of Ascending Cholangitis.
• As the disease progresses, patients may also display altered mental status and hypotension. These two symptoms in addition to
Charcot’s triad is known as Reynold’s pentad, which is indicative of more severe disease.
• Smell the breath for alcohol.
• Weight loss - malignancy
• Sweet smell on breath of fetor hepaticus
• Scratch marks (obstructive jaundice).
Examine ankles and sacrum for edema (hypoalbuminemia). Supraclavicular L.N. Enlargement (Troisier’s Sign)
Needle track marks: Evidence of drug misuse (hepatitis B and C) Tattoos and body piercing: Hepatitis B and C

42
Q

Signs of chronic liver disease

A

Finger clubbing, palmar erythema, leukonychia, Spider naevi, Gynecomastia, hair loss, testicular atrophy

43
Q

What are investigations for a jaundiced patient?

A

• Urinalysis: contain bile pigments, protein (?).
• Stoolexamination:Steatorrhea
• Serum Bilirubin: Direct versus indirect hyperbilirubinemia will differentiate prehepatic from hepatic causes of jaundice.
• Liver Enzymes: AST & ALT will be elevated in acute hepatic diseases
• Alkaline Phosphatase: Will be raised significantly in obstructive jaundice.
• Gamma-glutamyltransferase: Will be elevated in obstructive jaundice
• Serum Albumin: Decreased in liver failure
• Coagulation Profile: PT, PTT & INR will be deranged in liver dysfunction
Note: chronic jaundice is usually associated with liver disease
• CBC: In hemolytic diseases, and in malignancy (chronic disease can lead to low hemoglobin?) • Pancreatic enzymes: Amylase, Lipase, and Trypsin indicate pancreatic damage

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