Acute Epigastric Pain

Question 1

Where is epigastric ?

Answer 1

is the upper central portion of the abdomen.

Question 2

Epigastric region contains which organs?

Answer 2

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

Question 3

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

Answer 3

 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.

Question 4

What are the causes of Acute epigastric pain

Answer 4

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

Question 5

Tell me types of acute gastritis

Or what are causes of gastritis ???

Answer 5

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

Question 6

Pt come with AEP ,vomitting and diarrhea ?

Answer 6

Viral and bacterial gastroenteritis

Question 7

H.pylori detected by

Answer 7

CLO test also called rapid urease test

Question 8

Invs for gastritis

Answer 8

Endoscopy and biopsy to exclude PU and malignancy

Question 9

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

Answer 9

damage gastric mucosa and cause acute gastritis(Gastric erosion)

Question 10

History of cholecystectomy and partial gastric surgery

Answer 10

bile reflux gastritis.

Question 11

Describe biliary pain

Answer 11

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

Question 12

Describe pain of acute pancreatitis

Answer 12

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

Question 13

Cullens sign

Answer 13

Hemorrhagic pancreatits with necrosis

Question 14

oedematous pancreatitis

Answer 14

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)

Question 15

Examination

Moderate epigastric tendernesss

Answer 15

Acute gastritis

Question 16

Sealed perforation on examination

Answer 16

Muscle tenderness and guarding

Question 17

Detawaaaaa

Examination of cholecystitis

Answer 17

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

Question 18

Examination

Acute pancreatitis

Answer 18

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

Question 19

Diagnostic plan for acute epigastric pain

Answer 19

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

Question 20

What is done after biochemical invs and hematological

Answer 20

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.

Question 21

If the finding on radiology

Answer 21

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

Question 22

What are indication of US in acute epigastric pain ?

Answer 22

 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

Question 23

What we can see in ct

Answer 23

Oedema and necrosis is seen in pancreas

Question 24

Types of cholecyctitis

Answer 24

Calculous

Acalculous

Question 25

Talk about us findings of pancreas

Answer 25

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.

Question 26

What is suggested in pts with localized perforation of ulcer?

Answer 26

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

Question 27

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

Answer 27

Nazanm prsyaraka chibe:)

Question 28

When ERCP is indicated?

Answer 28

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.

Question 29

What is treatment of localized perforation

Answer 29

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

Question 30

What is treatment od free perforation

Answer 30

Laparascopy and or laparatomy is performed

Question 31

Rx of acute cholecyctitis and biliary colic

Answer 31

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.

Question 32

Rx of odematous pancreatitis

Answer 32

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.

Question 33

What are less common causes of epigastric pain

Answer 33

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

Question 34

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

Answer 34

Basallllll pneumoniaa

Question 35

Tumors of the ampulla & head of pancreas usually causes

Answer 35

Obstruction

Question 36

More than 85% are ductal adenocarcinoma mostly in the

Answer 36

Head

Question 37

Risk factors pf pancreatic cancer

Answer 37

Commonest age is 65-75years. | ➢Other risk factors include cigarette smoking, family history and male gender.

Question 38

Dark urine,Pale stool, Pruritis: Indicates Obstructive Jaundice

Answer 38

Dark urine,Pale stool, Pruritis: Indicates Obstructive Jaundice

Question 39

• Causes of benign biliary stricture

Answer 39

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

Question 40

Primary Sclerosing cholangitis :

Answer 40

➢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.

Question 41

Clinical general examination for pt with jaundice

Answer 41

• 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

Question 42

Signs of chronic liver disease

Answer 42

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

Question 43

What are investigations for a jaundiced patient?

Answer 43

• 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