Acute epigastric pain

Question 1

nausea, epigastric pain, radiates to back, pale, clammy, tender, ETOH XS

Differentials for epigastric pain

Answer 1

Gastrointestinal causes:
- Gastritis or peptic ulceration +/- perforation
- Pancreatitis
- Bowel obstruction

Biliary causes: include gallstones complications including cholecystitis and cholangitis although these are usually associated with pyrexia.

Urological causes: renal colic and pyelonephritis may cause mid to upper abdominal pain radiating to the back

Cardiovascular causes:
- Abdominal aortic aneurysm
- Myocardial infarction

Respiratory causes:
Lower lobe pneumonia may cause referred pain although there is no mention of respiratory symptoms and respiratory observations are within normal limits.

Question 2

How would you assess this patient?

Answer 2

Airway: ensure airway patency (with use of adjuncts if required)

Breathing:
- Recheck oxygen saturation and respiratory rate.
- Administer high flow oxygen (15L through non rebreather mask).
- Examine chest – inspect, auscultate and percuss

Circulation:
- Recheck blood pressure and pulse rate
- Capillary refill, JVP and ask an ECG
- IV access with 2 wide bore cannula
- Commence intravenous fluids 500mls stat (or 250mls if pre-existing cardiac condition)
- Bloods: FBC, U&E, LFT, amylase/lipase, Clotting, G&S
- Blood gas including serum lactate

Disability: Check: conscious level, blood glucose, temperature and pupils.

Exposure: Expose patient fully and examine the patient. examine the abdomen at this stage to assess for clinical signs to support my differential diagnoses.

Catheter for fluid monitoring
analgesia
antiemetics

Question 3

What first line investigations would you order and justify?

Answer 3

Haematological:
- FBC: ? Anaemia ? raised white cell count – infection/ inflammation
- U&E: ? dehydration/ AKI ? electrolyte disturbance
- LFTs: ? obstructive picture ? liver failure/ hepatitis
- Amylase or lipase: ? pancreatitis
- CRP: ? infection inflammation
- Clotting: ? liver dysfunction or identify abnormality pre-op/pre-procedure
- LDH, glucose: pancreatic impairment
- G&S: incase of upper GI bleed or preop
- ABG: acid-base balance, fast Hb and electrolytes, lactate, pO2 + pCO2 important to assess respiratory function, identify complications e.g. ARDS and scoring for pancreatitis.

Radiological
- Erect Chest XR: If peritonitis clinically, to look for gas under the diaphragm which would suggest perforation.
- Abdominal US: to assess the biliary system for gallstones, assess the pancreas and look at the abdominal aorta for an aneurysm.
- Abdominal CT: if required to confirm diagnosis or surgical planning e.g. severe pancreatitis, bowel perforation, etc.

Question 4

What is the most common cause of pancreatitis? What are other causes?

Answer 4

Most common: gallstones

I Idiopathic

G Gall stones

E Ethanol

T Trauma

S Steroids

M Mumps

A Autoimmune (e.g. SLE)

S Scorpion bites

H Hypothermia, hypercalcaemia, hyperlipidaemia

E ERCP

D Drugs e.g. NSAIDs, azathioprine, thiazides

Question 5

Why is lipase used more than amylase in pancreatitis?

Answer 5

Mostly because lipase levels remain elevated longer than amylase

Some evidence suggests lipase has a slightly higher specificity and sensitivity.

Question 6

What severity scoring systems do you know for pancreatitis?

Answer 6

Glasgow (most widely used),
APACHE II,
Ranson,
BISAP,
Balthazar (CT scan interpretation).

Question 7

Describe the Glasgow prognostic criteria (Imrie Criteria) for acute pancreatitis?

Answer 7

This is an 8-point prognostic scoring system based on age and 7 laboratory values, taken within the 48 hours following admission to predict severe pancreatitis. Parameters are one point for each (using PANCREAS mnemonic)

P - PaO2 <8kPa
A - Age >55-years-old
N - Neutrophilia: WCC >15x10(9)/L
C - Calcium <2 mmol/L
R - Renal function: Urea >16 mmol/L
E - Enzymes: LDH >600iu/L; AST >200iu/L
A - Albumin <32g/L (serum)
S - Sugar: blood glucose >10 mmol/L

Question 8

Glasgow score is 3. What does this mean in terms of patient management?

Answer 8

A score of 3 or more indicates severe pancreatitis and warrants referral to ITU/ critical care.

Question 9

An ultrasound scan shows obstructive gallstones. What definitive management is indicated for the gallstones?

Answer 9

• ERCP (Endoscopic Retrograde Cholangio-Pancreatography) to relieve the obstructing calculi in the acute setting.
• Laparoscopic cholecystectomy

Question 10

What complications of acute pancreatitis do you know?

Answer 10

• Pancreatitic necrosis
• Haemorrhage
• Hypovolaemic shock
• Chronic pancreatitis
• ARDS
• Pancreatic pseudocyst
• Death