Case 10: Epigastric Pain Flashcards
what is visceral pain
it is dull and poorly localised
is due to activation of nociceptors in organs (viscera)
stimulated by contraction, tension, stretching or ischaemia
what is somatic pain
originating from muscle, bone, joints, tendons, or blood vessels
pain receptors are in tissues and are activated by noxious substance causing inflammation of the parietal peritoneum
stimuli typically is force, temperature, vibration or swelling
what is colic
visceral pain caused by contraction/distension (renal, biliary, bowel)
what is a tympanic abdomen
distended abdomen (air) like balloon
what is a tender abdomen
abdominal pain present in response to touch/pressure
what is a peritonitic abdomen
there is inflammation of the peritoneum by a noxious substance
which cells of the stomach secrete hydrochloric acid
parietal cells
which cells of the stomach secrete gastrin
G cells
which cells of the stomach secrete mucous
mucous cells (goblet?)
which cells of the stomach secrete pepsinogen
chief cells
what are the functions of the exocrine pancreas
elastases break down elastin
chymotrypsin (chymotrypsinogen is inactive form) breaks down protein into amino acids
amylase breaks down starch and glycogen
lipase breaks down triglycerides into fatty acids and monoglycerides
what is the acceptable weekly unit of alcohol
less than 14 units
what is Cullens sign
periumbilical (below belly button) ecchymosis (redness/brusing) due to retroperitoneal bleed
what is peritonitis
inflammation of the peritoneum (can be generalised or localised)
what is peritonism
an indirect activation of the entire abdominal musculature due to peritoneal irritation and is called peritonism
what causes guarding
peritonism
2 conditions which may cause local peritonism in the upper abdomen (umbilical)
acute pancreatitis
acute cholecystitis
what type of peritonitis would a visceral perforation cause
generalised
do peptic ulcers cause guarding
no as there is no peritonism
what is acute pancreatitis
inflammation of the pancreas caused by activation of pancreatic enzymes and auto digestion
what can the consequences of acute pancreatitis be
systemic inflammatory response syndrome (SIRS) which can in turn causes organ failure such as:
acute kidney injury (AKI)
respiratory distress syndrome (respiratory failure)
causes of pancreatitis pneumonic
Idiopathic
Gallstones
Ethanol
Trauma (penetrating)
Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/hypercalxaemia
ERCP
Drugs
also family history/genetic factors
most common cause of acute pancreatitis
gallstones
most common cause of chronic pancreatitis
alcohol abuse
how to diagnose acute pancreatitis
abdominal pain (acute, persistent, epigastric pain radiating to the back)
serum lipase/amylase over 3 times the upper limit
radiological evidence of pancreatitis (MR/CT)
which cells of the pancreas release enzymes
acinar cells
why are amylase and lipase used for pancreatitis diagnosis
they are pathologically released by acinar cells of the inflamed pancreas
lipase is more sensitive
how do lipase levels rise during acute pancreatitis
peaks at 24hrs
can remain elevated between 8-14 days as it is reabsorbed by the renal tubules back into circulation
how do amylase levels rise during acute pancreatitis
rises rapidly within 2hrs of onset of acute pancreatitis
peaks between 12-72hrs
is then excreted rapidly by the kidneys
levels can return to normal as soon as 3 days
what is considered mild acute pancreatitis
no organ failure or local/systemic complications
what is considered moderate severe acute pancreatitis
transient organ failure (such as AKI) resolving within 48hrs
may have local complications (peripancreatic collection)
what is considered severe acute pancreatitis
persistent organ failure/ multi-organ failure
what are the two main types of acute pancreatitis
interstitial oedematous pancreatitis (90-95%)
necrotising pancreatitis (5-10%)
what can be the consequences of interstitial oedematous pancreatitis
acute peripancreatic fluid collection (APFC)- occurs within 4 weeks and fluid is extra pancreatic
if the above is not resolved within 4 weeks it may organise and become a pseudocyst
pseudocyst- this is a homogenous fluid-filled collection with a cyst wall, can compress the surrounding structures such as the stomach
what can be the consequences of necrotising pancreatitis
acute necrotic collection (ANC)- occurs within 4 weeks, fluid is intra and/or extra pancreatic, there is a homogenous collection of fluid and solid components and no wall
walled off necrosis (WON)- occurs after 4 weeks of onset of pain, is homogenous collection of fluid and solid components/necrotic tissue within a cyst wall
what is the name of the criteria for diagnosing acute pancreatitis
Atlanta criteria
raised what in the blood may suggest AKI
urea and creatinine
what on chest x-ray would suggest visceral perforation
free air under the diaphragm
what investigation is done with suspected pancreatitis
ultrasound of the abdomen- gallstones need to be ruled out/in as a cause
how to manage acute pancreatitis
analgesia
antiemetics (NG tube if vomiting)
fluid balance (IV fluid resuscitation and urinary catheter)
venous thromboembolism prophylaxis
under what circumstances would you 2 week wait someone for endoscopy
dysphagia
those over 55 with either weight loss and either abdominal pain, dyspepsia or reflux
what lifestyle changes would you recommend with GORD
smoking cessation
weight loss
avoid precipitating foods- chocolate, citrus, coffee
sleeping with head of the bed raised
what is GORD
symptomatic back flow of acid and stomach contents into the stomach causing heartburn
what can be the pathophysiology of GORD
abnormal transient relaxation of the LOS
impaired oesophageal clearance
delayed gastric emptying that increases gastric pressure
also associated with hiatus hernia
GORD risk factors
smoking and alcohol
obesity
stress
hiatus hernia
pregnancy
trigger foods
NSAIDs and beta-blocker use- these reduce the LOS tone
what can you offer patients with GORD who do not respond to acid suppression therapy
OGD- oesophago-gastro duodenoscopy
also:
oesophageal manometry
ambulatory 24hr oesophageal pH monitoring
surgical options for GORD
nissen fundoplication- laprascopic
fundus of the stomach is wrapped around lower oesophagus to reinforce the LOS
complications of ongoing GORD
barrets oesophagus- metaplastic changes to lower oesophagus from squamous cells to columnar
oesophagitis
recurrent chest infections- reflux can go into respiratory system potentially giving rise to aspiration pnuemonia, bronchitis and bronchial asthma
chronic cough- acid affects the larynx especially when lying down at night
benign stricture- ongoing oesophageal inflammation damages the epithelium causing a stricture, circular band of mucosa can form (Schazki ring) which can cause dysphagia
what would indicate surgery for GORD
failure of therapy (efficacy or side effects)
desire to discontinue medical therapy
hiatus hernia
ALARMS red flag symptoms for dyspepsia
Anemia
Loss of weight
Anorexia
Recent onset/progressive symptoms
Malena and haematemesis
Swallowing difficulties (dysphagia)
what is the most likely diagnosis given weight loss and dyspepsia
upper GI malignancy
what is the most common type of gastric cancer
adenocarcinoma- when it spreads primarily through the musculature of the stomach wall, the ‘thickening’ is called linitis plastica- ‘leather bottle appearance’
other types of gastric cancers
squamous cell carcinoma
non-Hodgkin’s lymphoma
gastrointestinal stromal tumours (GIST)
neuroendocrine tumours (NET)
risk factors for gastric adenocarcinoma
age (over 75)
male
H.pylori
FAP
ethnicity- black, hispanic, asian
smoking and alcohol
diet
obesity (more so in men)
investigations for gastric adenocarcinoma
upper GI endoscopy- minimum of 6 biopsies taken
staging- CT thorax, abdomen and pelvis
MDT discussion
staging laparoscopy surgery + chemotherapy if tumour is potentially resectable
what potential problems specific to gastric cancer may occur during end of life
nausea
vomiting
haematemesis- bleeding from the tumour
ascites
pain
what is a perforated viscus
intestinal/bowel perforation
enteric contents leak into the peritoneal cavity therefore causing severe abdominal pain
which blood tests are useful for perforated viscus
FBC (WCC)
lipase
CRP
urea and creatinine are also useful
what is SIRS
systemic inflammatory response syndrome (as a result of sepsis)
what would you see on chest xray with visceral perforation
on erect chest xray would see free air under the diaphragm
history of what disease could increase risk of gastric/duodenal perforation
peptic ulcer disease
what is peptic ulcer disease
a peptic ulcer is a break in the mucosal lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer)
distribution extends into submucosa or muscularis propria and is usually more than 5mm in diameter
what % of world have peptic ulcer disease
3%
risk factors for peptic ulcer disease
h.pylori
smoking
alcohol
NSAIDs- ibuprofen, naproxen
symptoms of peptic ulcer disease
epigastric pain that is constant and radiates into the back usually when hungry
early satiety
reflux symptoms
nausea
properties of h pylori
patients with infection can be asymptomatic
is naturally resistant to stomach acid
can be transmitted by oral-oral or faecal-oral route
triple therapy for h pylori
PPI + 2 antibiotics
PPI= omeprazole, lansoprazole, esomeprazole
clarythromycin
amoxicillin (metronidazole if penicillin allergy)
usual presentation of perforated peptic ulcer disease
rigid abdomen- indicative of generalised peritonitis (secondary to florid bowel contents in peritoneal cavity)
sudden onset of epigastric pain before becoming more generalised in nature
symptoms of distention and nausea and vomiting
what to do if perforation cannot be seen on chest xray
CT
treatment and management of perforated peptic ulcer disease
nil by mouth
analgesia
antibiotics
fluid balance (IV fluids and urinary catheter)
refer to on-call general surgery team for further management
VTE prophylaxis
antiemetics (with NG tube if actively vomiting)
what surgery is performed for perforated peptic ulcer disease
laparotomy- some omentum is sutured over perforation along with a thorough was out of the peritoneal cavity
common post operative complications of laparotomy
lower respiratory tract infections/pneumonia
postoperative ileus
UTIs
DVT
ongoing leak from site of perforation
