Case 18: functional Flashcards
1
Q
Some of the theories for functional abdo pain
A
- Early life events: Nociceptive somatic stimuli early in the neonatal period. Neonatal gastric suction
- Psychological factors: abuse, separation, failure in an exam, loss of parents jobs, hospitalisation
- Poor gastric emptying and poor antral motility, abnormality gastric accommodation
2
Q
Different causes of IBS
A
- Alteration of central processing of afferent stimuli due to an episode of severe or poorly controlled acute GI pain (i.e. gastroenteritis or abdo surgery)
- Anxiety and depression
- Post-infection IBS
- Post inflammatory IBS
- Bile acid malabsorption
- Visceral hyperalgesia
3
Q
Disrupted nociception and neuromodulation
A
- Lowers pain threshold causing non-nociceptive signals to be interpreted as pain i.e. gut peristalsis
- Can be triggered by an episode of severe or poorly controlled acute pain especially if current life stress or psychological distress i.e. gastroenteritis or abdo surgery. Good post op pain control is important in reducing rates of chronic pain
- Can co-exist or be caused by GI disease
- More common in patients with depression/anxiety or life stressors. Descending pain pathway is closely associated with limbic and emotional systems which receives input from the anterior cingulate cortex (part of the limbic system)
4
Q
GI red flags
A
- History: persistent RUQ or RLQ pain, persistent vomiting, GI blood loss, chronic severe diarrhoea, unintentional weight loss, unexplained fever, FH or IBD, coeliac etc
- Examination findings: deceleration of growth in paeds, uveitis, oral lesions, skin rashes, icterus, anaemia, hepatomegaly, splenomegaly, arthritis, costovertebral angle tenderness, tenderness over the spine, perianal abnormalties
5
Q
Management for functional abdo pain: move down the list
A
- General: supportive environment, validation of symptoms, patient education, agree and set realistic treatment goals.
- Support networks
- Improving co-morbid conditions
- Pharmacological: TCA’s, SNRI
- Psychological: CBT, Hypnotherapy
- Step up therapy: Gabapentin, Pregabalin
6
Q
Functional chronic pelvic pain
A
- Pain lasting >6 months in the lower abdomen or pelvic area
- Not purely associated with menstruation, intercourse or pregnancy
- Tends to be gyanecological
- Normal investigations
- Can be associated with abnormal uterine bleeding, urinary symptoms and constipation
- May be a result of central sensitisation, biopsychosocial factors and contributing organic pathology
7
Q
Differentials of chronic abdo pain other than functional
A
- GORD (epigastric pain, worse with spicy or fatty foods)
- chronic pancreatitis (pain after eating, foul stools, weight loss)
- peptic ulcer disease (pain with eating)
- chronic mesenteric ischaemia (pain after eating, bloody diarrhoea and pain)
8
Q
Differentials of chronic pelvic pain other than functional
A
- endometriosis: cyclical pain, dyspareunia
- PID: pelvic pain, discharge, dyspareunia and fever
- adhesions
- gynaecological malignancy
- ovarian cyst
- recurrent UTIs
9
Q
Red flags for pelvic pain
A
- Post-coital bleeding
- Post-menopausal bleeding
- PR bleeding
- New GI symptoms e.g. constipation, bloating, early satiety, especially age >50
- Pelvic mass
- Unexpected weight loss
10
Q
Organic differential diagnoses for pelvic pain
A
- Gynaecological: Endometriosis, adhesions, PID, gynaecological malignancy
- GI: IBS, IBD: colon mlignancy, coeliac
- Urological: irritable bladder, bladder malignancy, recurrent UTI’s
- Neurological: nerve entrapment, central neurological pain i.e. MS
- Musculoskeletal: fibromyalgia, joint/muscle tension
11
Q
What red flag symptoms would warrant further investigations of chronic abdo pain
A
- rectal bleeding
- weight loss
- over 60 and change to bowel habit
- anaemia
- abdominal or rectal masses
- FH of bowel or ovarian cancer
- raised inflammatory markers
12
Q
Medically unexplained chest pain
A
- not related to exertion
- Younger age
- Not necessarily related to FH
- Normal CT coronary angiogram and echocardiogram
- Personal and psychological stressors
13
Q
Other causes of non-cardiac chest pain
A
- Gastrointestinal:GORD, oesophageal spasm, swallow pathology. May be related to eating/swallow + acid/water brash.
- Respiratory:pleurisy, pneumonia, PE and rarely, cancer. Pain may be pleuritic, related to deep breathing + associated with cough.
- Musculoskeletal:chostochondritis, trauma, bony metastasis. May be tender to palpation and worsened by movement.
- Psychiatric:Generalised anxiety, panic disorder. Episodes of stress-response adrenaline leading to racing heart, palpitations, chest pain.
- Functional:No organic explanation. May felt felt constantly or intermittently with varied symptoms.
14
Q
Palpitations: causes and concerning features
A
- Cardiac causes: Afib or flutter, SVT, other arrhythmias, ectopics, sinus tachy, structural heart disease
- Other causes: anxiety, panic disorder, hyperthyroidism, pheochromocytoma, anaemia, menopause, caffeine, recreational drugs, drug withdrawal. beta 2 agonists i.e. salbutamol
15
Q
Concerning features of palpitations
A
- Accompanying chest pain, lightheadedness or syncope
- Family history of sudden cardiac death
- ECG changes (e.g. prolonged QTc, Brugada pattern, delta waves)
- Cardiac co-morbidities e.g. severe LVSD, known ischaemic heart disease, structural heart disease
16
Q
Investigations for palpitations
A
- Cardiac exam and relevant blood tests
- Refer to cardiology if cardiac disease suspected
- Echo if suspect heart failure
- ECG, ECG Holter monitors or loop recorders (combined with symptom diary)
17
Q
Benign palpitations
A
- Ectopic beats: atrial or ventricular. Feel like a ‘missed beat’ then a ‘heavy squeeze.’
- Atrial ectopics are common and do not affect prognosis.
- Ventricular ectopics can be associated with increased caffeine intake or stress (reducing caffeine and stress). More common with increased age. Lots of ventricular ectopics (e.g. bigeminy) can indicate electrolyte disturbances, underlying cardiac ischaemia or structural abnormalities and warrant further investigation.
- Sinus tachycardia- racing heart beat but the rhythm is regular Can be a physiological response to underlying pathology such as sepsis or PE. Sinus tachycardia is also associated with anxiety as the increase in catecholamine levels lead to increased heart rates.
18
Q
How to treat benign palpitations
A
- Reassurance, lifestyle advice and managing cardiac risk factors i.e. hypertension and hypercholesterolaemia
- Relaxation, mindfulness and coping strategies can be helpful in reducing palpitation frequency and severity.
19
Q
What associated features may suggest palpitations are concerning
A
- accompanying chest pain, lightheadedness or syncope
- FH of sudden cardiac death
- ECG changes
- cardiac co-morbidities
20
Q
What should be carried out to clarify the cause of death after someone is confirmed dead
A
- death certificate issued by doctor stating cause of death
- medico-legal investigation to establish cause of death
