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Z Year3 Clinical Presentations > Epigastric Pain > Flashcards

Epigastric Pain Flashcards

1
Q

What are some gastro differentials of epigastric pain?

A
  1. Acute pancreatitis
  2. Perforated peptic ukcer
  3. Gastritis/duodenitis
  4. Bilary colic
  5. Acute cholecytsitis
  6. Ascending cholangitis
  7. Oesophagitis
  8. Non-ulcer dyspepsia
  9. Chronic pancreatitis
  10. Gastric cancer
  11. Pancreatic cancer
  12. Acute hepatitis
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2
Q

What are non-gastro differentials of epigastric pain?

A
  1. MI
  2. Ruptured MI
  3. Mesenteric ischaemia
  4. Basal pneumonia
  5. Incomplete bowel obstruction
  6. Borehaave’s perforation
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3
Q

What would epigastric pain that spread to rest of abdomen suggest?

A

peritonitis from perforated GI tract

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4
Q

What would epigastric pain that spread to chest suggest?

A

cardiac cause

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5
Q

What would a sudden onset of epigastric pain suggest?

A
  1. perforation of viscus

2. MI

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6
Q

What would epigastric pain that develops max intensity in 10-20 min suggest?

A
  1. Acute pancreatitis

2. Biliary colic

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7
Q

What would epigastric pain that takes hours to reach peak pain suggest?

A
  1. Acute cholecystitis

2. Pneumonia

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8
Q

What would a crushing/tighteness epigastric pain suggest?

A

cardiac cause

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9
Q

What would a sharp/burning epigastric pain suggest?

A
  1. peptic ulcers
  2. duodenitis
  3. gastritis
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10
Q

What would a deep boring epigastric pain suggest?

A

pancreatitis

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11
Q

What would epigastric pain radiating to the back suggest?

A
  1. pancreatitis
  2. leaking AAA
  3. peptic ulcer
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12
Q

What would epigastric pain with shoulder tip pain suggest?

A
  1. basal pneumonia

2. subprehnic abscess

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13
Q

What would epigastric pain with radiating jaw, neck, arm pain suggest?

A

cardiac pathology

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14
Q

What would epigastric pain with retrosternal chest pain suggest?

A
  1. oesophagitis

2. myocardial ischaemia

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15
Q

What would epigastric pain that is relived when sitting forward suggest?

A

acute pancreatitis

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16
Q

What would epigastric pain that is self-limiting over 6-8 hours suggest?

A
  1. uncomplicated peptic ulcer
  2. gastritis
  3. duodenitis
  4. biliary colic
  5. non-ulcer dyspepsia
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17
Q

What sort of pain is biliary colic?

A

NOT colicky (constant)

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18
Q

What would epigastric pain that is worse when exercising suggest?

A

cardiac pathology

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19
Q

What would epigastric pain that is worsened when move suggest?

A
  1. severe pain or intrabdominal origin

2. peritonitis

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20
Q

What would pleuritic pain thats worsens epigastric pain suggest?

A
  1. basal pneumonia
  2. pulmonary embolus
  3. pneumothorax
  4. pericarditis
  5. any cause of pleural inflammation
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21
Q

What would epigastric pain triggered by fatty meals suggest?

A

biliary colic

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22
Q

What would less severe epigastric pain suggest?

A
  1. uncomplicated PUD
  2. gastritis
  3. duodenitis
  4. non-ulcer dyspepsia
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23
Q

What would very painful epigastric pain suggest?

A
  1. serve pancreatitis
  2. perforated peptic ulcers
  3. MI
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24
Q

What other symptoms must be asked about with epigastric pain?

A
  1. Nausea and vomiting?
  2. Fever?
  3. Dyspepsia and/or waterbrash?
  4. Change in stool?
  5. Cough?
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25
Q

What conditions may cause nausea and vomiting with epigastric pain?

A
  1. Small bowel obstruction (with colicky epigastric pain)
  2. Inferior MI cause vomiting
  3. Borehavve’s perforation, vomiting before
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26
Q

What could fever with epigastric pain suggest?

A

infection + inflammation

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27
Q

What infections would cause fever and epigastric pain?

A
  1. viral hep

2. pneumonia

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28
Q

What inflammation would cause fever and epigastric pain?

A

peritonitis

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29
Q

What would heartburn, retrosternal discomfort, bitter taste in mouth with epigastric pain suggest?

A
  1. GORD

2. Oesophagitis

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30
Q

What pale stools suggest?

A

bile not reaching bowel

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31
Q

What could foul smelling, steatorrhea with epigastric pain suggest?

A
  1. pancreatic exocrine insufficiency

2. long standing biliary disease

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32
Q

What would acute cough and/or productive sputum with only epigastric pain suggest?

A

basal pneumonia

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33
Q

What would a chronic cough with epigastric pain suggest?

A

GORD

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34
Q

What conditions do you need to check in PMHx with epigastric pain?

A
  1. Biliary disease
  2. PUD
  3. GORD
  4. Vascular disease
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35
Q

What do you ask about biliary disease in PMHx?

A

prone to:

  1. recurrence
  2. acute pancreatitis
  3. acute chonlangitis
  4. Acute cholcystitis
36
Q

Why do you ask about PUD in PMHx?

A

if they have and sudden onset severe epigastric pain: perforated ulcer until proven otherwise

37
Q

What do you ask about GORD in PMHx?

A

high rate of reccurence

38
Q

What do you ask about vascular disease in PMHx?

A

risk of mesenteric and myocardial ischaemia

39
Q

What is mesenteric angina?

A

work-related pain, colicky postprandial abdominal pain

40
Q

What are the risk factors for chronic mesenteric ischaemia?

A
  1. Smoking
  2. Hypertension
  3. DM
  4. Hypercholesterolaemia
  5. FHx of cardiovascular disease
41
Q

What are the risk factors for acute mesenteric ischaemia?

A
  • Potential sources of emboli:
    1. atrial fibrillation
    2. Recent MI
    3. Cardiac valvular disease
42
Q

What DHx should you ask about with epigastric pain?

A
  1. NSAIDs, steroids, bisphosphonates, salicylates

2. Sodium valoprate, steroids, thiazides, azathioprine

43
Q

Why do you ask about NSAIDs, steroids, bisphosphonates, salicylates?

A

peptic ulcer disease

44
Q

Why do you ask about sodium valoprate, steroids, thiazides, azathioprine?

A

acute pancreatitis

45
Q

What do you check in FHx with epigastric pain?

A

establish cardiovascular disease risk

46
Q

What SHx do you ask about in epigastric pain?

A
  1. smoking (PUD and vascular causes of epigastric pain)

2. alcohol

47
Q

What is important to consider in the examination of epigastric pain?

A
  1. Position
  2. Jaundice
  3. Cullen’s or Grey Turner’s sign
  4. Tenderness or guarding
  5. Masses
  6. Respiratory exam
48
Q

How would the position of the patient with peritonitis be like?

A

completely still + rigid any movement extremely painful

49
Q

What would the position of the patient with pancreatitis be like?

A

positional pain (unless severe then lie still)

50
Q

What conditions could cause jaundice with epigastric pain?

A
  1. ascending cholangitis
  2. gallstone induced pancreatitis
  3. acute hepatitis
  4. acute pancreatitis (after a few days of symptom onset)
51
Q

What can cause Cullen’s or Grey Turner’s sign with epigastric pain?

A

acute haemorrhagic pancreatitis (rare, non-specific and late signs)

52
Q

What can cause localised tenderness with epigastric pain?

A
  1. acute cholecystitis (Murphy’s sign)

2. mild pancreatitis

53
Q

What can cause serve generalised tenderness with guarding?

A

peritonitis

54
Q

What would a central, laterally expansile, pulsatile mass with epigastric pain suggest

55
Q

What hernias must you check for with epigastric pain?

A

inguinal fold and femoral canal for hernias which could cause bowel obstruction

56
Q

What are you looking for in a resp exam with epigastric pain?

A

check for signs of consolidation

57
Q

What are signs of consolidation?

A
  1. Decreased expansion
  2. Dullness to percussion
  3. Decreased breath sounds
  4. Increased vocal resonace
58
Q

What bloods do you order for epigastric pain?

A
  1. FBC
  2. CRP
  3. Amylase and lipase
  4. Liver enzymes
  5. Albumin
  6. U+Es + Creatinine
  7. Calcium
  8. Glucose
  9. ABG/VBG
  10. Troponin
59
Q

Why do you do a fbc for epigastric pain?

A
  • look for infection or inflammation (WBC)
  • blood loss (low Hb), due to bleeding peptic ulcer
  • neutrophilia may suggest pancreatitis
60
Q

Why do you do amylase and lipase in epigastric pain?

A

pancreatitis (but amylase takes hours to rise and will fall back 3-5 days)

61
Q

What would a high ALT and AST liver enzymes suggest?

A

pathology in liver

62
Q

What would a high ALP, Bilirubin, GGT suggest?

A

pathology in liver tree

63
Q

What would a high ALP but normal GGT suggest?

A

not liver (bone)

64
Q

What would just a high GGT suggest?

A

alcohol excess

65
Q

Why do you measure albumin?

A

prognostic factor for pancreatitis

66
Q

Why do you measure U+Es+Creatinine?

A

baseline before fluid resus and may be deranged if shock or vomiting

67
Q

What can hypercalcaemia cause?

A

pancreatitis

68
Q

What can pancreatitis cause?

A

hypocalcaemia

69
Q

Why do you check for hyperglycaemia?

A

reflects severity of pancreatitis

70
Q

When do you do an ABG?

A

if patient hypoxic

71
Q

When do you do a VBG?

A

not hypoxic

72
Q

What would a high pH and lactate suggest?

A
  • acute pancreatitis

- peritonitis

73
Q

Why do you measure troponin in epigastric pain?

A

check for MI

74
Q

When would you do an ECG for epigastric pain?

75
Q

What imaging may you do for epigastric pain?

A
  1. Erect Chest radiograph

2. CT

76
Q

What would air under diaphragm in CXR with epigastric pain suggest?

A

perforated peptic ulcer

77
Q

What would lower lobe consolidation in CXR with epigastric pain suggest?

A

basal pneumonia

78
Q

What would pleural effusion in CXR with epigastric pain suggest?

A
  • pancreatitis

- Boerhaave’s perforation

79
Q

When do you use an US in epigastric pain?

A
  1. if suspect AAA (>3cm in diameter), still need rule out with CT aortogram or surgically
  2. US useful to look for gallstones in acute pancreatitis
  3. Us can exclude biliary dilation (>6mm CBD) secondary to obstruction or inflammation
80
Q

What scale is used for acute pancreatitis?

A

Ranson + Glasgow scale

81
Q

When is the glasgow score results based on?

A

within 48hr of admission

82
Q

How is the Glasgow score calculated? (PANCREAS)

A 
PaO2 <8kPA or <60mmHg
Age > 55y
Neutrophilia >15x10^9 cells/L (WCC)
Calcium <2.0mM
Renal function: urea >16mM 
Enzymes: lactate dehydrogenase (LDH) >600U/L or AST >200 U/L
Albumin <32 g/L
Sugar >10mM (in non-diabetics)
83
Q

What GS is severe pancreatitis?

A

score of 3 or more out of 8

84
Q

How do you manage mild pancreatitis?

A
  1. Airway
  2. Breathing: if severe may have ARDS
  3. Circulation: severe may develop hypotension, so require IV acess and urinary catheter - prepare to move to HDU/ITU if worsens
85
Q

If patient is stable how do you treat the underlying factors e.g. gallstones?

A
  1. IV fluid, titrated to paramteters
  2. Oxygen
  3. Analgesia (usually have PCA)
  4. Antiemetics
  5. DVT prophylaxis
  6. low fast diet if tolerated: or NJ tube
86
Q

How long does it take to recover?

A
  1. Recover within week

2. Treat complications if arise

87
Q

What procedures would you consider doing to prevent reoccurrence?

A
  1. Mild Pancreatitis: laparscopic cholecystectomy

2. Severe: ERCP within 72 hours

Z Year3 Clinical Presentations (37 decks)

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