Epigastric Pain Flashcards
1
Q
What are some gastro differentials of epigastric pain?
A
- Acute pancreatitis
- Perforated peptic ukcer
- Gastritis/duodenitis
- Bilary colic
- Acute cholecytsitis
- Ascending cholangitis
- Oesophagitis
- Non-ulcer dyspepsia
- Chronic pancreatitis
- Gastric cancer
- Pancreatic cancer
- Acute hepatitis
2
Q
What are non-gastro differentials of epigastric pain?
A
- MI
- Ruptured MI
- Mesenteric ischaemia
- Basal pneumonia
- Incomplete bowel obstruction
- Borehaave’s perforation
3
Q
What would epigastric pain that spread to rest of abdomen suggest?
A
peritonitis from perforated GI tract
4
Q
What would epigastric pain that spread to chest suggest?
A
cardiac cause
5
Q
What would a sudden onset of epigastric pain suggest?
A
- perforation of viscus
2. MI
6
Q
What would epigastric pain that develops max intensity in 10-20 min suggest?
A
- Acute pancreatitis
2. Biliary colic
7
Q
What would epigastric pain that takes hours to reach peak pain suggest?
A
- Acute cholecystitis
2. Pneumonia
8
Q
What would a crushing/tighteness epigastric pain suggest?
A
cardiac cause
9
Q
What would a sharp/burning epigastric pain suggest?
A
- peptic ulcers
- duodenitis
- gastritis
10
Q
What would a deep boring epigastric pain suggest?
A
pancreatitis
11
Q
What would epigastric pain radiating to the back suggest?
A
- pancreatitis
- leaking AAA
- peptic ulcer
12
Q
What would epigastric pain with shoulder tip pain suggest?
A
- basal pneumonia
2. subprehnic abscess
13
Q
What would epigastric pain with radiating jaw, neck, arm pain suggest?
A
cardiac pathology
14
Q
What would epigastric pain with retrosternal chest pain suggest?
A
- oesophagitis
2. myocardial ischaemia
15
Q
What would epigastric pain that is relived when sitting forward suggest?
A
acute pancreatitis
16
Q
What would epigastric pain that is self-limiting over 6-8 hours suggest?
A
- uncomplicated peptic ulcer
- gastritis
- duodenitis
- biliary colic
- non-ulcer dyspepsia
17
Q
What sort of pain is biliary colic?
A
NOT colicky (constant)
18
Q
What would epigastric pain that is worse when exercising suggest?
A
cardiac pathology
19
Q
What would epigastric pain that is worsened when move suggest?
A
- severe pain or intrabdominal origin
2. peritonitis
20
Q
What would pleuritic pain thats worsens epigastric pain suggest?
A
- basal pneumonia
- pulmonary embolus
- pneumothorax
- pericarditis
- any cause of pleural inflammation
21
Q
What would epigastric pain triggered by fatty meals suggest?
A
biliary colic
22
Q
What would less severe epigastric pain suggest?
A
- uncomplicated PUD
- gastritis
- duodenitis
- non-ulcer dyspepsia
23
Q
What would very painful epigastric pain suggest?
A
- serve pancreatitis
- perforated peptic ulcers
- MI
24
Q
What other symptoms must be asked about with epigastric pain?
A
- Nausea and vomiting?
- Fever?
- Dyspepsia and/or waterbrash?
- Change in stool?
- Cough?
25
What conditions may cause nausea and vomiting with epigastric pain?
1. Small bowel obstruction (with colicky epigastric pain)
2. Inferior MI cause vomiting
3. Borehavve's perforation, vomiting before
26
What could fever with epigastric pain suggest?
infection + inflammation
27
What infections would cause fever and epigastric pain?
1. viral hep
| 2. pneumonia
28
What inflammation would cause fever and epigastric pain?
peritonitis
29
What would heartburn, retrosternal discomfort, bitter taste in mouth with epigastric pain suggest?
1. GORD
| 2. Oesophagitis
30
What pale stools suggest?
bile not reaching bowel
31
What could foul smelling, steatorrhea with epigastric pain suggest?
1. pancreatic exocrine insufficiency
| 2. long standing biliary disease
32
What would acute cough and/or productive sputum with only epigastric pain suggest?
basal pneumonia
33
What would a chronic cough with epigastric pain suggest?
GORD
34
What conditions do you need to check in PMHx with epigastric pain?
1. Biliary disease
2. PUD
3. GORD
4. Vascular disease
35
What do you ask about biliary disease in PMHx?
prone to:
1. recurrence
2. acute pancreatitis
3. acute chonlangitis
4. Acute cholcystitis
36
Why do you ask about PUD in PMHx?
if they have and sudden onset severe epigastric pain: perforated ulcer until proven otherwise
37
What do you ask about GORD in PMHx?
high rate of reccurence
38
What do you ask about vascular disease in PMHx?
risk of mesenteric and myocardial ischaemia
39
What is mesenteric angina?
work-related pain, colicky postprandial abdominal pain
40
What are the risk factors for chronic mesenteric ischaemia?
1. Smoking
2. Hypertension
3. DM
4. Hypercholesterolaemia
5. FHx of cardiovascular disease
41
What are the risk factors for acute mesenteric ischaemia?
- Potential sources of emboli:
1. atrial fibrillation
2. Recent MI
3. Cardiac valvular disease
42
What DHx should you ask about with epigastric pain?
1. NSAIDs, steroids, bisphosphonates, salicylates
| 2. Sodium valoprate, steroids, thiazides, azathioprine
43
Why do you ask about NSAIDs, steroids, bisphosphonates, salicylates?
peptic ulcer disease
44
Why do you ask about sodium valoprate, steroids, thiazides, azathioprine?
acute pancreatitis
45
What do you check in FHx with epigastric pain?
establish cardiovascular disease risk
46
What SHx do you ask about in epigastric pain?
1. smoking (PUD and vascular causes of epigastric pain)
| 2. alcohol
47
What is important to consider in the examination of epigastric pain?
1. Position
2. Jaundice
3. Cullen's or Grey Turner's sign
4. Tenderness or guarding
5. Masses
6. Respiratory exam
48
How would the position of the patient with peritonitis be like?
completely still + rigid any movement extremely painful
49
What would the position of the patient with pancreatitis be like?
positional pain (unless severe then lie still)
50
What conditions could cause jaundice with epigastric pain?
1. ascending cholangitis
2. gallstone induced pancreatitis
3. acute hepatitis
4. acute pancreatitis (after a few days of symptom onset)
51
What can cause Cullen's or Grey Turner's sign with epigastric pain?
acute haemorrhagic pancreatitis (rare, non-specific and late signs)
52
What can cause localised tenderness with epigastric pain?
1. acute cholecystitis (Murphy's sign)
| 2. mild pancreatitis
53
What can cause serve generalised tenderness with guarding?
peritonitis
54
What would a central, laterally expansile, pulsatile mass with epigastric pain suggest
AAA
55
What hernias must you check for with epigastric pain?
inguinal fold and femoral canal for hernias which could cause bowel obstruction
56
What are you looking for in a resp exam with epigastric pain?
check for signs of consolidation
57
What are signs of consolidation?
1. Decreased expansion
2. Dullness to percussion
3. Decreased breath sounds
4. Increased vocal resonace
58
What bloods do you order for epigastric pain?
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
Why do you do a fbc for epigastric pain?
- look for infection or inflammation (WBC)
- blood loss (low Hb), due to bleeding peptic ulcer
- neutrophilia may suggest pancreatitis
60
Why do you do amylase and lipase in epigastric pain?
pancreatitis (but amylase takes hours to rise and will fall back 3-5 days)
61
What would a high ALT and AST liver enzymes suggest?
pathology in liver
62
What would a high ALP, Bilirubin, GGT suggest?
pathology in liver tree
63
What would a high ALP but normal GGT suggest?
not liver (bone)
64
What would just a high GGT suggest?
alcohol excess
65
Why do you measure albumin?
prognostic factor for pancreatitis
66
Why do you measure U+Es+Creatinine?
baseline before fluid resus and may be deranged if shock or vomiting
67
What can hypercalcaemia cause?
pancreatitis
68
What can pancreatitis cause?
hypocalcaemia
69
Why do you check for hyperglycaemia?
reflects severity of pancreatitis
70
When do you do an ABG?
if patient hypoxic
71
When do you do a VBG?
not hypoxic
72
What would a high pH and lactate suggest?
- acute pancreatitis
| - peritonitis
73
Why do you measure troponin in epigastric pain?
check for MI
74
When would you do an ECG for epigastric pain?
CVD risk
75
What imaging may you do for epigastric pain?
1. Erect Chest radiograph
| 2. CT
76
What would air under diaphragm in CXR with epigastric pain suggest?
perforated peptic ulcer
77
What would lower lobe consolidation in CXR with epigastric pain suggest?
basal pneumonia
78
What would pleural effusion in CXR with epigastric pain suggest?
- pancreatitis
| - Boerhaave's perforation
79
When do you use an US in epigastric pain?
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
What scale is used for acute pancreatitis?
Ranson + Glasgow scale
81
When is the glasgow score results based on?
within 48hr of admission
82
How is the Glasgow score calculated? (PANCREAS)
```
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
What GS is severe pancreatitis?
score of 3 or more out of 8
84
How do you manage mild pancreatitis?
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
If patient is stable how do you treat the underlying factors e.g. gallstones?
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
How long does it take to recover?
1. Recover within week
| 2. Treat complications if arise
87
What procedures would you consider doing to prevent reoccurrence?
1. Mild Pancreatitis: laparscopic cholecystectomy
| 2. Severe: ERCP within 72 hours
