Epigastric Pain

Question 1

What are the 5 most likely differentials for a 60 year old man with acute epigastric pain?

Answer 1

Acute pancreatitis
Gastritis/duodenitis
Peptic ulcer disease (perforated)
Biliary colic
Acute cholecystitis

Question 2

What other symptoms are important to ask about in patients with epigastric pain?

Answer 2

Nausea/Vomiting?

Fever?

Dyspepsia?

Changes in their stool?

Cough?

Question 3

In the absence of abdominal symptoms other than abdominal pain, cough and/or productive sputum raises the likelihood of what?

Answer 3

Basal pneumonia

Question 4

What is of particular relevance in past medical history in a patient with epigastric pain?

Answer 4

Biliary disease
- Prone to recurrence

Peptic ulcer disease
- Perforated ulcer until proven otherwise

GORD
- High rates of recurrence

Vascular disease
- Mesenteric ischaemia

Question 5

Which drugs are associated with acute pancreatitis?

Answer 5

Sodium valproate
Steroids
Thiazides
Azathioprine

Question 6

What is Cullen’s or Grey Turner’s sign?

Answer 6

Discoloration due to extravasated blood in the retroperitoneum, around the umbilicus, flank respectively

These may be seen in acute haemorrhagic pancreatitis but are, non-specific, and late signs

Question 7

What are the signs of bowel obstruction?

Answer 7

A distended abdomen

Absent or tinkling bowel sounds

Question 8

What does severe, generalised tenderness and guarding suggest?

Answer 8

Peritonitis

Question 9

What are the causes of pancreatitis?

Answer 9

I GET SMASHED

Idiopathic (10-20%)
Gall stones
Ethanol
Trauma
Steroids
Mumps/HIV/Coxsackie infection
Autoimmune
Scorpion bite
Hyperlipidaemia
ERCP
Drugs

Question 10

What are the most common causes of acute pancreatitis?

Answer 10

Gallstones and ethanol

Question 11

What is the scoring mechanism used to assess the severity and prognosis of pancreatitis?

Answer 11

Glasgow scale

Question 12

What are the components of the Glasgow scale?

How many criteria are required to be positive for the patient to be considered to have severe pancreatitis

Answer 12

PANCREAS

PaO2: 55

Neutrophilia: >15x10^9 cells/L (WCC)

Calcium: 16mM

Enzyme: LDH >600 U/L or AST >200 U/L

Albumin: 10mM (non diabetics)

Question 13

How is H. pylori infection detected?

Answer 13

13C-urea breath test

Anti-Helicobacter blood serology

H pylori-positive endoscopic biopsy

Question 14

What are the NICE guidelines for the treatment of H. pylori?

Answer 14

7-day, twice daily course of full dose PPI

Metronidazole 400mg and clarithromycin 250mg

OR Amoxicillin 1g and 500mg clarithromycin

Question 15

What are the signs of duodenal perforation on CXR/abdo Xrays?

Answer 15

Air under the diaphragm

Supine abdominal Xray shows the ‘football sign’ (a large bubble of air, in the abdomen)

Question 16

What are the indications for endoscopic investigation if dyspepsia?

Answer 16

Persistent vomiting

Chronic GI bleeding

Weight loss

Progressive dysphagia

Iron-deficiency anaemia

Epigastric mass

Suspicious barium meal

Age >55 with unexplained and persistent, recent-onset dyspepsia

Question 17

How does the breath test for H. pylori work?

Answer 17

The patient is given a drink of 14C or 13C-unlabelled urea

This is metabolised by the bacteria, if present, into CO2

Breath test is conducted 15 minutes later, and will detect the labelled CO2 if H. pylori

Question 18

What are the complications of peptic ulcers?

Answer 18

Haemorrhage

Perforation

Penetration

Scarring

Malignancy

Question 19

How can the complications of pancreatitis be organised?

Answer 19

Local (pancreatic and other) or Systemic

Question 20

What are the local complications of pancreatitis?

Answer 20

Pancreatic

• Necrosis of the pancreas
• Abscess formation
• Pseudocyst (accumulation of fluid in the lesser peritoneal sac)

Other

• Paralytic ileus
• Duodenal stress ulceration
• Fistula formation to colon
• Obstructive jaundice

Question 21

What are the systemic complications of pancreatitis?

Answer 21

Sepsis

Shock

Acute renal failure

Respiratory compromise

Disseminated intravascular coagulation

Hypocalcaemia or hyperglycaemia

Pancreatitic encephalopathy

Question 22

What is the role of stool elastase in chronic pancreatitis management? Why?

Answer 22

Very good marker of pancreatic function

• Only synthesised in the pancreas
• Stable in transit through the GI tract, thus there is a direct correlation between elastase in the stool and in pancreatic fluid

Question 23

What are Cushing’s and Curling’s ulcers?

Answer 23

Both are peptic ulcers with different aetiology

Cushing’s ulcers arise after brain injury

Curling’s ulcers occur after burns

Question 24

How can the causes of elevated serum amylase be categorised?

Answer 24

Pancreatic

Other intra-abdominal pathology

Decreased amylase clearance

Miscellaneous conditions

Question 25

What are the pancreatic causes of an increased serum amylase?

Answer 25

Pancreatitis

Pancreatic trauma

Pancreatic carcinoma

Question 26

What are the other intra-abdominal pathologies that result in an increased serum amylase level?

Answer 26

Perforated peptic ulcer

Acute appendicitis

Acute cholecystitis

Ectopic pregnancy

Pelvic inflammatory disease

Mesenteric ischaemia

Leaking AAA

Question 27

What can cause an increased serum amylase through decreased amylase clearance?

Answer 27

Renal failure

Macroamylasaemia (amylase is bound to immunoglobin and cannot be renally excreted)

Question 28

What are the miscellaneous causes of a raised serum amylase level?

Answer 28

Diabetic ketoacidosis

Head injury