Epigastric Pain Flashcards
What are the 5 most likely differentials for a 60 year old man with acute epigastric pain?
Acute pancreatitis Gastritis/duodenitis Peptic ulcer disease (perforated) Biliary colic Acute cholecystitis
What other symptoms are important to ask about in patients with epigastric pain?
Nausea/Vomiting?
Fever?
Dyspepsia?
Changes in their stool?
Cough?
In the absence of abdominal symptoms other than abdominal pain, cough and/or productive sputum raises the likelihood of what?
Basal pneumonia
What is of particular relevance in past medical history in a patient with epigastric pain?
Biliary disease
- Prone to recurrence
Peptic ulcer disease
- Perforated ulcer until proven otherwise
GORD
- High rates of recurrence
Vascular disease
- Mesenteric ischaemia
Which drugs are associated with acute pancreatitis?
Sodium valproate
Steroids
Thiazides
Azathioprine
What is Cullen’s or Grey Turner’s sign?
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
What are the signs of bowel obstruction?
A distended abdomen
Absent or tinkling bowel sounds
What does severe, generalised tenderness and guarding suggest?
Peritonitis
What are the causes of pancreatitis?
I GET SMASHED
Idiopathic (10-20%) Gall stones Ethanol Trauma Steroids Mumps/HIV/Coxsackie infection Autoimmune Scorpion bite Hyperlipidaemia ERCP Drugs
What are the most common causes of acute pancreatitis?
Gallstones and ethanol
What is the scoring mechanism used to assess the severity and prognosis of pancreatitis?
Glasgow scale
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
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)
How is H. pylori infection detected?
13C-urea breath test
Anti-Helicobacter blood serology
H pylori-positive endoscopic biopsy
What are the NICE guidelines for the treatment of H. pylori?
7-day, twice daily course of full dose PPI
Metronidazole 400mg and clarithromycin 250mg
OR Amoxicillin 1g and 500mg clarithromycin
What are the signs of duodenal perforation on CXR/abdo Xrays?
Air under the diaphragm
Supine abdominal Xray shows the ‘football sign’ (a large bubble of air, in the abdomen)
What are the indications for endoscopic investigation if dyspepsia?
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
How does the breath test for H. pylori work?
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
What are the complications of peptic ulcers?
Haemorrhage
Perforation
Penetration
Scarring
Malignancy
How can the complications of pancreatitis be organised?
Local (pancreatic and other) or Systemic
What are the local complications of pancreatitis?
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
What are the systemic complications of pancreatitis?
Sepsis
Shock
Acute renal failure
Respiratory compromise
Disseminated intravascular coagulation
Hypocalcaemia or hyperglycaemia
Pancreatitic encephalopathy
What is the role of stool elastase in chronic pancreatitis management? Why?
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
What are Cushing’s and Curling’s ulcers?
Both are peptic ulcers with different aetiology
Cushing’s ulcers arise after brain injury
Curling’s ulcers occur after burns
How can the causes of elevated serum amylase be categorised?
Pancreatic
Other intra-abdominal pathology
Decreased amylase clearance
Miscellaneous conditions
What are the pancreatic causes of an increased serum amylase?
Pancreatitis
Pancreatic trauma
Pancreatic carcinoma
What are the other intra-abdominal pathologies that result in an increased serum amylase level?
Perforated peptic ulcer
Acute appendicitis
Acute cholecystitis
Ectopic pregnancy
Pelvic inflammatory disease
Mesenteric ischaemia
Leaking AAA
What can cause an increased serum amylase through decreased amylase clearance?
Renal failure
Macroamylasaemia (amylase is bound to immunoglobin and cannot be renally excreted)
What are the miscellaneous causes of a raised serum amylase level?
Diabetic ketoacidosis
Head injury
