Epigastric Pain Flashcards

1
Q

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

A
Acute pancreatitis
Gastritis/duodenitis
Peptic ulcer disease (perforated)
Biliary colic
Acute cholecystitis
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2
Q

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

A

Nausea/Vomiting?

Fever?

Dyspepsia?

Changes in their stool?

Cough?

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3
Q

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

A

Basal pneumonia

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4
Q

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

A

Biliary disease
- Prone to recurrence

Peptic ulcer disease
- Perforated ulcer until proven otherwise

GORD
- High rates of recurrence

Vascular disease
- Mesenteric ischaemia

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5
Q

Which drugs are associated with acute pancreatitis?

A

Sodium valproate
Steroids
Thiazides
Azathioprine

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6
Q

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

A

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

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7
Q

What are the signs of bowel obstruction?

A

A distended abdomen

Absent or tinkling bowel sounds

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8
Q

What does severe, generalised tenderness and guarding suggest?

A

Peritonitis

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9
Q

What are the causes of pancreatitis?

A

I GET SMASHED

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

What are the most common causes of acute pancreatitis?

A

Gallstones and ethanol

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11
Q

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

A

Glasgow scale

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12
Q

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

A

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)

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13
Q

How is H. pylori infection detected?

A

13C-urea breath test

Anti-Helicobacter blood serology

H pylori-positive endoscopic biopsy

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14
Q

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

A

7-day, twice daily course of full dose PPI

Metronidazole 400mg and clarithromycin 250mg

OR Amoxicillin 1g and 500mg clarithromycin

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15
Q

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

A

Air under the diaphragm

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

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16
Q

What are the indications for endoscopic investigation if dyspepsia?

A

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

17
Q

How does the breath test for H. pylori work?

A

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

18
Q

What are the complications of peptic ulcers?

A

Haemorrhage

Perforation

Penetration

Scarring

Malignancy

19
Q

How can the complications of pancreatitis be organised?

A

Local (pancreatic and other) or Systemic

20
Q

What are the local complications of pancreatitis?

A

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
21
Q

What are the systemic complications of pancreatitis?

A

Sepsis

Shock

Acute renal failure

Respiratory compromise

Disseminated intravascular coagulation

Hypocalcaemia or hyperglycaemia

Pancreatitic encephalopathy

22
Q

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

A

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
23
Q

What are Cushing’s and Curling’s ulcers?

A

Both are peptic ulcers with different aetiology

Cushing’s ulcers arise after brain injury

Curling’s ulcers occur after burns

24
Q

How can the causes of elevated serum amylase be categorised?

A

Pancreatic

Other intra-abdominal pathology

Decreased amylase clearance

Miscellaneous conditions

25
What are the pancreatic causes of an increased serum amylase?
Pancreatitis Pancreatic trauma Pancreatic carcinoma
26
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
27
What can cause an increased serum amylase through decreased amylase clearance?
Renal failure Macroamylasaemia (amylase is bound to immunoglobin and cannot be renally excreted)
28
What are the miscellaneous causes of a raised serum amylase level?
Diabetic ketoacidosis Head injury