Epigastric pain

Question 1

Which drugs associated with peptic ulcer, and which with acute pancreatitis

Answer 1

Peptic ulcer: NSAIDs, bisphosphonates, steroids, salicylates (aspirin)

Acute pancreatitis: sodium valproate, steroids, thiazides and azothioprine

Question 2

What does a slightly increased amylase mean (200-600 U/L). What does a highly increased amylase mean (>1000 U/L)?

Why is it important to consider the time since the epigastric pain started when looking at amylase

Answer 2

200-600 usually due to pancreatitis but at this concentration the amylase is non-specific.

Levels of >1000 are diagnostic of acute pancreatitis.

Because the amylase rises within hours of the onset of the pancreatitis, and is usually normal again within 3-5 days even if pancreatitis is unresolved

Question 3

Why might an acute pancreatitis patient present with normal amylase

Answer 3

Note: 30% of patients presenting with acute pancreatitis have a normal amylase

Reasons why:

1. Patient may present late
2. Very severe pancreatitis
3. Acute on chronic (amylase may not be raised because there is little active pancreas left)

Question 4

Which liver enzymes suggest what

Answer 4

AST/ALT: suggest pathology WITHIN the liver, as they are released by damaged hepatocytes

ALP/bilirubin and GGT suggest pathology in the biliary tree/extrinsic compression of the biliary tree.

A rise in ALP without GGT suggests a source other than the liver (e.g. bone or placenta).

A rise in GGT is more likely to reflect alcohol excess

Question 5

What is the relationship between calcium and pancreatitis

Answer 5

Hypercaclaemia can cause acute pancreatitis

Established pancreatitis can cause hypocalcaemia because the calcium binds to digested lipids from the pancreas to form soap, known as saponification of the pancreas.

Question 6

Why measure the o2 saturations in acute pancreatitis

Answer 6

Because ARDS is a complication of acute pancreatitis

Question 7

When might you want to do ABG in a suspected acute pancreatitis and why

What about VBG

Answer 7

If the patient is hypoxic because ARDS is a complication of acute pancreatitis AND low Pa02 is a poor prognostc indicator in pancreatis

A VBG will suffice in patients who aren’t hypoxic.. from this you want the pH and the lactate (see next for why)

Question 8

Why are you recording pH and lactate in a suspected acute pancreatitis and how can you do this

KEY POINT

Answer 8

Do it with an VBG

Lactate and pH elevated in conditions causing sever inflammatory responses as the vasodilation leads to hypoperfusion of tissues with subsequent increase in anaerobic respiration and lactic acid production

Question 9

What are the prognositc indicators/indicators of severity of pancreatits

Answer 9

Use the Glasgow scale in UK (8 indicators): PANCREAS

PaO2 (<60mmHg) 
Age (>55) 
Neutrophilia (>15*10^9 cells/L) 
Calcium (<2mM)
Renal function (urea >16mM) 
Enzymes (LDH>800U/L, AST>200U/L) 
Albumin (<32g/L) 
Sugar (>10mM in non-diabetics)

NOT AMYLASE/LIPASE

Question 10

T/F Lactate/lipase are good prognostic indicators in pancreatitis

Answer 10

F! It’s not, and neither is lipase.

Look at the Glasgow cell in card above

Question 11

How would you prevent futre pancreatitis in a patient who has recently been admitted for a mild vs severe acute pancreatitis caused by gallstones

Answer 11

Mild… a laparoscopic cholecystectomy within the same hospital admission as the acute pancreatitis or within 2 weeks of admission

Severe… an ERCP with sphincterotomy, and then a delayed cholecystectomy once the patient is well enough for surgery

Question 12

Most common cause of stomach ulcer

Answer 12

H. Pylori infection

Question 13

How do you check for H. Pylori infection

Answer 13

C-urea breath test, anti-helicobacter blood serology or H. Pylori- positive endoscopy sample

Question 14

What is the standard treatment for H. Pylori infection

Answer 14

Triple therapy….

7 day, twice daily PPI with either:

metronidazole 400mg + clarithromycin 250mg

OR

amoxicillin 1g + clarithromycin 500mg

Question 15

When should a patient with dyspepsia be referred to endoscopy?

Answer 15

2 week endoscopy if:

• 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 16

What is a common cause of medical malpractice pain in USA relating to epigastric pain

Answer 16

MIs are often mistaken for heartbearn or indigestion. It is very serious if this is missed. Remember to check troponin and ECG.

Even if the ECG is normal, the troponin could be high indicating an NSTEMI

Question 17

T/F a mildly elevated amylase can be consistent with pancreatitis but not a perforated peptic ulcer

Answer 17

F! Severely raised amylase (>1000U/L) is typical in acute pancreatits

If it is not wildly raised, it might still be sufficiently elevated for peptic ulcer perforation, bowel obstruction, mesenteric ischaemia, mumps, pancreatic carcinoma or opiate medications

Question 18

Air under the diaphragm?

Answer 18

DIAGNOSTIC of a perforation of GI tract, unless the patient has had recent abdominal surgery to explain this

Question 19

What medication can cause a raised amylase (independent of pancreatitis)

Answer 19

Opiate

Question 20

How is acute pancreatitis pain described, comapred to peptic ulcer/gastric irritation pain

Answer 20

Sharp, ‘burning’ pain is typical of peptic ulcers, gastritis, and duodenitis.

Deep ‘boring’ pain is typical of pancreatitis.

Question 21

The triggering of self-limiting pain by fatty meals?

Answer 21

Biliary colic.

Note that this pain is usually relatively constant over a single episode. A single episode commonly 6-8hrs and is self limiting

Question 22

What kind of symptom are you expecting with chronic mesenteric ischaemia

Answer 22

It can be regarded in a similar way to cardiac ischaemia in that it may
be preceded by work-related pain which, in the case of the gut, is manifested
as colicky post-prandial abdominal pain

Question 23

Risk factors for chronic mesenteric ischaemia vs acute

Answer 23

Chronic:
-HTN, diabetes, smoking, hypercholesterolaemia, family Hx of cardiovascular disease

Acute:
-Potential sources of emboli e.g. AF, recent MI and cardiac valvular disease

Question 24

What is smoking a RF for in epigastric pain

Answer 24

Smoking and mesenteric ischaemia

Question 25

T/F pancreatitis only causes jaundice when it is caused by gallstones

Answer 25

F….

Jaundice is seen with post-hepatic causes of biliary obstruction such as ascending cholangitis and gallstone-induced acute
pancreatitis.

Acute pancreatitis can also cause jaundice in the absence of gallstones, because oedema of the head of the pancreas compresses the common
bile duct (usually 2–3 days after symptom onset).

Question 26

If the patient susepcts late with what you think is acute pancreatitis, is serum amylase the best test? What else could you use

Answer 26

No, it’s not because it falls within 3-5 days of the onset of acute pancreatitis.

Urinary amylase takes longer to fall than serum amylase so this could be useful

Serum lipase has a longer half life so this might be good too

Question 27

What might an abdominal radiograph show in acute pancreatitis, and chronic pancreatitis

Why else might abdominal radiograph be useful if patient presents with epigastric pain?

Answer 27

ACUTE PANCREATITS: It might show a few ‘sentinel loops’ (local ileus). This when bits of the bowel are dilated in response to local inflammation, for example of the pancreas (typically a
duodenal sentinel loop).

OR

CHRONIC PANCREATITIS: Calcification speckled over the pancreas

Dilated loops of small bowel (>3 cm) could indicate small bowel obstruction (although epigastric pain would be a slightly unusual presentation of small bowel obstruction it is still possible)

Question 28

Can gall stones be seen on abdominal radiograph?

Answer 28

Only 10% of them are radio-opaque. In these cases you will see spots of calcification in the biliary system

Question 29

What is first line and what is goldstandard for visualisation of gall stones. How do you investigate for presence of gall stones

Answer 29

An abdominal ultrasound examination — this may confirm the presence of one or more gallstones.
The absence of stones on ultrasound scan does not exclude their existence. Also check liver enzymes because they can be deranged if there’s gallstone in the CBD

Consider referral for further investigation if results are normal but clinical suspicion remains high.

This may include:
-Magnetic resonance cholangiopancreatography (MRCP), if ultrasound has not detected common bile duct stones

-Endoscopic ultrasound (EUS) if MRCP does not allow a diagnosis to be made.

Question 30

What would you consider common bile duct dilation

Answer 30

> 6mm diameter

Question 31

What defines severe pancreatitis

Answer 31

A glasgow score of greater than 3/8 (and this will require transfer to an ICU)