Epigastric pain Flashcards
Which drugs associated with peptic ulcer, and which with acute pancreatitis
Peptic ulcer: NSAIDs, bisphosphonates, steroids, salicylates (aspirin)
Acute pancreatitis: sodium valproate, steroids, thiazides and azothioprine
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
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
Why might an acute pancreatitis patient present with normal amylase
Note: 30% of patients presenting with acute pancreatitis have a normal amylase
Reasons why:
- Patient may present late
- Very severe pancreatitis
- Acute on chronic (amylase may not be raised because there is little active pancreas left)
Which liver enzymes suggest what
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
What is the relationship between calcium and pancreatitis
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.
Why measure the o2 saturations in acute pancreatitis
Because ARDS is a complication of acute pancreatitis
When might you want to do ABG in a suspected acute pancreatitis and why
What about VBG
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)
Why are you recording pH and lactate in a suspected acute pancreatitis and how can you do this
KEY POINT
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
What are the prognositc indicators/indicators of severity of pancreatits
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
T/F Lactate/lipase are good prognostic indicators in pancreatitis
F! It’s not, and neither is lipase.
Look at the Glasgow cell in card above
How would you prevent futre pancreatitis in a patient who has recently been admitted for a mild vs severe acute pancreatitis caused by gallstones
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
Most common cause of stomach ulcer
H. Pylori infection
How do you check for H. Pylori infection
C-urea breath test, anti-helicobacter blood serology or H. Pylori- positive endoscopy sample
What is the standard treatment for H. Pylori infection
Triple therapy….
7 day, twice daily PPI with either:
metronidazole 400mg + clarithromycin 250mg
OR
amoxicillin 1g + clarithromycin 500mg
When should a patient with dyspepsia be referred to endoscopy?
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
What is a common cause of medical malpractice pain in USA relating to epigastric pain
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
T/F a mildly elevated amylase can be consistent with pancreatitis but not a perforated peptic ulcer
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
Air under the diaphragm?
DIAGNOSTIC of a perforation of GI tract, unless the patient has had recent abdominal surgery to explain this
What medication can cause a raised amylase (independent of pancreatitis)
Opiate
How is acute pancreatitis pain described, comapred to peptic ulcer/gastric irritation pain
Sharp, ‘burning’ pain is typical of peptic ulcers, gastritis, and duodenitis.
Deep ‘boring’ pain is typical of pancreatitis.
The triggering of self-limiting pain by fatty meals?
Biliary colic.
Note that this pain is usually relatively constant over a single episode. A single episode commonly 6-8hrs and is self limiting
What kind of symptom are you expecting with chronic mesenteric ischaemia
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
Risk factors for chronic mesenteric ischaemia vs acute
Chronic:
-HTN, diabetes, smoking, hypercholesterolaemia, family Hx of cardiovascular disease
Acute:
-Potential sources of emboli e.g. AF, recent MI and cardiac valvular disease
What is smoking a RF for in epigastric pain
Smoking and mesenteric ischaemia
T/F pancreatitis only causes jaundice when it is caused by gallstones
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).
If the patient susepcts late with what you think is acute pancreatitis, is serum amylase the best test? What else could you use
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
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?
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)
Can gall stones be seen on abdominal radiograph?
Only 10% of them are radio-opaque. In these cases you will see spots of calcification in the biliary system
What is first line and what is goldstandard for visualisation of gall stones. How do you investigate for presence of gall stones
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.
What would you consider common bile duct dilation
> 6mm diameter
What defines severe pancreatitis
A glasgow score of greater than 3/8 (and this will require transfer to an ICU)
