Epigastric Pain Flashcards
List some differential diagnoses of epigastric pain.
Acute pancreatitis Perforated peptic ulcer Gastritis/duodenitis Peptic ulcer disease Biliary colic Acute cholecystitis Ascending cholangitis MI Ruptured AAA Mesenteric ischaemia Basal pneumonia
Describe the pattern of pain that would be caused by a perforated peptic ulcer.
There would initially be an intense pain in the epigastrium This would spread across the whole abdomen as the patient becomes peritonitic
What does sudden-onset pain suggest?
Perforated viscus MI
How long does pain from acute pancreatitis or biliary colic take to reach maximum intensity?
10-20 mins
How long do inflammatory processes such as pneumonia and cholecystitis take to reach their peak in terms of pain?
A matter of hours
Which diseases cause epigastric pain that radiates to the back?
Acute pancreatitis Leaking AAA
What can cause shoulder-tip pain?
Diaphragmatic irritation (e.g. by basal pneumonia, subphrenic abscess)
Which diseases cause retrosternal pain?
Oesophagitis Myocardial ischaemia
What can relieve the pain caused by pancreatitis?
Sitting forward
Describe how gastric ulcers and duodenal ulcers can be differentiated based on when the pain is worst.
Gastric Ulcers – pain is worse when eating Duodenal Ulcers – pain is relieved by eating
What does pain triggered by fatty meals suggest?
Biliary colic
Which of the causes of epigastric pain cause particularly severe pain?
Severe pancreatitis MI Perforated peptic ulcer
List some important associated symptoms that should be enquired about when taking a history.
Nausea and vomiting Fever Dyspepsia and waterbrash Changes in stool Cough
List some diseases that cause epigastric pain and nausea and vomiting.
Small bowel obstruction
Inferior MI
Boerhaave’s perforation (vomiting precedes the epigastric pain)
Which pathology is associated with causing pale stools?
Obstruction of bile outflow
Which diseases cause steatorrhoea?
Long-standing biliary disease
Pancreatic exocrine insufficiency
Why is it important to ask a patient with epigastric pain whether they’ve had a cough?
Basal pneumonia can cause epigastric pain and it will also cause an acute, productive cough
List the four main diseases in the past medical history that are important to ask a patient with epigastric pain about.
GORD Peptid ulcer disease Biliary disease (e.g. gallstones) Vascular disease
Why is it important to ask about previous vascular disease and cardiovascular risk factors?
A history of vascular disease increases the risk of mesenteric ischaemia and myocardial infarction
Which two diseases that cause epigastric pain can be caused by drugs? Which drugs are associated with each of these diseases?
- Peptic ulcer disease: NSAIDs Aspirin Bisphosphonates Steroids
- Acute pancreatitis: Sodium valproate Thiazides Steroids Azathioprine (SATS)
List some significant features of the social history.
Alcohol – excess can cause acute pancreatitis
Smoking – associated with peptic ulcer disease, MI and mesenteric ischaemia
Describe the appearance of a peritonitic patient.
Patients lie completely still
Taking shallow breaths
Movement is painful
(motionless, T+G, absent bowel sounds)
How can acute pancreatitis lead to jaundice in the absence of gallstones?
Oedema of the head of an inflamed pancreas can obstruct the common bile duct
Describe Grey-Turner’s and Cullen’s Signs. What are they signs of?
They are signs of severe pancreatitis Cullen’s Sign – bruising/discolouration around the umbilicus Grey-Turner’s Sign – bruising/discolouration on the flanks
List signs of small bowel obstruction.
Abdominal distension Tinkling bowel sounds Absolute constipation
What is Murphy’s sign?
A finger is placed just below the tip of the right 9th costal cartilage and the patient is asked to breathe in deeply Inspiration is arrested when the inflamed gallbladder strikes the finger of the examiner This is indicative of cholecystitis
Which masses might you palpate for in the abdomen of a patient with epigastric pain?
AAA – central expansile and pulsatile mass
Check hernia orifices because a strangulated hernia could cause bowel obstruction
List some important blood tests that you would perform in a patient with epigastric pain.
FBC – check for raised WCC, anaemia, neutrophilia CRP Pancreatic Amylase and Lipase Liver enzymes Albumin U&Es Calcium Glucose ABG
Describe different patterns of derangement of liver enzymes and state what they indicate.
High AST + ALT (transaminitis) = liver pathology (e.g. hepatitis) High ALP + GGT = biliary disease Isolated raised GGT = alcoholic liver disease High AST: ALT ratio (> 2:1) = alcoholic liver disease
List some prognostic indicators in pancreatitis.
Neutrophilia Albumin Blood glucose
Describe the time taken for serum amylase to rise and fall in a case of pancreatitis.
Rises within hours Returns to normal after 3-5 days
Why is it important to measure serum calcium in a patient with pancreatitis?
Hypercalcaemia – can cause pancreatiits Hypocalcaemia – can result from severe pancreatitis (a process called saponification occurs where calcium binds to digested lipids)
Why is it important to perform a VBG in a patient with epigastric pain?
Allows assessment of pH and lactate pH will decrease and lactate will increase in conditions causing a severe inflammatory response (e.g. acute pancreatitic, peritonitis) NOTE: this is because a systemic inflammatory response –> vasodilation –> hypoperfusion of tissues –> increase in anaerobic respiration –> lactic acidosis
Other than Bloods and CXR which form of investigation might be important to carry out in a patient with epigastric pain?
ECG
Which forms of imaging are useful in patients with epigastric pain?
Erect CXR AXR Ultrasound
Which sign on erect CXR suggests that there has been a GI perforation?
Air under the diaphragm (pneumoperitoneum)
Why might ultrasound be useful in investigating a patient with epigastric pain?
Allows visualisation of AAA Allows visualisation of gallstone disease
What is the downfall with the use of ultrasound to investigate AAAs?
It does not show whether the AAA is leaking/ruptured A CT aortogram is required to confirm a leak
List the causes of acute pancreatitis.
Idiopathic
GALLSTONES
ETHANOL
Trauma
Steroids
Mumps/HIV/Coxsackie
Autoimmune
Scorpion venom
Hypercalcaemia/ hyperlipidaemia/hypothermia
ERCP
Drugs (e.g. sodium valproate, thiazides)
What are the two main scoring systems for pancreatitis?
Glasgow Ranson
What criteria are on the Glasgow scoring system?
PANCREAS
- PaO2 <8kpa
- Age >55
- Neutrophilia >15 x 109 cells/L (WCC)
- Calcium <2.0mM
- Renal Function: urea >16mM
- Enzymes: LDH >600U/L or AST >200 U/L
- Albumin <32g/L
- Sugar >10mM (in non-diabetics)
With regards to the Glasgow scoring system, what score is considered severe pancreatitis?
3 and above
Outline the management of acute pancreatitis.
Assess ABC (NOTE: pancreatitis can cause ARDS) IV fluids Oxygen Analgesia Anti-emetics DVT prophylaxis Low-fat diet
How can you reduce the recurrence of pancreatitis?
Cholecystectomy
Stop drinking alcohol
Describe the two main tests for Helicobacter pylori.
1) Urease Breath Test – the patient is asked to swallow a sample of urea containing radio-labelled carbon. After 10-30 mins, the patients breath is tested and if the radio-labelled carbon is identified in the patient’s breath, it suggests that urease, produced by H. pylori, is present in the patient’s stomach
2) Campylobacter-like Organism (CLO) Test – a biopsy is taking from the patient’s stomach and placed on a medium containing urea and an indicator. If urease (produced by H. pylori) is present in the patient’s stomach, it will convert the urea to carbon dioxide (and other by-products) and cause a change in the colour of the indicator
Describe the treatment of H. pylori.
Triple therapy – 2 x antibiotics (amoxicillin + clarithromycin/ metronidazole + clarithromycin) + PPI
What is non-ulcer dyspepsia?
Chronic epigastric pain with normal blood tests, normal OGD and normal biliary ultrasound (there is no organic cause for the pain)
How would you manage a patient who complains of diffuse abdominal pain, is motionless, displays tenderness and gurading and has absent bowel sounds?
Peritonitis
- IV fluids
- NBM
- Nasogastric decompression
- Analgesics
- Oxygen
- IV antibiotics
- Urine monitoring
What ae the indications for endoscopic investigation of dyspepsia?
- Vomitting
- Iron deifiency Anaemia
- Weight Loss
- Progressive dysphagia
- Chronic GI bleed
- Palpable mass
- Supsicious barium meal
- Age >55yrs
What are the 5 complication of peptic ulcers? What symptoms would indicate them?
- Haemorrhage- especailly in anitcoagulant patients. Haematemesis/ melaena
- Perforation- especially in NSAID patients. Peritonitis
- Penetration- Chronic history. Change in symptoms- no concurrence with meal times, not relieved by antacids, weight loss and diarrhoea
- Scarring- may lead to gastric outlet obstruction. Early satiety, bloating, vomitting (of patially digested food)
- Malignancy- chronic ulcers.
List some of the complications of pancreatits… (think about how you’d categorise the consequences)
LOCAL
- PANCREATIC
- Necrosis
- Abscess formation
- Pseudocyst
- OTHER
- Paralytic ileus
- Duodenal stress ulceration
- Fistual formation with colon
- Obstructive jaundice
SYSTEMIC
- sepsis
- shock
- acute renal failure
- resp compromise
- DIC
- MEtabolic- hypo/hyperglycaemia
- Pancreatic encepalopathy
What can be used as an indicator of chronic pancreatits? Which conditions might interfere with the reliability of this test?
Faecal elastase
Crohns. coeliac and short gut syndrome
What is the ddx for a raised amylase?
- PANCREATIC
- pancreatitis
- pancreatic trauma
- pancreatic carcinoma
- OTHER ABDO
- perforated PUD
- acute appendicitis
- acute cholecystitis
- ectopic pregnancy
- pelvic inflam disease
- mesenteric ischaemia
- leaking AAA
- DECREASED CLEARANCE
- renal failure
- MISCELLANEOUS
- DKA
- Head injury
