Epigastric pain Flashcards
Differentials for a 40 year old man with acute epigastric pain?
ACUTE PANCREATITIS PERFORATED PEPTIC ULCER RUPTURED AAA Gastritis/ Duodenitis Biliary colic Acute cholecystitis Myocardial infarction - Check ECG & Trop Mesenteric ischaemia Basal pneumonia Oesophagitis (GORD) Non-ulcer dyspepsia Chronic pancreatitis Incomplete bowel obstruction
What differential is more likely in an elderly patient presenting with acute epigastric pain?
Abdominal Aortic Aneurysm
What condition presents with epigastric pain that spreads from the epigastrium to the rest of the abdomen?
Peritonitis
If the pain spreads from the epigastrium to the chest region, what is the nature of the underlying pathology?
Cardiac
If the pain is very SUDDEN ONSET, what does this suggest about the origin of the pain?
Most likely a viscus perforation eg. duodenal ulcer perforation or Boerhaave’s perforation
How does pain from acute pancreatitis develop over time?
Over 10-20 hours
If the pain is ‘crushing’ or complaining of ‘tightness’, what type of pathology is likely?
Cardiac
What could be the origin of sharp burning pain?
Peptic ulcer disease, gastritis or duodenitis
Origin of deep boring pain?
Pancreatitis
If the pain radiates to the back, what could be the cause?
Pancreatitis, a leaking AAA and sometimes peptic ulcers
Origin of shoulder tip pain?
Irritation of the phrenic nerve due to diaphragmatic involvement eg. a basal pneumonia or subphrenic abcess
Origin of jaw, neck and arm pain?
Cardiac pathology
Origin of retrosternal chest pain?
Myocardial ischaemia or oesphagitis
In which condition does sitting forward help relieve pain?
Acute pancreatitis
How does eating affect pain from duodenal and gastric ulcers?
Eating relieves pain from duodenal ulcer patients but worsens gastric ulcer pain
Which conditions present an onset of <6-8 hours?
Biliary colic, uncomplicated peptic ulcer disease, gastritis, duodenitis, non ulcer dyspepsia
Epigastric pain with cardiac origin is usually made worse by?
Exercise
In which conditions is pain exacerbated by movement?
Peritonitis
Which conditions are made worse by deep breathing, and what type of pain is this called?
Basal pneumonia, pulmonary embolus, pneumothorax, pericarditis
Pleuritic pain
Which condition is made worse by eating fatty meals?
Biliary colic
Causes of VERY painful epigastric pain?
Severe pancreatitis, perforated peptic ulcers and MI
How painful are uncomplicated peptic ulcers, gastritis, duodenitis and non-ulcer dyspepsia?
Usually not too severe (and many won’t present to hospital)
Once pain is characterised, what other associated symptoms should you ask about?
Nausea/Vomiting? (small bowel obstruction presents with colicky pain with N&V; Boerhaave’s perforation is precipitated by forceful vomiting)
Fever? (Hepatitis, pneumonia?, Peritonitis?)
Dyspepsia? (Heartburn, retrosternal discomfort and bitter taste in mouth points to GORD)
Any changes in stool? (Steatorrhoea indicates pancreatic exocrine insufficiency or long standing biliary disease)
Cough? (Basal pneumonia in acute setting? GORD in chronic setting)
How is previous history of biliary disease relevant to a patient?
Patients with a history of gallstone disease are prone to recurrence of biliary disease and to complications eg. acute pancreatitis, acute cholecystitis or ascending cholangitis
How is history of peptic ulcer disease and GORD relevant?
If a patient presents with sudden-onset epigastric pain with previous history of PUD, treat as if they have a perforated ulcer
GORD has a high rate of recurrence
How is history of vascular disease important?
Patients with widespread arterial disease are at increased risk of MI and mesenteric ischaemia. Mesenteric ischaemia presents with colicky postprandial abdominal pain
Which drugs increase risk of developing peptic ulcers?
NSAIDS, steroids, bisphosphonates, salicylates (aspirin)
Which drugs increase the risk of developing acute pancreatitis?
Sodium valproate, steroids, thiazides and azathioprine
Which gene mutations can increase risk of acute pancreatitis?
SPINK1, CFTR, PRSS1
Smoking is a risk factor for which conditions that present with epigastric pain?
Peptic ulcer disease, myocardial infarction, mesenteric ischaemia
On examination, what indications are there if a patient is sitting still or sitting forwards?
Peritonitis - any movement is painful
Mild pancreatitis - Pain improves when sitting forward
