Epigastric pain

Question 1

Differentials for a 40 year old man with acute epigastric pain?

Answer 1

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

Question 2

What differential is more likely in an elderly patient presenting with acute epigastric pain?

Answer 2

Abdominal Aortic Aneurysm

Question 3

What condition presents with epigastric pain that spreads from the epigastrium to the rest of the abdomen?

Answer 3

Peritonitis

Question 4

If the pain spreads from the epigastrium to the chest region, what is the nature of the underlying pathology?

Answer 4

Cardiac

Question 5

If the pain is very SUDDEN ONSET, what does this suggest about the origin of the pain?

Answer 5

Most likely a viscus perforation eg. duodenal ulcer perforation or Boerhaave’s perforation

Question 6

How does pain from acute pancreatitis develop over time?

Answer 6

Over 10-20 hours

Question 7

If the pain is ‘crushing’ or complaining of ‘tightness’, what type of pathology is likely?

Answer 7

Cardiac

Question 8

What could be the origin of sharp burning pain?

Answer 8

Peptic ulcer disease, gastritis or duodenitis

Question 9

Origin of deep boring pain?

Answer 9

Pancreatitis

Question 10

If the pain radiates to the back, what could be the cause?

Answer 10

Pancreatitis, a leaking AAA and sometimes peptic ulcers

Question 11

Origin of shoulder tip pain?

Answer 11

Irritation of the phrenic nerve due to diaphragmatic involvement eg. a basal pneumonia or subphrenic abcess

Question 12

Origin of jaw, neck and arm pain?

Answer 12

Cardiac pathology

Question 13

Origin of retrosternal chest pain?

Answer 13

Myocardial ischaemia or oesphagitis

Question 14

In which condition does sitting forward help relieve pain?

Answer 14

Acute pancreatitis

Question 15

How does eating affect pain from duodenal and gastric ulcers?

Answer 15

Eating relieves pain from duodenal ulcer patients but worsens gastric ulcer pain

Question 16

Which conditions present an onset of <6-8 hours?

Answer 16

Biliary colic, uncomplicated peptic ulcer disease, gastritis, duodenitis, non ulcer dyspepsia

Question 17

Epigastric pain with cardiac origin is usually made worse by?

Answer 17

Exercise

Question 18

In which conditions is pain exacerbated by movement?

Answer 18

Peritonitis

Question 19

Which conditions are made worse by deep breathing, and what type of pain is this called?

Answer 19

Basal pneumonia, pulmonary embolus, pneumothorax, pericarditis
Pleuritic pain

Question 20

Which condition is made worse by eating fatty meals?

Answer 20

Biliary colic

Question 21

Causes of VERY painful epigastric pain?

Answer 21

Severe pancreatitis, perforated peptic ulcers and MI

Question 22

How painful are uncomplicated peptic ulcers, gastritis, duodenitis and non-ulcer dyspepsia?

Answer 22

Usually not too severe (and many won’t present to hospital)

Question 23

Once pain is characterised, what other associated symptoms should you ask about?

Answer 23

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)

Question 24

How is previous history of biliary disease relevant to a patient?

Answer 24

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

Question 25

How is history of peptic ulcer disease and GORD relevant?

Answer 25

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

Question 26

How is history of vascular disease important?

Answer 26

Patients with widespread arterial disease are at increased risk of MI and mesenteric ischaemia. Mesenteric ischaemia presents with colicky postprandial abdominal pain

Question 27

Which drugs increase risk of developing peptic ulcers?

Answer 27

NSAIDS, steroids, bisphosphonates, salicylates (aspirin)

Question 28

Which drugs increase the risk of developing acute pancreatitis?

Answer 28

Sodium valproate, steroids, thiazides and azathioprine

Question 29

Which gene mutations can increase risk of acute pancreatitis?

Answer 29

SPINK1, CFTR, PRSS1

Question 30

Smoking is a risk factor for which conditions that present with epigastric pain?

Answer 30

Peptic ulcer disease, myocardial infarction, mesenteric ischaemia

Question 31

On examination, what indications are there if a patient is sitting still or sitting forwards?

Answer 31

Peritonitis - any movement is painful

Mild pancreatitis - Pain improves when sitting forward