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
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
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
