Epigastric Pain

Question 1

What are the ddx for acute epigastric pain

*must be excluded asap

Answer 1

Acute pancreatitis*
Perforated peptic ulcer*
Gastritis/duodenitis
Peptic ulcer disease
Biliary colic
Acute cholecystitis
Ascending cholangitis*
Myocardial infarction*
AAA rupture*
Mesenteric ischaemia*

Question 2

What kind of site of pain would be consistent with peritonitis from a perforated GI tract

Answer 2

Pain spreads from epigastrium to involve rest of abdomen

Question 3

Very sudden onset epigastric pain suggests?

Answer 3

Perforation of a viscus

Question 4

Pain from acute pancreatitis and biliary colic develops maximal intensity over what time period

Answer 4

10-20 mins

Question 5

How long do inflammatory processes e.g. acute cholecystitis or pneumonia take to peak?

Answer 5

Hours

Question 6

“Sharp, burning” pain indicates what pathology?

Answer 6

Peptic ulcers, gastritis, duodenitis

Question 7

Deep, “boring” pain indicates what pathology?

Answer 7

Pancreatitis

Question 8

Ruptured AAA, pancreatitis and occasionally peptic ulcers may cause pain to radiate where?

Answer 8

Back

Question 9

Shoulder-tip pain may arise from irritation of the phrenic nerve, suggesting involvement of the diaphragm. What pathologies may this be consistent with

Answer 9

Basal pneumonia or subphrenic abscess

Question 10

Retrosternal chest pain indicates what pathology?

Answer 10

Oesophagitis / MI

Question 11

Patients with acute pancreatitis may find that doing what relieves their pain?

Answer 11

Sitting forwards

Question 12

In patients with peritonitis and intra-abdominally originating pains, what makes the pain worse

Answer 12

Movement

Question 13

If self-limiting pain is triggered by fatty meals, what pathology is this highly suggestive of?

Answer 13

Biliary colic

Question 14

What symptoms should you ask about in patients with epigastric pain?

Answer 14

1. N+V - small bowel obstruction may give colicky epigastric pain w N+V. Inferior MI irritating diaphragm may also cause vomiting.
2. Fever? - infection (viral hepatitis, pneumonia) or widespread inflammation (i.e. peritonitis)
3. Dyspepsia/waterbrash? - GORD/oesophagitis
4. Stool changes? - pale stools = bile not reaching bowel. Steatorrhoea = pancreatic exocrine insufficiency or long-standing biliary disease
5. Cough - may indicate basal pneumonia

Question 15

In patients who have had biliary disease (e.g. gallstones) are prone to which complications?

Answer 15

Acute pancreatitis, acute cholecystitis and ascending cholangitis

Question 16

Postprandial pain may signify what pathology

Answer 16

Mesenteric ischaemia

Question 17

Which drugs may predispose to peptic ulcer disease

Answer 17

NSAIDS, steroids, bisphosphonates.

NB steroids may mask signs of peritonism

Question 18

What drugs are linked with increased incidence of acute pancreatitis

Answer 18

Sodium valproate, steroids, thiazides, azathioprine

Question 19

What is alcohol a RF for?

What about smoking?

Answer 19

Alcohol - acute pancreatitis

Smoking - peptic ulcer disease, vascular causes

Question 20

Describe the position that someone with peritonitis adopts?

What about someone who has pancreatitis

Answer 20

Peritonitis - lie completely still and rigid - movement causes pain

Pancreatitis - patient sit/lie forwards

Question 21

Jaundice may be due to which causes? Name 3

Answer 21

Ascending cholangitis
Acute pancreatitis
Acute hepatitis (but this rarely causes pain)

Question 22

What is Grey-Turners sign and what does it indicate

Answer 22

Extravasated blood in retroperitoneum causes discolouration of umbilicus and flank.

May be seen in acute haemorrhagic pancreatitis

Question 23

What may guarding indicate?

Answer 23

Guarding with tenderness may suggest acute cholecystitis or mild pancreatitis.

Severe tenderness with guarding and rigidity may indicate peritonitis

Question 24

A central, laterally expansile, pulsatile mass suggests?

Answer 24

Ruptured AAA

Question 25

Which blood tests would you do in someone with epigastric pain?

Answer 25

1. FBC - WCC, Hb (bleeding peptic ulcer). Neutrophilia is prognostic indicator in pancreatitis 2. CRP 3. Pancreatic amylase/lipase - slight increases = pancreatitis. Very high amylase (>1000)/lipase (>300) = acute pancreatitis 4. Liver enzymes - high AST/ALT = hepatocyte damage. High ALP/GGT/Bilirubin - pathology in biliary tree or compression of biliary tree. 5. Albumin 6. U&Es, creatinine 7. Ca - hypercalcaemia can cause pancreatitis. Pancreatitis can cause hypocalcaemia as pancreas gets saponificated. Low Ca is prognostic in pancreatitis. 8. Glucose - indicates damage to pancreas (hyperglycaemia) 9. ABG - ARDS is a complication of acute pancreatitis. If pt not hypoxic do VBG 10. Troponin

Question 26

If ALP rises without corresponding GGT increase - what does this suggest?

Answer 26

Bone or placenta cause of problem - not liver.

Question 27

In a VBG, if there is elevated pH and lactate, what conditions does this indicate

Answer 27

Acute pancreatitis or peritonitis

Question 28

Loss of psoas muscle shadow indicates what?

Answer 28

AAA rupture

Question 29

When is it necessary to do a US?

Answer 29

If AAA rupture suspected If acute pancreatitis is diagnosed, US can be useful to look for gallstones. If no gallstones, consider MRCP.

Question 30

Causes of acute pancreatitis? I GET SMASHED

Answer 30

``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps/HIV/Coxsackie Autoimmune Scorpion bites Hyperlipidaemia/hypercalcaemia/hypothermia ERCP Drugs (sodium valproate, steroids, thiazides, azathioprine) ``` Gallstones and ethanol most common

Question 31

What scoring system is used to predict outcome of pancreatitis A score of what is considered severe pancreatitis

Answer 31

Glasgow score 3 or more is severe pancreatitis. Less is mild

Question 32

If a patient has mild pancreatitis, and gallstones are the cause, what is done

Answer 32

Laparoscopic cholecystectomy If severe pancreatitis, ERCP within 3 days

Question 33

A patient who smokes and drinks, with epigastric pain for a few weeks, no radiation of pain, burning pain, no water brash or vomiting, no change in pain on position, indicates what pathology

Answer 33

Peptic ulcer disease/gastritis/non-ulcer dyspepsia Conservative management, if that fails then give PPIs fora month or H. pylori treatment. H pylori most common cause of peptic ulcers

Question 34

Someone who has severe epigastric pain (10/10), long term NSAID use, significant alcohol consumption points to which diagnosis

Answer 34

Perforated peptic ulcer

Question 35

Absent bowel sounds, motionless patient and tenderness and guarding on palpation indicates what?

Answer 35

Peritonitis

Question 36

Low stool elastase indicates compromise of which organ?

Answer 36

Pancreas