Epigastric Pain Flashcards
What are the ddx for acute epigastric pain
*must be excluded asap
Acute pancreatitis* Perforated peptic ulcer* Gastritis/duodenitis Peptic ulcer disease Biliary colic Acute cholecystitis Ascending cholangitis* Myocardial infarction* AAA rupture* Mesenteric ischaemia*
What kind of site of pain would be consistent with peritonitis from a perforated GI tract
Pain spreads from epigastrium to involve rest of abdomen
Very sudden onset epigastric pain suggests?
Perforation of a viscus
Pain from acute pancreatitis and biliary colic develops maximal intensity over what time period
10-20 mins
How long do inflammatory processes e.g. acute cholecystitis or pneumonia take to peak?
Hours
“Sharp, burning” pain indicates what pathology?
Peptic ulcers, gastritis, duodenitis
Deep, “boring” pain indicates what pathology?
Pancreatitis
Ruptured AAA, pancreatitis and occasionally peptic ulcers may cause pain to radiate where?
Back
Shoulder-tip pain may arise from irritation of the phrenic nerve, suggesting involvement of the diaphragm. What pathologies may this be consistent with
Basal pneumonia or subphrenic abscess
Retrosternal chest pain indicates what pathology?
Oesophagitis / MI
Patients with acute pancreatitis may find that doing what relieves their pain?
Sitting forwards
In patients with peritonitis and intra-abdominally originating pains, what makes the pain worse
Movement
If self-limiting pain is triggered by fatty meals, what pathology is this highly suggestive of?
Biliary colic
What symptoms should you ask about in patients with epigastric pain?
- N+V - small bowel obstruction may give colicky epigastric pain w N+V. Inferior MI irritating diaphragm may also cause vomiting.
- Fever? - infection (viral hepatitis, pneumonia) or widespread inflammation (i.e. peritonitis)
- Dyspepsia/waterbrash? - GORD/oesophagitis
- Stool changes? - pale stools = bile not reaching bowel. Steatorrhoea = pancreatic exocrine insufficiency or long-standing biliary disease
- Cough - may indicate basal pneumonia
In patients who have had biliary disease (e.g. gallstones) are prone to which complications?
Acute pancreatitis, acute cholecystitis and ascending cholangitis
Postprandial pain may signify what pathology
Mesenteric ischaemia
Which drugs may predispose to peptic ulcer disease
NSAIDS, steroids, bisphosphonates.
NB steroids may mask signs of peritonism
What drugs are linked with increased incidence of acute pancreatitis
Sodium valproate, steroids, thiazides, azathioprine
What is alcohol a RF for?
What about smoking?
Alcohol - acute pancreatitis
Smoking - peptic ulcer disease, vascular causes
Describe the position that someone with peritonitis adopts?
What about someone who has pancreatitis
Peritonitis - lie completely still and rigid - movement causes pain
Pancreatitis - patient sit/lie forwards
Jaundice may be due to which causes? Name 3
Ascending cholangitis
Acute pancreatitis
Acute hepatitis (but this rarely causes pain)
What is Grey-Turners sign and what does it indicate
Extravasated blood in retroperitoneum causes discolouration of umbilicus and flank.
May be seen in acute haemorrhagic pancreatitis
What may guarding indicate?
Guarding with tenderness may suggest acute cholecystitis or mild pancreatitis.
Severe tenderness with guarding and rigidity may indicate peritonitis
A central, laterally expansile, pulsatile mass suggests?
Ruptured AAA
Which blood tests would you do in someone with epigastric pain?
- FBC - WCC, Hb (bleeding peptic ulcer). Neutrophilia is prognostic indicator in pancreatitis
- CRP
- Pancreatic amylase/lipase - slight increases = pancreatitis. Very high amylase (>1000)/lipase (>300) = acute pancreatitis
- Liver enzymes - high AST/ALT = hepatocyte damage. High ALP/GGT/Bilirubin - pathology in biliary tree or compression of biliary tree.
- Albumin
- U&Es, creatinine
- Ca - hypercalcaemia can cause pancreatitis. Pancreatitis can cause hypocalcaemia as pancreas gets saponificated. Low Ca is prognostic in pancreatitis.
- Glucose - indicates damage to pancreas (hyperglycaemia)
- ABG - ARDS is a complication of acute pancreatitis. If pt not hypoxic do VBG
- Troponin
If ALP rises without corresponding GGT increase - what does this suggest?
Bone or placenta cause of problem - not liver.
In a VBG, if there is elevated pH and lactate, what conditions does this indicate
Acute pancreatitis or peritonitis
Loss of psoas muscle shadow indicates what?
AAA rupture
When is it necessary to do a US?
If AAA rupture suspected
If acute pancreatitis is diagnosed, US can be useful to look for gallstones. If no gallstones, consider MRCP.
Causes of acute pancreatitis? I GET SMASHED
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
What scoring system is used to predict outcome of pancreatitis
A score of what is considered severe pancreatitis
Glasgow score
3 or more is severe pancreatitis. Less is mild
If a patient has mild pancreatitis, and gallstones are the cause, what is done
Laparoscopic cholecystectomy
If severe pancreatitis, ERCP within 3 days
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
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
Someone who has severe epigastric pain (10/10), long term NSAID use, significant alcohol consumption points to which diagnosis
Perforated peptic ulcer
Absent bowel sounds, motionless patient and tenderness and guarding on palpation indicates what?
Peritonitis
Low stool elastase indicates compromise of which organ?
Pancreas
