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Oxford Clinical Cases > Epigastric Pain > Flashcards

Epigastric Pain Flashcards

1
Q

List some differential diagnoses of epigastric pain.

A 
Gastrointestinal:
Stomach:
-Perforated peptic ulcer 
-Gastritis/duodenitis
-Peptic ulcer disease

Pancreas:
-Acute pancreatitis

Biliary system:

  • Biliary colic
  • Acute cholecystitis
  • Ascending cholangitis

Vascular:

  • MI
  • Ruptured AAA
  • Mesenteric ischaemia

Lung:
Basal pneumonia

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2
Q

Describe the pattern of pain that would be caused by a perforated peptic ulcer.

A

There would initially be an intense pain in the epigastrium

This would spread across the whole abdomen as the patient becomes peritonitic

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3
Q

What does sudden-onset pain suggest?

A

Perforated viscus

MI

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4
Q

How long does pain from acute pancreatitis or biliary colic take to reach maximum intensity?

A

10-20 mins

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5
Q

How long do inflammatory processes such as pneumonia and cholecystitis take to reach their peak in terms of pain?

A

A matter of hours

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6
Q

Which diseases cause epigastric pain that radiates to the back?

A

Acute pancreatitis

Leaking AAA

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7
Q

What can cause shoulder-tip pain?

A

Diaphragmatic irritation (e.g. by basal pneumonia, subphrenic abscess)

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8
Q

Which diseases cause retrosternal pain?

A

Oesophagitis

Myocardial ischaemia

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9
Q

What can relieve the pain caused by pancreatitis?

A

Sitting forward

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10
Q

Describe how gastric ulcers and duodenal ulcers can be differentiated based on when the pain is worst.

A

Gastric Ulcers – pain is worse when eating

Duodenal Ulcers – pain is relieved by eating

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11
Q

What does pain triggered by fatty meals suggest?

A

Biliary colic

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12
Q

Which of the causes of epigastric pain cause particularly severe pain?

A

Severe pancreatitis
MI
Perforated peptic ulcer

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13
Q

List some important associated symptoms that should be enquired about when taking a history.

A 
Nausea and vomiting 
Fever
Dyspepsia and waterbrash
Changes in stool
Cough
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14
Q

List some diseases that cause epigastric pain and nausea and vomiting.

A

Small bowel obstruction
Inferior MI
Boerhaave’s perforation (vomiting precedes the epigastric pain)

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15
Q

Which pathology is associated with causing pale stools?

A

Obstruction of bile outflow

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16
Q

Which diseases cause steatorrhoea?

A

Long-standing biliary disease

Pancreatic exocrine insufficiency

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17
Q

Why is it important to ask a patient with epigastric pain whether they’ve had a cough?

A

Basal pneumonia can cause epigastric pain and it will also cause an acute, productive cough

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18
Q

List the four main diseases in the past medical history that are important to ask a patient with epigastric pain about.

A

GORD
Peptid ulcer disease
Biliary disease (e.g. gallstones)
Vascular disease

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19
Q

Why is it important to ask about previous vascular disease and cardiovascular risk factors?

A

A history of vascular disease increases the risk of mesenteric ischaemia and myocardial infarction

20
Q

Which two diseases that cause epigastric pain can be caused by drugs? Which drugs are associated with each of these diseases?

A 
- Peptic ulcer disease 
NSAIDs
Aspirin
Bisphosphonates
Steroids
- Acute pancreatitis 
Sodium valproate 
Thiazides 
Steroids
Azathioprine
21
Q

List some significant features of the social history.

A

Alcohol – excess can cause acute pancreatitis

Smoking – associated with peptic ulcer disease, MI and mesenteric ischaemia

22
Q

Describe the appearance of a peritonitic patient.

A

Patients lie completely still
Taking shallow breaths
Movement is painful

23
Q

How can acute pancreatitis lead to jaundice in the absence of gallstones?

A

Oedema of the head of an inflamed pancreas can obstruct the common bile duct

24
Q

Describe Grey-Turner’s and Cullen’s Signs. What are they signs of?

A

They are signs of severe pancreatitis
Cullen’s Sign – bruising/discolouration around the umbilicus
Grey-Turner’s Sign – bruising/discolouration on the flanks

25
Q

List signs of small bowel obstruction.

A

Abdominal distension
Tinkling bowel sounds
Absolute constipation

26
Q

What is Murphy’s sign?

A

A finger is placed just below the tip of the right 9th costal cartilage and the patient is asked to breathe in deeply
Inspiration is arrested when the inflamed gallbladder strikes the finger of the examiner
This is indicative of cholecystitis

27
Q

Which masses might you palpate for in the abdomen of a patient with epigastric pain?

A

AAA – central expansile and pulsatile mass

Check hernia orifices because a strangulated hernia could cause bowel obstruction

28
Q

List some important blood tests that you would perform in a patient with epigastric pain.

A 
FBC – check for raised WCC, anaemia, neutrophilia
CRP
Pancreatic Amylase and Lipase
Liver enzymes 
Albumin 
U&Es
Calcium
Glucose 
ABG
29
Q

Describe different patterns of derangement of liver enzymes and state what they indicate.

A

High AST + ALT (transaminitis) = liver pathology (e.g. hepatitis)
High ALP + GGT = biliary disease
Isolated raised GGT = alcoholic liver disease
High AST: ALT ratio (> 2:1) = alcoholic liver disease

30
Q

List some prognostic indicators in pancreatitis.

A

Neutrophilia
Albumin
Blood glucose

31
Q

Describe the time taken for serum amylase to rise and fall in a case of pancreatitis.

A

Rises within hours

Returns to normal after 3-5 days

32
Q

Why is it important to measure serum calcium in a patient with pancreatitis?

A

Hypercalcaemia – can cause pancreatiits
Hypocalcaemia – can result from severe pancreatitis (a process called saponification occurs where calcium binds to digested lipids)

33
Q

Why is it important to perform a VBG in a patient with epigastric pain?

A

Allows assessment of pH and lactate
pH will decrease and lactate will increase in conditions causing a severe inflammatory response (e.g. acute pancreatitic, peritonitis)
NOTE: this is because a systemic inflammatory response –> vasodilation –> hypoperfusion of tissues –> increase in anaerobic respiration –> lactic acidosis

34
Q

Which forms of imaging are useful in patients with epigastric pain?

A

Erect CXR
AXR
Ultrasound

35
Q

Which sign on erect CXR suggests that there has been a GI perforation?

A

Air under the diaphragm (pneumoperitoneum)

36
Q

Why might ultrasound be useful in investigating a patient with epigastric pain?

A

Allows visualisation of AAA

Allows visualisation of gallstone disease

37
Q

What is the downfall with the use of ultrasound to investigate AAAs?

A

It does not show whether the AAA is leaking/ruptured

A CT aortogram is required to confirm a leak

38
Q

List the causes of acute pancreatitis.

A 
GALLSTONES
ETHANOL
Trauma
Steroids
Mumps/HIV/Coxsackie
Autoimmune
Scorpion venom
Hypercalcaemia/ hyperlipidaemia/hypothermia
ERCP
Drugs (e.g. sodium valproate, thiazides)
39
Q

What are the 3 main scoring systems for pancreatitis?

A

APACHE II
Glasgow
Ranson

40
Q

With regards to the Glasgow scoring system, what score is considered severe pancreatitis?

A

3 and above

41
Q

Outline the management of acute pancreatitis.

A 
Assess ABC (NOTE: pancreatitis can cause ARDS)
IV fluids 
Oxygen 
Analgesia
Anti-emetics 
DVT prophylaxis 
Low-fat diet
42
Q

How can you reduce the recurrence of pancreatitis?

A

Cholecystectomy

Stop drinking alcohol

43
Q

Describe the main tests for Helicobacter pylori.

A

Non-invasive tests:
1) Urease Breath Test – the patient is asked to swallow a sample of urea containing radio-labelled carbon. After 10-30 mins, the patients breath is tested and if the radio-labelled carbon is identified in the patient’s breath, it suggests that urease, produced by H. pylori, is present in the patient’s stomach
2) stool antigen tests
Invasive tests:
2) Campylobacter-like Organism (CLO) Test – a biopsy is taken DURING OGD from the patient’s stomach and placed on a medium containing urea and an indicator. If urease (produced by H. pylori) is present in the patient’s stomach, it will convert the urea to carbon dioxide (and other by-products) and cause a change in the colour of the indicator

44
Q

Describe the treatment of H. pylori.

A

Triple therapy – 2 x antibiotics + PPI

45
Q

What is non-ulcer dyspepsia?

A

Chronic epigastric pain with normal blood tests, normal OGD and normal biliary ultrasound (there is no organic cause for the pain)

46
Q

What are the criteria in the modified glasgow scale

A 
Po2
Age over 55
Neutrophilia
Calcium
Raisd urea
Enzymes
Albumin
Sugar

Oxford Clinical Cases (29 decks)

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