Epigastric pain Flashcards
What are the differentials for acute epigastric pain
Acute pancreatitis (or chronic) Perforated peptic ulcer/disease Gastritis/duodenitis/oeseophagitis Biliary colic Acute cholecystitis Ascending cholangitis MI AAA Mesenteric ischaemia Boerhaave's perforation Gastric cancer
Which differentials must be excluded on presentation with acute epigastric pain
Acute pancreatitis Perforated peptic ulcer Ascending cholangitis MI AAA Mesenteric ischaemia Boerhaave's perforation
What are the differentials if the pain is from the following sites: spread to the rest of the abdomen, spread to the chest, pain in RUQ
Spread to abdomen: indicates peritonitis from perforated GI tract e.g. gastric ulcer
Spread to the chest: cardiac
RUQ: cholecystitis, cholangitis
What are the differentials if the pain has the following onsets: Very sudden, increasing intensity over minutes, hours
Very sudden: perforation e.g. duodenal ulcer, boerhaave’s or MI
Increasing in intensity over minutes: Acute pancreatitis and biliary colic
Hours: Acute cholecystitis or pneumonia
What are the differentials if the pain is of the following Characters: Crushing/tightness, sharp/burning, deep/boring
Crushing: cardiac
sharp/burn: peptic ulcers, gastritis, duodenitis
Deep/boring: pancreatitis
What are the differentials if the pain is follows the following radiations: back pain, shoulder tip pain, jaw/neck/arm, retrosternal
Back: pancreatitis, AAA, peptic ulcer
Shoulder tip: irritation of phrenic nerve, basal pneumonia
Jaw/neck/arm: cardiac
Retrosternal: oesophagitis or MI
What are the differentials if the pain is relieved by the following attenuating factors: sitting forwards
Sitting forwards: acute pancreatitis
What are the differentials if the pain has the following timings: self limiting (6-8h), constant, exacerbation by exercise
Self limiting: peptic ulcer disease, gastritis, duodenitis, non-ulcer dyspepsia
Constant: biliary colic
Exacerbation by exercise: cardiac
What are the differentials if the pain has the following exacerbating factors: movement, deep breathing, fatty meals
Movement: intra-abdominal origin + peritonitis
Deep breathing (pleuritic): basal pneumonia, PE, pneumothorax, pericarditis
Fatty meals: biliary colic
What other symptoms should be asked about with epigastric pain and what might they suggest
N+V: SB obstruction, inferior MI, Boeerhaave’s
Fever: infection, widespread inflammation
Dyspepsia and waterbrash: GORD
Changes in stool: Biliary obstruction (pale), Pancreatic exocrine insufficiency or biliary disease (foul smelling steatorrhoea)
Cough: basal pneumonia, chronic cough (GORD)
What features of the past medical history would be relevant for epigastric pain
Biliary disease
Peptic ulcer disease
GORD
Valvular disease
What features of the drug history would be relevant for epigastric pain
NSAIDs, steroids, bisphosphonates, aspirin - peptic ulcers
Sodium valproate, steroids, thiazides, azathioprine - acute pancreatitis
What features of the social history would be relevant for epigastric pain
Smoking and alcohol
Alcohol intake important: pancreatitis
Smoking: peptic ulcer disease and vascular causes of pain
What signs would you look for on exam for epigastric pain
Position: is patient still (peritonitis), relieved by sitting forward (pancreatitis)
Jaundice
Cullen’s/Grey-Turners - pancreatitis
Abdominal distension, absent or tinkling bowel sounds
Tenderness and guarding
Masses, including expansile AAA
Resp exam and signs e.g. creps, dullness, resonance
Investigations (blood) for epigastric pain and why
FBC: infection/inflam, blood loss CRP: inflam Amylase/lipase: pancreatitis Liver enzymes: hepatic path Albumin: prognostic for pancreatitis Urea and electrolytes: fluid resus, vomiting Calcium: hyper causes pancreatitis, hypo feature of chronic pancreatitis Glucose: severity of pancreatitis ABG : resus Trops: rule out cardiac cause
Imaging investigations for epigastric pain and why
Erect CXR: pneumoperitoneum, rule out pneumonia
Abdominal radiograph: to look for bowel dilatation in suspected obstruction or foreign bodies
(ECG: rule out cardiac cause)
What are abdominal USS used for in epigastric pain
Suspicion of AAA
Visualisation of gallstones e.g. in pancreatitis
Exclusion of biliary dilation
What score is commonly used for grading severity of pancreatitis in the UK
Glasgow (Imrie), total score 8. 3 or more is severe -> ITU PaO2 <8 kPa Age >55 Neutrophilia >15 Calcium <2 Renal function, urea >16 Enzymes: LDH >600 or AST >200 Albumin <32 Sugar >10
Management of pancreatitis
ABC (check for ARDS and hypovolaemia) IV fluids Oxygen Analgesia Antiemetics DVT prophylaxis Low-fat diet
How to prevent pancreatitis recurrence
Most patients recover without further therapy within a week
Mild gallstones - biliary USS and laparoscopic cholecystectomy
Severe - ERCP within 72 hours (+ sphincterectomy, delayed cholecystectomy)
How does peptic ulcer disease present
Epigastric pain that follows meals and does not radiate or change with position
Waterbrash
Management for peptic ulcer disease
Lifestyle: reduce alcohol, caffeine, chocolate and fatty foods and smoking cessation + weight loss
If this fails - full-dose PPI for 1 month for H. pylori (Test and treat) -> triple therapy
WHat may amylase be elevated in if it is not >1000 (as seen in acute pancreatitis)
Perforated peptic ulcer Bowel obstruction Mesenteric ischaemia Mumps Pancreatic carcinoma Opiate medications
How should a patient with peptic ulcer perforation and peritonitis be managed before surgery
Analgesia IV fluid resus IV Abs Oxygen as required NBM and NG tube passed Urine output monitored (consider catheter)
