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Y3 Oxford Cases > Epigastric pain > Flashcards

Epigastric pain Flashcards

1
Q

What are the differentials for acute epigastric pain

A 
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
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2
Q

Which differentials must be excluded on presentation with acute epigastric pain

A 
Acute pancreatitis
Perforated peptic ulcer
Ascending cholangitis
MI 
AAA
Mesenteric ischaemia 
Boerhaave's perforation
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3
Q

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

A

Spread to abdomen: indicates peritonitis from perforated GI tract e.g. gastric ulcer
Spread to the chest: cardiac
RUQ: cholecystitis, cholangitis

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4
Q

What are the differentials if the pain has the following onsets: Very sudden, increasing intensity over minutes, hours

A

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

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5
Q

What are the differentials if the pain is of the following Characters: Crushing/tightness, sharp/burning, deep/boring

A

Crushing: cardiac

sharp/burn: peptic ulcers, gastritis, duodenitis

Deep/boring: pancreatitis

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6
Q

What are the differentials if the pain is follows the following radiations: back pain, shoulder tip pain, jaw/neck/arm, retrosternal

A

Back: pancreatitis, AAA, peptic ulcer

Shoulder tip: irritation of phrenic nerve, basal pneumonia

Jaw/neck/arm: cardiac

Retrosternal: oesophagitis or MI

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7
Q

What are the differentials if the pain is relieved by the following attenuating factors: sitting forwards

A

Sitting forwards: acute pancreatitis

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8
Q

What are the differentials if the pain has the following timings: self limiting (6-8h), constant, exacerbation by exercise

A

Self limiting: peptic ulcer disease, gastritis, duodenitis, non-ulcer dyspepsia

Constant: biliary colic

Exacerbation by exercise: cardiac

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9
Q

What are the differentials if the pain has the following exacerbating factors: movement, deep breathing, fatty meals

A

Movement: intra-abdominal origin + peritonitis

Deep breathing (pleuritic): basal pneumonia, PE, pneumothorax, pericarditis

Fatty meals: biliary colic

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10
Q

What other symptoms should be asked about with epigastric pain and what might they suggest

A

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)

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11
Q

What features of the past medical history would be relevant for epigastric pain

A

Biliary disease
Peptic ulcer disease
GORD
Valvular disease

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12
Q

What features of the drug history would be relevant for epigastric pain

A

NSAIDs, steroids, bisphosphonates, aspirin - peptic ulcers

Sodium valproate, steroids, thiazides, azathioprine - acute pancreatitis

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13
Q

What features of the social history would be relevant for epigastric pain

A

Smoking and alcohol
Alcohol intake important: pancreatitis
Smoking: peptic ulcer disease and vascular causes of pain

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14
Q

What signs would you look for on exam for epigastric pain

A

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

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15
Q

Investigations (blood) for epigastric pain and why

A 
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
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16
Q

Imaging investigations for epigastric pain and why

A

Erect CXR: pneumoperitoneum, rule out pneumonia
Abdominal radiograph: to look for bowel dilatation in suspected obstruction or foreign bodies
(ECG: rule out cardiac cause)

17
Q

What are abdominal USS used for in epigastric pain

A

Suspicion of AAA
Visualisation of gallstones e.g. in pancreatitis
Exclusion of biliary dilation

18
Q

What score is commonly used for grading severity of pancreatitis in the UK

A 
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
19
Q

Management of pancreatitis

A 
ABC (check for ARDS and hypovolaemia)
IV fluids
Oxygen
Analgesia
Antiemetics 
DVT prophylaxis
Low-fat diet
20
Q

How to prevent pancreatitis recurrence

A

Most patients recover without further therapy within a week
Mild gallstones - biliary USS and laparoscopic cholecystectomy
Severe - ERCP within 72 hours (+ sphincterectomy, delayed cholecystectomy)

21
Q

How does peptic ulcer disease present

A

Epigastric pain that follows meals and does not radiate or change with position
Waterbrash

22
Q

Management for peptic ulcer disease

A

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

23
Q

WHat may amylase be elevated in if it is not >1000 (as seen in acute pancreatitis)

A 
Perforated peptic ulcer 
Bowel obstruction 
Mesenteric ischaemia 
Mumps
Pancreatic carcinoma
Opiate medications
24
Q

How should a patient with peptic ulcer perforation and peritonitis be managed before surgery

A 
Analgesia
IV fluid resus 
IV Abs
Oxygen as required
NBM and NG tube passed
Urine output monitored (consider catheter)
25
Q

What is the characteristics of Non ulcer dyspepsia (NUD)

A

Epigastric burning pain

Normal bloods, normal OGD and normal biliary USS

26
Q

What are the indications for endoscopic investigation of dyspepsia

A 
Urgent (within 2 weeks) endoscopic investigation is indicated if any of the following signs are present:
Persistent vomiting
Chronic GI bleeding
Weight loss
Progressive dysphagia 
Iron deficiency anaemia
Epigastric mass
Suspicious barium meal 
>55 with unexplained and persistent dyspepsia
27
Q

What are the complications of peptic ulcers

A 
Haemorrhage (RF: anticoagulant therapy)
Perforation (RF: NSAIDs)
Penetration (through the bowel wall without leakage)
Scarring -> gastric outlet obstruction 
Malignancy
28
Q

What are the local complications of pancreatitis

A 
Necrosis of the pancreas
Abscess formation
Pseudocyst (fluid in lesser peritoneal sac)
Paralytic ileus 
Duodenal stress ulceration 
Fistula formation to colon 
Obstructive jaundice
29
Q

What are the systemic complications of pancreatitis

A

Sepsis
Shock (third space loss) or haemorrhage
Acute renal failure, secondary to hypoperfusion
Resp. compromise (pleural effusion, RDS etc.)
DIC
Metabolic (hypocalcaemia or hyperglycaemia)
Pancreatic encephalopathy due to cerebral hypoperfusion

30
Q

What is the role of stool elastase in chronic pancreatitis

A

Marker of pancreatic function

Stable in transit through the GI tract (-> direct correlation with elastase in stool and pancreatic fluid)

31
Q

What are Cushing’s and Curling’s ulcers

A

Cushing’s - ulcers after brain injury

Curling’s - ulcers after burns

32
Q

What are the extra-pancreatic causes of raised amylase

A 
Perforated peptic ulcer
Acute appendicitis 
Acute cholecystitis
Ectopic pregnancy 
Pelvic inflammatory disease
Mesenteric ishcaemia
Leaking AAA 
Renal failure (reduced clearance)
DKA
Head injury
33
Q

Where are benign peptic ulcers likely to be located

A

Antrum

Y3 Oxford Cases (29 decks)

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