Epigastric pain (oxford clin cases)

Question 1

What does epigastric pain that has spread to involve the whole abdomen suggest?

Answer 1

Peritonitis

Question 2

What does epigastric pain that has spread to involve the chest indicate?

Answer 2

Cardiac pathology eg IHD or ACS (MI etc)

Question 3

Where is biliary pain usually? Where else can it be?

Answer 3

Usually RUQ but can present as purely epigastric pain too

Question 4

What does very sudden onset epigastric pain suggest pathologically?

Answer 4

Perforation eg of a duodenal ulcer or Boerhaave’s

Question 5

How long does pain from acute pancreatitis take to develop to maximal intensity?

Answer 5

10-20 mins

Question 6

How long does pain from biliary colic take to develop to maximal intensity?

Answer 6

10-20 mins

Question 7

How long does pain from acute cholecystitis take to develop to maximal intensity?

Answer 7

Hours

Question 8

How long does pain from pneumonia take to develop to maximal intensity?

Answer 8

Hours

Question 9

What character will cardiac pain have?

Answer 9

Crushing or tightness

Question 10

What character will pain from peptic ulcer be?

Answer 10

Sharp and burning

Question 11

What character will pain from gastritis be?

Answer 11

Sharp and burning

Question 12

What character will pain from duodenitis be?

Answer 12

Sharp or burning

Question 13

What character will pain from pancreatitis be?

Answer 13

Deep and boring

Question 14

Where may epigastric pain from pancreatitis radiate to?

Answer 14

To the back

Question 15

What position will relieve pain from pacreatitis?

Answer 15

Sitting forward

Question 16

How can you differentiate epigastric pain that has a pulmonary cause eg basal pneumonia, pulmonary embolus, pneumothorax, pericarditis?

Answer 16

It will be worse when a patient breathes deeply (pleuritic pain)
It may involve the shoulder tip (diaphragmatic involvement irritates the phrenic nerve)

Question 17

What might a cough associated with epigastric pain suggest?

Answer 17

GORD (stomach acid irritates the vocal chords)

If the cough is acute and the patient is producing sputum it may be basal pneumonia

Question 17

What might a cough associated with epigastric pain suggest?

Answer 17

GORD (stomach acid irritates the vocal chords)

If the cough is acute and the patient is producing sputum it may be basal pneumonia

Question 18

When someone presents with epigastric pain, what may you discover in their family history and what does this suggest?

Answer 18

They may have a family history of cardiac disease and so their pain may be cardiac related

There are also some hereditary factors that may increase someone’s risk of having pancreatitis

Question 19

What will lower lobe consolidation on an erect chest radiograph suggest if a patient presents with epigastric pain?

Answer 19

Basal pneumonia

Question 20

What is the best imaging method for those with abdominal pain?

Answer 20

Ultrasound or CT

Question 21

What imaging modality is not helpful for those with abdominal pain most of the time? In what situations will it actually be helpful?

Answer 21

Abdominal radiograph

Only useful when looking for foreign bodies or to look for bowel dilation

Question 22

What must you always consider a possibility when someone has epigastric pain/ heartburn?

Answer 22

Myocardial infarction

Question 23

What are red flags to refer someone to endoscopy?

Answer 23

Persistent vomitting
Chronic GI bleeding
Weight loss
Progressive dysphagia 
Iron deficiency anaemia
Epigastric mass
Over 55 with persistent recent onset dyspepsia, reflux and GI pain alongside weight loss