12. Epigastric Pain

Question 1

List some differential diagnoses of epigastric pain.

Answer 1

Acute pancreatitis 
Perforated peptic ulcer 
Gastritis/duodenitis
Peptic ulcer disease 
Biliary colic 
Acute cholecystitis 
Ascending cholangitis 
MI
Ruptured AAA
Mesenteric ischaemia 
Basal pneumonia

Question 2

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

Answer 2

There would initially be an intense pain in the epigastrium

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

Question 3

What does sudden-onset pain suggest?

Answer 3

Perforated viscus

MI

Question 4

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

Answer 4

10-20 mins

Question 5

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

Answer 5

A matter of hours

Question 6

Which diseases cause epigastric pain that radiates to the back?

Answer 6

Acute pancreatitis

Leaking AAA

Question 7

What can cause shoulder-tip pain?

Answer 7

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

Question 8

Which diseases cause retrosternal pain?

Answer 8

Oesophagitis

Myocardial ischaemia

Question 9

What can relieve the pain caused by pancreatitis?

Answer 9

Sitting forward

Question 10

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

Answer 10

Gastric Ulcers – pain is worse when eating

Duodenal Ulcers – pain is relieved by eating

Question 11

What does pain triggered by fatty meals suggest?

Answer 11

Biliary colic

Question 12

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

Answer 12

Severe pancreatitis
MI
Perforated peptic ulcer

Question 13

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

Answer 13

Nausea and vomiting 
Fever
Dyspepsia and waterbrash
Changes in stool
Cough

Question 14

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

Answer 14

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

Question 15

Which pathology is associated with causing pale stools?

Answer 15

Obstruction of bile outflow

Question 16

Which diseases cause steatorrhoea?

Answer 16

Long-standing biliary disease

Pancreatic exocrine insufficiency

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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

Question 19

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

Answer 19

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

Question 20

Which two diseases that cause epigastric pain can be caused by drugs?

Answer 20

Peptic Ulcer Disease

Acute Pancreatitis

Question 21

Which drugs are associated with Peptic Ulcer Disease?

Answer 21

NSAIDs
Aspirin
Bisphosphonates
Steroids

Question 22

Which drugs are associated with Acute Pancreatitis?

Answer 22

Sodium valproate
Thiazides
Steroids
Azathioprine

Question 23

List some significant features of the social history.

Answer 23

Alcohol – excess can cause acute pancreatitis

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

Question 24

Describe the appearance of a peritonitic patient.

Answer 24

Patients lie completely still
Taking shallow breaths
Movement is painful

Question 25

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

Answer 25

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

Question 26

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

Answer 26

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

Question 27

List signs of small bowel obstruction.

Answer 27

Abdominal distension Tinkling bowel sounds Absolute constipation

Question 28

What is Murphy’s sign?

Answer 28

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

Question 29

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

Answer 29

AAA – central expansile and pulsatile mass | Check hernia orifices because a strangulated hernia could cause bowel obstruction

Question 30

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

Answer 30

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

Question 31

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

Answer 31

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

Question 32

List some prognostic indicators in pancreatitis.

Answer 32

Neutrophilia Albumin Blood glucose

Question 33

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

Answer 33

Rises within hours | Returns to normal after 3-5 days

Question 34

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

Answer 34

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

Question 35

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

Answer 35

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

Question 36

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

Answer 36

Erect CXR AXR Ultrasound

Question 37

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

Answer 37

Air under the diaphragm (pneumoperitoneum)

Question 38

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

Answer 38

Allows visualisation of AAA | Allows visualisation of gallstone disease

Question 39

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

Answer 39

It does not show whether the AAA is leaking/ruptured | A CT aortogram is required to confirm a leak

Question 40

List the causes of acute pancreatitis.

Answer 40

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

Question 41

What are the two main scoring systems for pancreatitis?

Answer 41

Glasgow | Ranson

Question 42

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

Answer 42

3 and above

Question 43

Outline the management of acute pancreatitis.

Answer 43

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

Question 44

How can you reduce the recurrence of pancreatitis?

Answer 44

Cholecystectomy | Stop drinking alcohol

Question 45

Describe the two main tests for Helicobacter pylori.

Answer 45

Urease Breath Test – pt swallows sample of urea containing radio-labelled carbon. After 10-30 mins, breath tested -> 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 Campylobacter-like Organism (CLO) Test – biopsy from 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

Question 46

Describe the treatment of H. pylori.

Answer 46

Triple therapy – 2 x antibiotics + PPI

Question 47

What is non-ulcer dyspepsia?

Answer 47

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