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Semester 1 ( 3rd Year) > Case 10: Epigastric Pain > Flashcards

Case 10: Epigastric Pain Flashcards

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1
Q

what is visceral pain

A

it is dull and poorly localised

is due to activation of nociceptors in organs (viscera)

stimulated by contraction, tension, stretching or ischaemia

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2
Q

what is somatic pain

A

originating from muscle, bone, joints, tendons, or blood vessels

pain receptors are in tissues and are activated by noxious substance causing inflammation of the parietal peritoneum

stimuli typically is force, temperature, vibration or swelling

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3
Q

what is colic

A

visceral pain caused by contraction/distension (renal, biliary, bowel)

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4
Q

what is a tympanic abdomen

A

distended abdomen (air) like balloon

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5
Q

what is a tender abdomen

A

abdominal pain present in response to touch/pressure

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6
Q

what is a peritonitic abdomen

A

there is inflammation of the peritoneum by a noxious substance

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7
Q

which cells of the stomach secrete hydrochloric acid

A

parietal cells

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8
Q

which cells of the stomach secrete gastrin

A

G cells

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9
Q

which cells of the stomach secrete mucous

A

mucous cells (goblet?)

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10
Q

which cells of the stomach secrete pepsinogen

A

chief cells

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11
Q

what are the functions of the exocrine pancreas

A

elastases break down elastin

chymotrypsin (chymotrypsinogen is inactive form) breaks down protein into amino acids

amylase breaks down starch and glycogen

lipase breaks down triglycerides into fatty acids and monoglycerides

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12
Q

what is the acceptable weekly unit of alcohol

A

less than 14 units

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13
Q

what is Cullens sign

A

periumbilical (below belly button) ecchymosis (redness/brusing) due to retroperitoneal bleed

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14
Q

what is peritonitis

A

inflammation of the peritoneum (can be generalised or localised)

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15
Q

what is peritonism

A

an indirect activation of the entire abdominal musculature due to peritoneal irritation and is called peritonism

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16
Q

what causes guarding

A

peritonism

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17
Q

2 conditions which may cause local peritonism in the upper abdomen (umbilical)

A

acute pancreatitis
acute cholecystitis

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18
Q

what type of peritonitis would a visceral perforation cause

A

generalised

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19
Q

do peptic ulcers cause guarding

A

no as there is no peritonism

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20
Q

what is acute pancreatitis

A

inflammation of the pancreas caused by activation of pancreatic enzymes and auto digestion

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21
Q

what can the consequences of acute pancreatitis be

A

systemic inflammatory response syndrome (SIRS) which can in turn causes organ failure such as:

acute kidney injury (AKI)
respiratory distress syndrome (respiratory failure)

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22
Q

causes of pancreatitis pneumonic

A

Idiopathic

Gallstones
Ethanol
Trauma (penetrating)

Steroids
Mumps
Autoimmune
Scorpion venom
Hyperlipidaemia/hypercalxaemia
ERCP
Drugs

also family history/genetic factors

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23
Q

most common cause of acute pancreatitis

A

gallstones

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24
Q

most common cause of chronic pancreatitis

A

alcohol abuse

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25
how to diagnose acute pancreatitis
abdominal pain (acute, persistent, epigastric pain radiating to the back) serum lipase/amylase over 3 times the upper limit radiological evidence of pancreatitis (MR/CT)
26
which cells of the pancreas release enzymes
acinar cells
27
why are amylase and lipase used for pancreatitis diagnosis
they are pathologically released by acinar cells of the inflamed pancreas lipase is more sensitive
28
how do lipase levels rise during acute pancreatitis
peaks at 24hrs can remain elevated between 8-14 days as it is reabsorbed by the renal tubules back into circulation
29
how do amylase levels rise during acute pancreatitis
rises rapidly within 2hrs of onset of acute pancreatitis peaks between 12-72hrs is then excreted rapidly by the kidneys levels can return to normal as soon as 3 days
30
what is considered mild acute pancreatitis
no organ failure or local/systemic complications
31
what is considered moderate severe acute pancreatitis
transient organ failure (such as AKI) resolving within 48hrs may have local complications (peripancreatic collection)
32
what is considered severe acute pancreatitis
persistent organ failure/ multi-organ failure
33
what are the two main types of acute pancreatitis
interstitial oedematous pancreatitis (90-95%) necrotising pancreatitis (5-10%)
34
what can be the consequences of interstitial oedematous pancreatitis
acute peripancreatic fluid collection (APFC)- occurs within 4 weeks and fluid is extra pancreatic if the above is not resolved within 4 weeks it may organise and become a pseudocyst pseudocyst- this is a homogenous fluid-filled collection with a cyst wall, can compress the surrounding structures such as the stomach
35
what can be the consequences of necrotising pancreatitis
acute necrotic collection (ANC)- occurs within 4 weeks, fluid is intra and/or extra pancreatic, there is a homogenous collection of fluid and solid components and no wall walled off necrosis (WON)- occurs after 4 weeks of onset of pain, is homogenous collection of fluid and solid components/necrotic tissue within a cyst wall
36
what is the name of the criteria for diagnosing acute pancreatitis
Atlanta criteria
37
raised what in the blood may suggest AKI
urea and creatinine
38
what on chest x-ray would suggest visceral perforation
free air under the diaphragm
39
what investigation is done with suspected pancreatitis
ultrasound of the abdomen- gallstones need to be ruled out/in as a cause
40
how to manage acute pancreatitis
analgesia antiemetics (NG tube if vomiting) fluid balance (IV fluid resuscitation and urinary catheter) venous thromboembolism prophylaxis
41
under what circumstances would you 2 week wait someone for endoscopy
dysphagia those over 55 with either weight loss and either abdominal pain, dyspepsia or reflux
42
what lifestyle changes would you recommend with GORD
smoking cessation weight loss avoid precipitating foods- chocolate, citrus, coffee sleeping with head of the bed raised
43
what is GORD
symptomatic back flow of acid and stomach contents into the stomach causing heartburn
44
what can be the pathophysiology of GORD
abnormal transient relaxation of the LOS impaired oesophageal clearance delayed gastric emptying that increases gastric pressure also associated with hiatus hernia
45
GORD risk factors
smoking and alcohol obesity stress hiatus hernia pregnancy trigger foods NSAIDs and beta-blocker use- these reduce the LOS tone
46
what can you offer patients with GORD who do not respond to acid suppression therapy
OGD- oesophago-gastro duodenoscopy also: oesophageal manometry ambulatory 24hr oesophageal pH monitoring
47
surgical options for GORD
nissen fundoplication- laprascopic fundus of the stomach is wrapped around lower oesophagus to reinforce the LOS
48
complications of ongoing GORD
barrets oesophagus- metaplastic changes to lower oesophagus from squamous cells to columnar oesophagitis recurrent chest infections- reflux can go into respiratory system potentially giving rise to aspiration pnuemonia, bronchitis and bronchial asthma chronic cough- acid affects the larynx especially when lying down at night benign stricture- ongoing oesophageal inflammation damages the epithelium causing a stricture, circular band of mucosa can form (Schazki ring) which can cause dysphagia
49
what would indicate surgery for GORD
failure of therapy (efficacy or side effects) desire to discontinue medical therapy hiatus hernia
50
ALARMS red flag symptoms for dyspepsia
Anemia Loss of weight Anorexia Recent onset/progressive symptoms Malena and haematemesis Swallowing difficulties (dysphagia)
51
what is the most likely diagnosis given weight loss and dyspepsia
upper GI malignancy
52
what is the most common type of gastric cancer
adenocarcinoma- when it spreads primarily through the musculature of the stomach wall, the 'thickening' is called linitis plastica- 'leather bottle appearance'
53
other types of gastric cancers
squamous cell carcinoma non-Hodgkin's lymphoma gastrointestinal stromal tumours (GIST) neuroendocrine tumours (NET)
54
risk factors for gastric adenocarcinoma
age (over 75) male H.pylori FAP ethnicity- black, hispanic, asian smoking and alcohol diet obesity (more so in men)
55
investigations for gastric adenocarcinoma
upper GI endoscopy- minimum of 6 biopsies taken staging- CT thorax, abdomen and pelvis MDT discussion staging laparoscopy surgery + chemotherapy if tumour is potentially resectable
56
what potential problems specific to gastric cancer may occur during end of life
nausea vomiting haematemesis- bleeding from the tumour ascites pain
57
what is a perforated viscus
intestinal/bowel perforation enteric contents leak into the peritoneal cavity therefore causing severe abdominal pain
58
which blood tests are useful for perforated viscus
FBC (WCC) lipase CRP urea and creatinine are also useful
59
what is SIRS
systemic inflammatory response syndrome (as a result of sepsis)
60
what would you see on chest xray with visceral perforation
on erect chest xray would see free air under the diaphragm
61
history of what disease could increase risk of gastric/duodenal perforation
peptic ulcer disease
62
what is peptic ulcer disease
a peptic ulcer is a break in the mucosal lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer) distribution extends into submucosa or muscularis propria and is usually more than 5mm in diameter
63
what % of world have peptic ulcer disease
3%
64
risk factors for peptic ulcer disease
h.pylori smoking alcohol NSAIDs- ibuprofen, naproxen
65
symptoms of peptic ulcer disease
epigastric pain that is constant and radiates into the back usually when hungry early satiety reflux symptoms nausea
66
properties of h pylori
patients with infection can be asymptomatic is naturally resistant to stomach acid can be transmitted by oral-oral or faecal-oral route
67
triple therapy for h pylori
PPI + 2 antibiotics PPI= omeprazole, lansoprazole, esomeprazole clarythromycin amoxicillin (metronidazole if penicillin allergy)
68
usual presentation of perforated peptic ulcer disease
rigid abdomen- indicative of generalised peritonitis (secondary to florid bowel contents in peritoneal cavity) sudden onset of epigastric pain before becoming more generalised in nature symptoms of distention and nausea and vomiting
69
what to do if perforation cannot be seen on chest xray
CT
70
treatment and management of perforated peptic ulcer disease
nil by mouth analgesia antibiotics fluid balance (IV fluids and urinary catheter) refer to on-call general surgery team for further management VTE prophylaxis antiemetics (with NG tube if actively vomiting)
71
what surgery is performed for perforated peptic ulcer disease
laparotomy- some omentum is sutured over perforation along with a thorough was out of the peritoneal cavity
72
common post operative complications of laparotomy
lower respiratory tract infections/pneumonia postoperative ileus UTIs DVT ongoing leak from site of perforation

Semester 1 ( 3rd Year) (12 decks)

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