Epigastric Abdominal Pain

Question 1

What is meant by the term ‘distended abdomen’?

Answer 1

The abdomen is greater in size than normal (may need to ask patient about this!).

Question 2

What is meant by the term ‘tympanic abdomen’?

Answer 2

The abdomen is distended due to air (like a balloon).

Question 3

What is meant by the term ‘tender abdomen’?

Answer 3

Abdominal pain is present in response to touch/pressure.

Question 4

What is meant by the term ‘soft abdomen’?

Answer 4

There is no peritonism, even though pain might be present.

Question 5

What is meant by the term ‘peritonitic’?

Answer 5

Inflammation of the peritoneum by a noxious substance.

Question 6

What is meant by the term ‘rebound tenderness’?

Answer 6

Pain when releasing pressure from palpation (a sign of peritonism).

Question 7

What is ‘guarding’?

Answer 7

Involuntary tensing of the abdominal wall muscle on palpation (a sign of local peritonism if in one quadrant only).

Question 8

What is meant by the term ‘rigid abdomen’?

Answer 8

Involuntary guarding in all four quadrants (a sign of general peritonitis).

Question 9

Which type of cell in the stomach secretes hydrochloric acid?

Answer 9

Parietal cells

Question 10

What is the role of G cells in the stomach?

Answer 10

They secrete the hormone gastrin.

Question 11

What type of cells in the stomach produce pepsinogen?

Answer 11

Chief cells

Question 12

What abdominal structures arise from the embryological midgut?

Answer 12

Organs from the duodenum (distal to entrance of common bile duct) to junction of proximal 2/3 of transverse colon with distal 1/3.

Question 13

Where is pain from abdominal structures of each embryological origin felt? (3)

Answer 13

Foregut - epigastrium (initially - can localise later on)
Midgut - umbilical region
Hindgut - hypogastric (suprapubic) region

Question 14

What abdominal structures arise from the embryological foregut? (6)

Answer 14

Oesophagus, stomach, pancreas, liver, gallbladder, and duodenum (proximal to entrance of common bile duct).

Question 15

What abdominal structures arise from the embryological hindgut?

Answer 15

Distal 1/3 of transverse colon to upper part of anal canal.

Question 16

What is the limit for acceptable weekly alcohol consumption for a man?

Answer 16

Less than 14 units per week.

Question 17

What is Grey-Turner’s sign?

Answer 17

Ecchymosis (bruising) in either flank.

Question 18

What is Cullen’s sign?

Answer 18

Visible periumbilical ecchymosis (bruising)

Question 19

What are ‘caput medusae’?

Answer 19

Periumbilical varices that branch out from the umbilicus, that occur with portal hypertension from liver cirrhosis.

Question 20

What is Murphy’s sign?

Answer 20

Pain in the Right Upper Quadrant from local peritonism due to acute cholecystitis.

Question 21

What is Rovsing’s sign?

Answer 21

Pain felt in the right iliac fossa during palpation of the left iliac fossa, due to local peritonism from acute appendicitis.

Question 22

What abdominal signs are indicative of internal haemorrhage?

Answer 22

Cullen’s Sign and Grey-Turner’s Sign

Question 23

What causes of internal haemorrhage can cause abdominal signs? (3)

Answer 23

Acute pancreatitis, splenic rupture or perforated peptic ulcer disease.

Question 24

Why do peptic ulcers not cause guarding?

Answer 24

There is no peritonism.

Question 25

What is involved in a Nissen fundoplication?

Answer 25

A laparoscopic surgery offered to control symptoms of GORD, where the fundus of the stomach is wrapped around the lower oesophagus to reinforce the lower oesophageal sphincter.

Question 26

What are the indications for surgery for gastroesophageal reflux disease (GORD)? (3)

Answer 26

Failure of medical therapy (either through efficacy or side effects) Desire to discontinue medical therapy Presence of a hiatus hernia

Question 27

What red flag symptoms do you need to ask about in a patient with dyspepsia? (6)

Answer 27

Anaemia (lethargy, breathlessness) Loss of weight Anorexia Recent onset/progressive symptoms Malaena and haematemesis Swallowing difficulty (dysphagia) [ALARMS]

Question 28

What are the NICE criteria for a direct access upper GI endoscopy for suspected cancer? (2)

Answer 28

Individual with dysphagia OR age > 55 with weight loss and any of the following: upper abdominal pain, reflux, or dyspepsia.

Question 29

What is the most common histological type of gastric cancer?

Answer 29

Adenocarcinoma

Question 30

What is linitis plastica?

Answer 30

A rare type of gastric adenocarcinoma where there is ‘thickening’ of the stomach wall, seen when adenocarcinoma spreads primarily through the musculature of the stomach wall.

Question 31

What does the TNM staging system mean in the context of gastric adenocarcinoma?

Answer 31

T - how far the tumour has grown into the stomach wall N - degree of lymph node spread M - presence of metastases

Question 32

What are the appropriate investigations required for gastric adenocarcinoma? (5)

Answer 32

-Upper GI endoscopy -Minimum of 6 biopsies taken during the endoscopy -Initial staging CT thorax, abdomen and pelvis -Discussion at local upper GI cancer MDT -If tumour is potentially resectable, a staging laparoscopy is performed, and perioperative chemotherapy is given.

Question 33

What is a peptic ulcer?

Answer 33

A break in the mucosal lining of the stomach (gastric ulcer) or duodenum (duodenal ulcer) - this disruption extends into the submucosa or muscularis propria and is usually more than 5mm in diameter.

Question 34

What tests can confirm successful H. pylori eradication? (3)

Answer 34

Urea breath test, faecal antigen testing, and endoscopy (rapid urease test, histology and culture)

Question 35

What is involved in triple therapy for treatment of H. pylori infection?

Answer 35

Treatment with a PPI and two different antibacterials.

Question 36

What signs and symptoms may a patient with peptic ulcer perforation present with? (5)

Answer 36

-Rigid abdomen (indicative of generalised peritonitis secondary to florid bowel contents in the peritoneal cavity) -Sudden onset of epigastric pain (before becoming more generalised in nature) -Distention -Nausea -Vomiting.

Question 37

What investigations are diagnostic for gastric perforation? (2)

Answer 37

Erect chest x-ray (will show air under diaphragm indicative of perforation in around 60% of patients) If clinical features of perforation but normal CXR, CT scan required to confirm diagnosis (98% sensitive)

Question 38

What is the standard management for a perforated gastric ulcer? (4)

Answer 38

-Laparotomy to repair perforation (usually by patching omentum over perforation) -Washout of enteric contents from peritoneal cavity -H. pylori eradication therapy -Investigation for more sinister causes of perforation (such as cancer)

Question 39

What is the main cause of a distended abdomen following surgery?

Answer 39

A postoperative ileus - a functional bowel obstruction resulting from any noxious insult to the bowel; usually resolves within a week.