Epigastric Pain Flashcards by Tyler Rzucidlo

What is the Epigastric Area?

Abdominal surface beneath the xiphoid process and between the 2 sets of ribs above the umbilicus

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What is the most common cause of Epigastric Pain?

Functional (Non-ulcer) Dyspepsia

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What is the most likely diagnosis for epigastric pain that is worse with food?

Gastic Ulcer

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What is the most likely diagnosis for Epigastric pain that is better with food?

Duodenal Ulcer

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What is the most likely diagnosis for Epigastric pain that is associated with weight loss?

Cancer or gastric ulcer

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What is the most likely diagnosis for epigastric pain that is associated with tenderness?

Pancreatitis

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What is the most likely diagnosis for epigastric pain that is associated with Bad taste, cough and hoarseness?

GERD

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What is the most likely diagnosis for epigastric pain that is associated with diabetes and bloating?

Gastroparesis

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What is the diagnostic modality for Epigastric pain?

Endoscopy: only tool that can give a precise diagnosis

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How do you treat epigastric pain?

PPIs first
-H2 blockers less effective
-Liquid antacids = H2 blockers efficacy

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Differential for RUQ pain?

Cholecystitis
Biliary Colic
Cholangitis
Perforated Duodenal Ulcer

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Differential for LUQ pain?

Splenic Rupture
IBS: splenic flexure syndrome

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Differential for RLQ Pain?

Apendicitis
Ovarian Torsion
Ectopic Pregnancy
Cecal Diverticulitis

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Differential for LLQ Pain?

Sigmoid Volvulus
Sigmoid Diverticulitis
Ovarian Torsion
Ectopic Pregnancy

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Differential for Midepigastrium pain?

Pancreatitis
Aortic Dissection
Peptic Ulcer Disease

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What Is GERD?

inappropriate relaxation of the LES causing acidic stomach contents to enter the esophagus

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What are common symptoms of GERD?

Sore throat
Bad taste
Hoarseness
Cough

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What things typically worsen symptoms of GERD?

Nicotine
Alcohol
Caffeine
Chocolate
Peppermint
Late-night meals
Obesity

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What can be used to confirm the diagnosis of GERD?

24-hour pH monitoring

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When is Endoscopy indicated for GERD?

Signs of obstruction: dysphagia or Odynohagia

Weight loss

Anemia or heme-(+) stools

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What is the first line treatment for GERD?

Lifestyle management
-weight loss
-avoid alcohol, nicotine, caffeine, chocolate and mint
-avoid eating within 3 hours of bedtime
-elevate head of bed 6-8 inches

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What treatments can you add for Mild or Intermittent GERD symptoms?

Liquid antacids or H2 blockers

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What treatments can you add for persistent symptoms of erosive esophagitis in GERD?

PPIs: all equally effective

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How do you treat GERD symptoms unresponsive to medical treatment?

Nissen Fundoplication

Endocinch

Local heat or radiation of LES to cause scarring

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What is a Nissen Fundoplication?

Wrapping the stomach around the LES

What is an Endocinch?

Using a scope to place a suture around the LES to tighten it

What is Barrett Esophagus?

Histologic changes in the lower esophagus with columnar metaplasia as a result of long-standing GERD

How long does reflux need to be present to cause Barret Esophagus?

5 years

What is the only way to diagnose Barrett Esophagus?

Biopsy

What form of Barrett Esophagus has the greatest risk of transformation into Esophageal Cancer?

Columnar Metaplasia with Intestinal Features

If you have Barrett alone (metaplasia) how do you manage it?

PPIs and rescope every 3-5 years

If you have low-grade Dysplasia In barrett esophagus how do you manage it?

PPIs and rescope every 6-12 months

If you have high-grade dysplasia in Barrett esophagus how do you manage it

Endoscopic ablation Photodynamic Therapy Radiofrequency Ablation Endoscopic Mucosal Resection

What is Gastritis?

"Gastropathy": Inflammation or erosion of the gastric lining

What are common causes of Gastritis?

Alcohol NSAIDs Helicobacter Pylori Portal Hypertension Stress: Burns, Trauma, Sepsis, Multiorgan failure (uremia)

What is atrophic gastritis associated with?

Vitamin B12 deficiency

How does Gastritis typically present?

GI bleed without pain -if severe can have epigastric pain

What is a clinical clue for Gastritis?

Hx of NSAIDs of alcoholism

How can GI bleeding appear in Gastritis?

Mild "Coffee-ground" emesis to a large volume vomit of red blood, to black stool (Melena)

If you have a patient with epigastric pain, no alarm symptoms and age <60 what is your best first step in management?

PPI

If you have a patient with epigastric pain, no alarm symptoms and age <60 that does not improve with PPI use what is your next best step?

Scope

If you have a patient with epigastric pain and no alarm symptoms aged >60 what is your best first step?

Scope

If you scope a patient for epigastric pain and the scope is (-) what is your most likely diagnosis?

Functional (Non-Ulcer) Dyspepsia

If you have a positive scope for epigastric pain what is your top 3 differential?

Duodenal Ulcer Gastric Ulcer Gastritis

If you have a Positive scope for epigastric pain, what condition do you repeat the biopsy for?

Gastric Ulcer

If you Have a positive scope and treat for H. Pylori and a test of cure shows persistent H. Pylori what is your next best step?

Change Antibiotics to Metronidazole and Tetracycline

What is the only method to diagnose erosive gastritis?

Endoscopy

What is the most accurate test for H. Pylori?

Endoscopic Biopsy: however it is invasive

What is good about using Serology to test for H. Pylori?

Inexpensive and it easily excludes infection if (-)

What is good about using Urea C13 or C14 breath testing to diagnose H. Pylori?

Positive only in active infection: 95% Sensitive and specific

What is good about using H. Pylori Stool Ag to test for H. Pylori?

Positive only in active infection: 95% sensitive and specific

How do you treat gastritis?

PPI -H2 blocker, sucralfate and Liquid antacids are not as effective

What is Peptic Ulcer Disease (PUD)?

Includes Duodenal Ulcer (DU) disease and Gastric Ulcer (GU) Disease

What is the most common cause of Peptic Ulcer Disease (PUD)?

H. Pylori

What is the 2nd most common cause of Peptic Ulcer Disease (PUD)?

NSAIDs

How do NSAIDS lead to Peptic Ulcer Disease (PUD)?

Inhibit prostaglandins which normally produce protective mucous layer Produce more bleeding than pain

What are less common caused of PUD?

Burns Head Trauma Crohn Disease Gastric Cancer Gastrinoma (Zollinger-Ellison)

How does PUD typically present?

Recurrent episodes of Epigastric pain that are dull, sore and gnawing

What is the most accurate test for PUD?

Upper endoscopy to distinguish DU from GU

What is the most accurate test for H. Pylori?

Biopsy

How do you treat PUD?

PPIs: will recur unless H. Pylori is eradicated if present -DU associated with H. Pylori >80-90% -GU associated with H. Pylori 50-70%

What is the triple therapy for H. Pylori?

PPI + 2 abx (usually Clarithromycin and amoxicllin)

What are alternative antibiotic options for H. Pylori?

Metronidazole and tetracycline Lefofloxacin

What is standard triple therapy for H. Pylori?

PPI + Clarithromycin + Amoxicillin

What is Triple therapy for H. Pylori in a patient with allergy to Penicillin?

PPI + Clarithromycin + Metronidazole

When you change Abx for H. Pylori what can you add to form Quadruple therapy?

Bismuth

What conditions are stress ulcer prophylaxis indicated for?

Head trauma Burns Intubated patient Sepsis with Coagulopathy

What is Functional (Non-ulcer) Dyspepsia?

epigastric pain with no identified etiology

How do you diagnose Functional (Non-Ulcer) Dyspepsia?

Endoscopy that is negative

How does Gastrinoma (Zollinger-Ellison Syndrome) typically present?

Large >1-2cm, recurrent distal ulcers in the duodenum after H. Pylori eradication

What are your lab testing options to confirm the diagnosis of Gastrinoma?

High gastrin off antisecretory therapy (PPI or H2 blockers) High gastrin despite a high gastric acid output Persistent high gastrin despite injecting secretin

What is Gastrinoma often associated with?

Diarrhea because acid inactivated Lipase

After the diagnosis of Gastrinoma is confirmed what must you do?

Imaging to exclude metastatic disease -Abd CT/MRI first: poor sensitivity -Somatostatin-R Scintagraphy with Endoscopic US to r/o

What is the most accurate test to confirm Gastrinoma?

Functional test: response to secretin

How is Gastrinoma treated?

Local disease: removed surgically Metastatic Disease: unresectable: treated with Lifelong PPI to block acid production

What is Gastroparesis?

Autonomic Neuropathy leading to dysmotility due to inability to sense stretch in the GI tract

What is the best initial test for Gastroparesis?

Upper endoscopy or Abd CT to exclude a luminal gastric mass or abdominal mass compressing the stomach

What is the most accurate test for Gastroparesis?

Bolus of food tagged with technetium that shows a delay in emptying of food

How do you treat Gastroparesis?

Start with dietary modifications Metoclopramide 2nd 3rd: Erythromycin and antiemetics 4th: Gastric electrical stimulation (Gastric pacemaker)

What are the adverse effects of Metoclopramide?

Tardive dyskinesia Dystonia Long QT Hyperprolactinemia

Epigastric Pain Flashcards

(80 cards)