Flashcards in Epigastric Pain Deck (45):
List some differential diagnoses of epigastric pain.
Perforated peptic ulcer
Peptic ulcer disease
Describe the pattern of pain that would be caused by a perforated peptic ulcer.
There would initially be an intense pain in the epigastrium
This would spread across the whole abdomen as the patient becomes peritonitic
What does sudden-onset pain suggest?
How long does pain from acute pancreatitis or biliary colic take to reach maximum intensity?
How long do inflammatory processes such as pneumonia and cholecystitis take to reach their peak in terms of pain?
A matter of hours
Which diseases cause epigastric pain that radiates to the back?
What can cause shoulder-tip pain?
Diaphragmatic irritation (e.g. by basal pneumonia, subphrenic abscess)
Which diseases cause retrosternal pain?
What can relieve the pain caused by pancreatitis?
Describe how gastric ulcers and duodenal ulcers can be differentiated based on when the pain is worst.
Gastric Ulcers – pain is worse when eating
Duodenal Ulcers – pain is relieved by eating
What does pain triggered by fatty meals suggest?
Which of the causes of epigastric pain cause particularly severe pain?
Perforated peptic ulcer
List some important associated symptoms that should be enquired about when taking a history.
Nausea and vomiting
Dyspepsia and waterbrash
Changes in stool
List some diseases that cause epigastric pain and nausea and vomiting.
Small bowel obstruction
Boerhaave’s perforation (vomiting precedes the epigastric pain)
Which pathology is associated with causing pale stools?
Obstruction of bile outflow
Which diseases cause steatorrhoea?
Long-standing biliary disease
Pancreatic exocrine insufficiency
Why is it important to ask a patient with epigastric pain whether they’ve had a cough?
Basal pneumonia can cause epigastric pain and it will also cause an acute, productive cough
List the four main diseases in the past medical history that are important to ask a patient with epigastric pain about.
Peptid ulcer disease
Biliary disease (e.g. gallstones)
Why is it important to ask about previous vascular disease and cardiovascular risk factors?
A history of vascular disease increases the risk of mesenteric ischaemia and myocardial infarction
Which two diseases that cause epigastric pain can be caused by drugs? Which drugs are associated with each of these diseases?
- Peptic ulcer disease
- Acute pancreatitis
List some significant features of the social history.
Alcohol – excess can cause acute pancreatitis
Smoking – associated with peptic ulcer disease, MI and mesenteric ischaemia
Describe the appearance of a peritonitic patient.
Patients lie completely still
Taking shallow breaths
Movement is painful
How can acute pancreatitis lead to jaundice in the absence of gallstones?
Oedema of the head of an inflamed pancreas can obstruct the common bile duct
Describe Grey-Turner’s and Cullen’s Signs. What are they signs of?
They are signs of severe pancreatitis
Cullen’s Sign – bruising/discolouration around the umbilicus
Grey-Turner’s Sign – bruising/discolouration on the flanks
List signs of small bowel obstruction.
Tinkling bowel sounds
What is Murphy’s sign?
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
Which masses might you palpate for in the abdomen of a patient with epigastric pain?
AAA – central expansile and pulsatile mass
Check hernia orifices because a strangulated hernia could cause bowel obstruction
List some important blood tests that you would perform in a patient with epigastric pain.
FBC – check for raised WCC, anaemia, neutrophilia
Pancreatic Amylase and Lipase
Describe different patterns of derangement of liver enzymes and state what they indicate.
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
List some prognostic indicators in pancreatitis.
Describe the time taken for serum amylase to rise and fall in a case of pancreatitis.
Rises within hours
Returns to normal after 3-5 days
Why is it important to measure serum calcium in a patient with pancreatitis?
Hypercalcaemia – can cause pancreatiits
Hypocalcaemia – can result from severe pancreatitis (a process called saponification occurs where calcium binds to digested lipids)
Why is it important to perform a VBG in a patient with epigastric pain?
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
Which forms of imaging are useful in patients with epigastric pain?
Which sign on erect CXR suggests that there has been a GI perforation?
Air under the diaphragm (pneumoperitoneum)
Why might ultrasound be useful in investigating a patient with epigastric pain?
Allows visualisation of AAA
Allows visualisation of gallstone disease
What is the downfall with the use of ultrasound to investigate AAAs?
It does not show whether the AAA is leaking/ruptured
A CT aortogram is required to confirm a leak
List the causes of acute pancreatitis.
Drugs (e.g. sodium valproate, thiazides)
What are the two main scoring systems for pancreatitis?
With regards to the Glasgow scoring system, what score is considered severe pancreatitis?
3 and above
Outline the management of acute pancreatitis.
Assess ABC (NOTE: pancreatitis can cause ARDS)
How can you reduce the recurrence of pancreatitis?
Stop drinking alcohol
Describe the two main tests for Helicobacter pylori.
1) Urease Breath Test – the patient is asked to swallow a sample of urea containing radio-labelled carbon. After 10-30 mins, the patients breath is tested and 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
2) Campylobacter-like Organism (CLO) Test – a biopsy is taking from the 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
Describe the treatment of H. pylori.
Triple therapy – 2 x antibiotics + PPI