Epigastric Pain Flashcards Preview

Oxford Clinical Cases > Epigastric Pain > Flashcards

Flashcards in Epigastric Pain Deck (45):
1

List some differential diagnoses of epigastric pain.

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

2

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

3

What does sudden-onset pain suggest?

Perforated viscus
MI

4

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

10-20 mins

5

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

A matter of hours

6

Which diseases cause epigastric pain that radiates to the back?

Acute pancreatitis
Leaking AAA

7

What can cause shoulder-tip pain?

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

8

Which diseases cause retrosternal pain?

Oesophagitis
Myocardial ischaemia

9

What can relieve the pain caused by pancreatitis?

Sitting forward

10

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

11

What does pain triggered by fatty meals suggest?

Biliary colic

12

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

Severe pancreatitis
MI
Perforated peptic ulcer

13

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

Nausea and vomiting
Fever
Dyspepsia and waterbrash
Changes in stool
Cough

14

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

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

15

Which pathology is associated with causing pale stools?

Obstruction of bile outflow

16

Which diseases cause steatorrhoea?

Long-standing biliary disease
Pancreatic exocrine insufficiency

17

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

18

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

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

19

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

20

Which two diseases that cause epigastric pain can be caused by drugs? Which drugs are associated with each of these diseases?

- Peptic ulcer disease
NSAIDs
Aspirin
Bisphosphonates
Steroids
- Acute pancreatitis
Sodium valproate
Thiazides
Steroids
Azathioprine

21

List some significant features of the social history.

Alcohol – excess can cause acute pancreatitis
Smoking – associated with peptic ulcer disease, MI and mesenteric ischaemia

22

Describe the appearance of a peritonitic patient.

Patients lie completely still
Taking shallow breaths
Movement is painful

23

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

24

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

25

List signs of small bowel obstruction.

Abdominal distension
Tinkling bowel sounds
Absolute constipation

26

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

27

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

28

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

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

29

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

30

List some prognostic indicators in pancreatitis.

Neutrophilia
Albumin
Blood glucose

31

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

32

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)

33

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

34

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

Erect CXR
AXR
Ultrasound

35

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

Air under the diaphragm (pneumoperitoneum)

36

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

Allows visualisation of AAA
Allows visualisation of gallstone disease

37

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

38

List the causes of acute pancreatitis.

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

39

What are the two main scoring systems for pancreatitis?

Glasgow
Ranson

40

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

3 and above

41

Outline the management of acute pancreatitis.

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

42

How can you reduce the recurrence of pancreatitis?

Cholecystectomy
Stop drinking alcohol

43

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

44

Describe the treatment of H. pylori.

Triple therapy – 2 x antibiotics + PPI

45

What is non-ulcer dyspepsia?

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