Abdominal Pain Epigastric 27

Perforated peptic ulcer disease

Untreated, a peptic ulcer may progress to perforation resulting in
initially localised peritonitis, subsequently becoming generalised if
the condition is not treated. Typically a patient has symptoms asso-
ciated with gastritis (see above) but subsequent perforation results
in a sudden increase in upper abdominal pain that may radiate
through to the back. Nausea is fairly common as are ndings of
tachycardia, dehydration and low grade pyrexia. On examination,
there is signicant epigastric tenderness with signs of either loca-
lised or generalised peritonism (guarding, rigidity, rebound and
percussion tenderness). Bowel sounds are often absent reecting an
ileus that often ensues.
Pancreatitis
Acute pancreatitis is characterised by severe epigastric pain typi-
cally radiating through to the back. It is often associated with nausea
and vomiting. There are many causes of pancreatitis (see Box 7.1),
but the vast majority of cases in the UK are due to gallstones and
alcohol. The patient with mild pancreatitis may have very few signs
or may have shock, pyrexia, generalised abdominal tenderness and
guarding with abdominal wall discolouration (peri-umbilical
Cullens sign, anks Grey Turners sign) with severe necrotising
pancreatitis. Diagnosis is conrmed either biochemically (serum
amylase greater than four times the upper limit of the laboratory
reference range), or radiologically. Investigations include ultra-
sound, contrast-enhanced CT and MRI, and are used to establish
the cause and assess the severity and complications.
Musculoskeletal
A pain of musculoskeletal origin should be suspected if the patient
gives a history of trauma or unaccustomed exertion prior to the
development of pain. In the event of a signicant mechanism of
injury, damage to internal solid organs (particularly blunt trauma),
or damage to the viscera (particularly with rapid deceleration forces),
should always be considered and actively ruled out. A diagnosis of
musculoskeletal pain would only be made with an appropriate his-
tory coupled with the absence of any other abnormalities (i.e. normal
temperature, blood pressure and pulse rate backed up by normal
biochemical, haematological and radiological investigations).
Myocardial infarction
This would typically present with severe chest pain that often occurs
at rest associated with nausea, vomiting, sweating and breath-
lessness, and may radiate to the neck or arms. However, atypical
presentations of myocardial infarction are well recognised and
the pain may be experienced exclusively in the epigastrium.
Consequently, ischaemic heart disease should always be considered
in the differential diagnosis of any at risk patient presenting with
epigastric pain (see Figure 7.2).
Other causes of epigastric abdominal pain not
suggested by the history
Leaking abdominal aortic aneurysm (AAA)
An aneurysm is a focal dilatation of an artery to more than 50% of
that of the normal adjacent vessel. The prevalence of AAA is esti-
mated to be 78% of men aged 65 years and older and is therefore
unlikely in a man aged 44.
A ruptured aneurysm should always be considered in a patient
with sudden onset severe abdominal pain radiating to the back,
associated with circulatory collapse. Rupture into the retroperi-
toneal space is initially contained by the resultant hypotension
and tamponading effect of bleeding into a xed space. This situ-
ation must be rapidly diagnosed to provide an opportunity for
emergency life-saving vascular intervention. Free intraperito-
neal rupture or subsequent rupture of a retroperitoneal bleed is
invariably fatal.
Figure 7.2 Infero-lateral myocardial infarction.
Box 7.1 Causes of acute pancreatitis
G Gallstones
E Ethanol
T Trauma
S Steroids
M Mumps
A Autoimmune (e.g. polyarteritis nodosa)
S Scorpion bites
H Hyperlipidaemia, hypercalcaemia, hypothermia
E ERCP (endoscopic retrograde cholangiopancreatography)
D Drugs (e.g. azathioprine, mercaptopurine)
28 ABC of Emergency Differential Diagnosis
Case history revisited
This patients history is quite non-specic and a number of diag-
noses are quite plausible. A musculoskeletal cause for the pain
whilst possible would be unlikely given his relative inactivity at the
time of deterioration. He does have a number of risk factors for
cardiovascular diseases (male gender, increasing age, hypertension,
ex-smoker) and gastrointestinal diseases (alcohol intake, aspirin,
NSAIDs and stress from recent unemployment).
Examination
In order to determine the diagnosis in this patient a thorough phys-
ical examination and further investigations are required.
On examination, he is apyrexial with a blood pressure of
140/80 mmHg and is tachycardic at 110 beats/min. His respiratory
rate is 22 breaths/minute and his oxygen saturation is 97% on air.
He is still complaining of pain in his abdomen.
Examination of his cardiorespiratory system is unremarkable
other than the tachycardia and tachypnoea.
Examination of his abdomen demonstrates marked epigastric
tenderness with generalised rigidity, guarding and rebound tender-
ness. His bowel sounds are absent. No masses were felt.
An ECG revealed sinus tachycardia but was otherwise normal.
His blood test results are seen in Box 7.3. His chest X-ray is seen in
Figure 7.4.
Question: Given the history, examination
ndings and investigations what is your
principal working diagnosis?
Principal working diagnosis perforated
peptic ulcer
The clinical ndings are those of peritonitis.
His history contains several risk factors for peptic ulcer disease:
NSAID usage, alcohol usage and stress. His symptoms have per-
sisted for some time and with the sudden onset of worsening pain,
his rigid abdomen and free air under the diaphragm all suggest per-
foration of an underlying peptic ulcer.
Management
He requires rehydration with intravenous uids to restore his
circulatory volume. A combination of vomiting and sequestration
of uid within the gastrointestinal tract (third space loss) almost
always results in dehydration at presentation that needs correct-
ing prior to surgical intervention. He requires a urinary catheter
to ensure good urine output and to conrm he is adequately uid
resuscitated. In addition, he should be given broad spectrum
intravenous antibiotics (cefuroxime and metronidazole). The
surgical team should review him and consideration given to
an urgent laparotomy. This man was resuscitated and taken to
theatre, where he underwent emergency surgery. This conrmed
Box 7.2 Uncommon causes of upper abdominal pain
Pulmonary embolism
Basal pneumonia (see Figure 7.3)
Ischaemic bowel
Dissecting aortic aneurysm
Addisons disease
Hypercalcaemia
Renal colic
Figure 7.3 Right basal pneumonia.
Box 7.3 Blood test results
FBC Hb 14.6, WCC 15.0, Plt 315
U+Es Na
+
141, K
+
3.9, Urea 8.0, Creatinine 122
LFTs Normal
Amylase 170 (ref. range 70140)
Glucose 6.2
Calcium (corrected) 2.46
Cardiac markers (performed at 12 h) normal
Figure 7.4 Erect chest X-ray.
Other uncommon causes are contained in Box 7.2
Abdominal Pain Epigastric 29
a perforated pre-pyloric gastric ulcer. He underwent thorough
peritoneal lavage and oversewing of his ulcer.
Outcome
Post-operatively he made an uneventful recovery and was treated
with a proton pump inhibitor. A course of H. pylori eradication
therapy was undertaken as he was found to have a positive serology.
Upon discharge he underwent a check endoscopy to conrm both
healing of the ulcer and successful eradication of H. pylori.
Further reading
Knot A, Polmear A. Practical General Practice: Guidelines for Effective
Clinical Management, Fourth Edition. Butterworth-Heinemann,
Oxford, 2004.
Simon C, Everitt H, Kendrick T. Oxford Handbook of General Practice, Second
Edition. Oxford University Press, Oxford, 2002.
Tintinalli J, Kelen G, Stapczynski S, et al. Emergency Medicine: A Comprehensive
Study Guide. Sixth Edition. McGraw-Hill, New York, 2003.
Wyatt JP, Illingworth R, Graham C, et al. Oxford Handbook of Emergency
Medicine, Third Edition. Oxford University Press, Oxford, 2006.