- b. A patient presenting with epigastric pain and vomiting.
A 35 years gentle woman presents with epigastric pain and vomiting for 7 days. She gives h/o same pain for several days with pain free interval for last 2 years.
What are the diagnoses striking in your mind?
- Peptic ulcer disease
- Chronic pancreatitis
What key questions would you ask?
Pain-epigastric burning or gnawing pain with anorexia and vomiting, no radiation
but episodic in nature with nocturnal pain relieved by food- peptic ulcer disease.
Recurrent attacks of High epigastric constant pain with radiation to back, relieved by sitting up or stooping forward- Chronic pancreatitis.
Vomiting– Content of vomitus
Vomiting of blood- peptic ulcer disease
Weight loss– gastric ulcer, chronic pancreatitis.
History of diarrhea- chronic pancreatitis
History of NSAIDS- peptic ulcer disease
History of alcohol- chronic pancreatitis
What will you examine?
General examination- may be anaemic, cachectic
Abdominal examination- tenderness in epigastrium on palpation- peptic ulcer disease or chronic pancreatitis.
Erythema ab igni(reticular pattern of hypopigmentation and hyperpigmentation due to application of heat)- chronic pancreatitis.
Clinical diagnosis– Peptic ulcer disease
Investigation-
CBC –Hb may be low.
Anti-H.pylori IgG – presence of H.pylori infection.
USG of abdomen- pancreatic duct dilatation and calculi- chronic pancreatitis.
Plain X-ray abdomen- pancreatic calcification- chronic pancreatitis
Other essential investigations- Endoscopy of upper GI tract-usually not available at primary and secondary level.
Treatment-
- pylori eradication therapy-
Antibiotic regimens for H. pylori eradication
‘First-line therapy is a proton pump inhibitor (12-hourly), clarithromycin 500 mg 12-hourly, and amoxicillin 1 g 12-hourly or metronidazole 400 mg 12-hourly, for 7 days.
Followed by maintenance therapy proton pump inhibitor (12-hourly) for 6-8 weeks.
Symptomatic treatment- antispasmodic tablet or injection for relieve of pain.