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Probability diagnosis

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GORD/gastritis

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Gastric ulcer

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Duodenal ulcer/duodenitis

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Non-ulcer heartburn

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Gallstones/biliary colic

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Abdominal muscular strain

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Irritable upper GIT

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Serious disorders not to be missed

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Vascular:

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  • Acute coronary syndromes esp. AMI

  • Ruptured abdominal aortic aneurysm (AAA)

  • Mesenteric artery ischaemia

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Infection:

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  • Cholecystitis

  • Hepatitis

  • Lower lobe pneumonia

  • Ascending cholangitis

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Cancer/tumour:

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  • Cancer of stomach or pancreas

  • Metastatic cancer

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Other:

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  • Pancreatitis

  • Perforated ulcer/viscus

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Pitfalls (often missed)

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Oesophageal spasm

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Biliary motility disorder

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Aerophagy

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Rarities:

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  • Porphyria

  • Addison disease

  • Sickle cell disease

  • Epigastric hernia

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Masquerades checklist

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Depression

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Drugs e.g. NSAIDs, antibiotics, bisphosphonates, alcohol

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Spinal dysfunction—referred

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Is the patient trying to tell me something?

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A consideration if nil findings.

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Key history

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Clarify the exact nature of the presenting complaint: the nature of the pain/discomfort, indigestion or heartburn. Analyse any pain according to the SOCRATES formulation. Include associated general symptoms such as weight loss, fever or vomiting. Examine past medical history incl. peptic ulcer, diabetes, hypertension and cerebrovascular disease, as well as drug history, esp. alcohol and NSAID use.

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Key examination

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  • General features: appearance of patient and vital signs

  • Abdominal examination, particularly inspection, palpation and auscultation

  • Palpate for nodes in the neck (ca. stomach)

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Key investigations

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Nil for most cases.

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First line:

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  • urinalysis

  • FBE

  • ESR/CRP

  • Helicobacter pylori test

  • upper GIT endoscopy

  • ultrasound (?gallstones)

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Consider:

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  • cardiac enzymes

  • s lipase/amylase

  • ECG

  • CXR

  • oesophageal manometry

  • other imaging if indicated e.g. CT or MRI esp. if epigastric mass

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Diagnostic tips

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Epigastric pain aggravated by any food and relieved by antacids indicates chronic gastric ulcer. Pain before meals relieved by food indicates chronic duodenal ulcer.

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Epigastric pain waking the person soon after falling asleep (e.g. 3am) indicates gastric ulcer or biliary colic. Pain can be referred from disorders of the heart, lungs, pancreas, biliary tract and spine.

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