Severe epigastric pain radiating to the back and elevated lipase levels are indicative of pancreatitis. Usually in the Emergency department amylase levels are taken to show pancreatitis however raised lipase levels are more specific for pancreatitis. The most common risk factors for pancreatitis are the presents of gallstones and alcohol consumption. Once pancreatitis is suspected patients should be referred to surgical teams and intravenous fluids, oxygen, intravenous analgesics and antibiotics should be initiated where appropriate.

Gastric and duodenal ulcers present with epigastric pain but not elevated lipase levels.

GERD presents with heartburn and regurgitation.

Cholecystitis presents with right upper quadrant pain and fever.

More information:

Scenario: Diagnosis | Management | Pancreatitis | CKS | NICE 

• Recurrent abdominal pain (≥1 day per week for 3 months)
• Related to defecation
• Associated with change in stool frequency or form
• No structural or inflammatory cause

• Normal FBC & CRP rule out active inflammation (IBD, infection)
• Negative coeliac serology rules out coeliac disease
• Normal faecal calprotectin (<50 µg/g) excludes IBD

• Lifestyle: Regular meals, reduced caffeine, FODMAP diet trial

• Antispasmodics (e.g., mebeverine) for cramping
• Loperamide for diarrhoea-predominant IBS
• Fibre supplements (e.g., ispaghula husk) for constipation
• SSRIs or TCAs if stress-related

Severe right upper quadrant pain, fever, and jaundice constitute Charcot's triad, indicative of ascending cholangitis. This is most commonly caused by the presence of gallstones causing obstruction of the bile ducts resulting in a bacterial infection. ERCP is the gold standard diagnostic imaging for ascending cholangitis, this can also be used for therapeutic drainage. Management includes fluid resuscitating and broad-spectrum antibiotics.

Acute pancreatitis presents with epigastric pain radiating to the back.

Cholecystitis presents with right upper quadrant pain and fever but not jaundice. Hepatitis presents with jaundice but not typically with severe pain and fever.

Peptic ulcer disease presents with epigastric pain but not fever or jaundice.

More information:

Patient info - Ascending cholangitis

1A - Constipation.

Constipation is a difficulty passing stool. This can be with pain, discomfort, distension, bloating or excessive straining. It can also be passing infrequent stool - typically less than three times per week. However, it is important to remember every patient is different so it is often just classified as a passage of stool less frequently compared to their usual bowel habits. In the elderly this can lead to confusion, nausea, overflow diarrhoea and urinary retention. Diverticular disease is also common in this age group and can sometimes be a cause of constipation. However this pain typically presents in the left iliac fossa. This may be the underlying cause of this patient's symptoms but this question is focusing on your ability to recognise constipation as it is a very common problem for all age groups. Exam questions often put more than one possible correct answer in the options and it is up to you to recognise the most likely correct option. Diverticulitis occurs when an outpouching caused by diverticular disease becomes inflamed or infected. This often presents with more severe pain and the patient could have other systemic symptoms like a high temperature. Bowel Cancer is not the most likely differential but a change in bowel habits for people over the age of 60 is a red flag and should be investigated. Ileus is where the bowel fails to operate normally and it is often associated with recent surgery.

More information:

https://cks.nice.org.uk/topics/constipation/diagnosis/diagnosis/

• Oesophageal stricture – Typically caused by chronic GERD, strictures cause progressive dysphagia, but they do not affect liquids early. They also usually lack weight loss
• Oesophageal cancer – While oesophageal cancer also causes progressive dysphagia and weight loss, it usually begins with solids before progressing to liquids. In contrast, achalasia affects both early on. Endoscopy would help differentiate the two.
• GERD can cause dysphagia due to oesophagitis, but it typically presents with heartburn and regurgitation, without progressive worsening
• Zenker’s diverticulum – This condition involves pharyngeal pouch formation, leading to halitosis, regurgitation, and a sensation of food sticking in the throat, rather than true oesophageal dysphagia.

• Ulcerative colitis – Typically presents with bloody diarrhoea and left-sided abdominal pain. Unlike Crohn’s, it involves continuous inflammation from the rectum upwards and does not cause skip lesions.
• Irritable bowel syndrome (IBS) – IBS can cause diarrhoea and abdominal pain, but it does not cause weight loss, rectal bleeding, or systemic inflammation (raised CRP).
• Coeliac disease – This can present with diarrhoea and weight loss, but it does not cause bloody stools or inflammatory markers. Small bowel biopsy would confirm villous atrophy.
• Diverticulitis – Typically presents in older adults with left lower quadrant pain, fever, and raised inflammatory markers, but it does not cause chronic diarrhoea or weight loss.

This patient is classically presenting with acute cholecystitis with fever and RUQ pain. Risk factors for acute cholecystitis are the four “F’s”: female, fat, forty and fertile. This patient is also experiencing referred pain to her right shoulder and has a positive Murphy's sign - other classical signs of acute cholecystitis. A positive Murphy's sign is pain when palpating the right subcostal area during held inspiration. USS abdomen can quickly identify any stones and is used to help make the diagnosis. To support a diagnosis of acute cholecystitis, you could also add white cell count and CRP to look for signs of inflammation. Serum amylase should also be measured, along with monitoring blood pressure, pulse and urine output.

More information:

https://cks.nice.org.uk/topics/cholecystitis-acute/management/management/#management-of-suspected-acute-cholecystitis

The presentation of recurrent epigastric pain and diarrhoea with multiple ulcers in the oesophagus, stomach and duodenum is characteristic of Zollinger-Ellison Syndrome (ZES). 

Zollinger Ellison Syndrome (ZES) is a rare disorder characterised by neuroendocrine tumours that secrete gastrin. Excessive gastrin secretion stimulates parietal cells in the stomach to produce too much gastric acid resulting in the formation of multiple ulcers in the stomach, duodenum and oesophagus.  

To confirm the diagnosis of ZES, a serum gastrin is performed.  

Carbon 13 urea breath test and stool antigen test is used to test for H.Pylori which is a cause of peptic ulcers. However, multiple ulcers and presence of ulcers in the oesophagus along with diarrhoea is characteristic of ZES.  

Alpha-fetoprotein (AFP) test – is a tumour marker for the liver, testicles and ovaries  

Faecal calprotectin – is a stool test to measure inflammation in Inflammatory Bowel Disease (IBD)  

More information: 

https://patient.info/doctor/zollinger-ellison-syndrome

2B: Pancreatic cancer

This questions is relying on you being aware of the red flag symptoms for pancreatic cancer and knowing when the 2 week rule is appropriate. As this patient is over the age of 60 with symptoms of jaundice and diarrhoea, the most important step according to NICE guidelines is to refer under the 2 week rule cancer pathway and arrange an urgent CT scan. Treating the diarrhoea symptoms may be important later in the management but currently it is not the most appropriate thing to do as this could mask symptoms and will not treat the underlying cause. Reassurance and reassessment is the incorrect answer as the patient has red flag symptoms for pancreatic cancer. Requesting bloods including Ca 19-9 will be part of the investigative work-up for this patient however it is more urgent to arrange a CT scan and refer through the cancer pathway. The NICE referral criteria for pancreatic cancer is outlined below: - Refer anyone aged 40 and over who has jaundice to the suspected cancer pathways (2 week rule) - Consider an urgent direct access CT scan (to be performed within 2 weeks), or an urgent ultrasound scan if CT is not available, to assess for pancreatic cancer in people aged 60 years and over with weight loss and any of the following: Diarrhoea, Back pain, Abdominal pain, Nausea, Vomiting, Constipation, New-onset diabetes.

More Information:

https://cks.nice.org.uk/topics/gastrointestinal-tract-upper-cancers-recognition-referral/management/referral-for-suspected-gastrointestinal-tract-upper-cancer/#referral-for-suspected-pancreatic-cancer

• Mallory-Weiss tear – Typically follows forceful vomiting or retching and causes small-volume haematemesis, but it does not cause significant hypotension or melaena.
• Peptic ulcer disease – Peptic ulcers can cause GI bleeding, but they usually present with epigastric pain and positive stool occult blood test, rather than large-volume haematemesis in a cirrhotic patient.
• Gastric cancer – Can cause chronic occult bleeding, leading to anaemia and weight loss, but it is less likely to cause massive haematemesis.
• Angiodysplasia – A cause of occult bleeding or iron-deficiency anaemia, but it does not typically cause massive GI bleeding.

• A. IBS – IBS does not cause malabsorption, anaemia, or weight loss.
• C. Crohn’s disease – Can cause weight loss and diarrhoea, but is typically associated with bloody stools, perianal disease, and raised inflammatory markers (CRP).
• D. Lactose intolerance – Causes bloating and diarrhoea, but does not lead to anaemia or weight loss.
• E. Chronic pancreatitis – Causes steatorrhoea, but is associated with alcohol history and pancreatic enzyme insufficiency rather than positive tTG antibodies.

1A: Peptic ulcer disease  

Mrs Jones likely has Helicobacter pylori (H.Pylori) due to symptoms that are unresponsive to lifestyle and PPI use with a positive urea (13C) breath test. As she is allergic to penicillin, the answer is oral PPI, clarithromycin and metronidazole for 7 days.  If she was not penicillin allergic then the answer would be oral PPI, amoxicillin and either clarithromycin or metronidazole.  

PPI, clarithromycin and metronidazole for 10 days: Is incorrect as it is given for 7 days. 

PPI, amoxicillin and clarithromycin for 7 days: Is incorrect as she is penicillin allergic.  

PPI, amoxicillin and clarithromycin for 10 days: Is incorrect as she is penicillin allergic, and it is only given for 7 days 

PPI, amoxicillin and metronidazole for 7 days: Is incorrect as she is penicillin allergic  

More information: 

https://bnf.nice.org.uk/treatment-summaries/helicobacter-pylori-infection/  

Author – Matthew Chan (Physician Associate) 

• Peptic ulcer disease – Peptic ulcers can cause epigastric pain but typically present with burning pain that improves with food or antacids. Perforated ulcers cause peritonitis and guarding, which is absent here.
• Acute cholecystitis – This causes right upper quadrant (RUQ) pain, often with fever and positive Murphy’s sign (pain on inspiration when palpating the RUQ). The patient’s pain is epigastric and radiates to the back, making cholecystitis unlikely.
• Gastroesophageal reflux disease (GERD) – GERD presents with retrosternal burning, worse when lying down, but does not typically cause severe epigastric pain or raised inflammatory markers.
• Mesenteric ischaemia – Mesenteric ischaemia can present with severe abdominal pain but is more common in older patients with atrial fibrillation. It typically shows lactic acidosis, which is absent in this case.

Epigastric pain that is relieved by eating is characteristic of a duodenal ulcer.

Gastric ulcer pain is typically worse with eating. The presence of peptic ulcers is confirmed by endoscopy. Initial management includes PPIs , antibiotics if H-pylori infection is present and conservative measures such as stopping medications that are risk factors for ulcer formation such as NSAID’s as well as caffeine, alcohol and tobacco.

GORD presents with heartburn and regurgitation.

Pancreatitis presents with severe, constant epigastric pain radiating to the back.

Cholecystitis presents with right upper quadrant pain, often after eating fatty foods.

More information:

Scenario: Diagnosis | Management | Peptic ulcers | CKS | NICE

This question gives a presentation suggestive of coeliac disease. Coeliac disease is an autoimmune condition in which exposure to gluten causes an immune reaction which creates inflammation of the small intestine. Patients who are diagnosed with T1DM should be screened for coeliac disease on diagnosis as the conditions often present together.

IBS presents with abdominal pain and changes in bowel habits but not weight loss or anaemia.

Crohn's disease and ulcerative colitis present with chronic diarrhoea and abdominal pain but are often associated with bloody stools.

Gastroenteritis presents with acute, not chronic, diarrhoea.

More information:

Scenario: Diagnosis | Management | Coeliac disease | CKS | NICE  

Heartburn and regurgitation that worsen after meals and when lying down are characteristic of GORD. GORD is a common presentation to GP and patients can present reporting chest pain or a chronic cough. Diagnosis is mostly clinical but can involve endoscopy to determine severity especially if concerns of Barretts Oesophagus.

Peptic ulcer disease presents with epigastric pain.

Cholecystitis presents with right upper quadrant pain and fever.

Gastritis presents with epigastric pain and nausea.

Oesophageal spasm presents with chest pain and dysphagia.

More information:

Scenario: Diagnosis | Management | GORD | CKS | NICE 

1A: Appendicitis  

This sign is called Rovsing’s sign, where palpation of LIF causes pain in the RIF and indicates appendicitis. Other symptoms of appendicitis include poorly localised, dull periumbilical pain that moves to RIF and becomes sharp, as well as nausea, vomiting, anorexia and fever.  

Murphy’s sign: Murphy’s sign positive is when pain occurs during palpation of the right upper quadrant (RUQ) during deep inspiration. This occurs when the gallbladder is inflamed and comes into contact with the examiners hand. It indicates acute cholecystitis.  

Boas sign: hyperaesthesia in the right lower scapular region due to referred pain from the gallbladder. It indicates acute cholecystitis.   

Trousseau’s sign: Associated with hypocalcemia, it refers to carpopedal spasm that occurs after the compression of the upper arm with a blood pressure cuff, leading to ischaemia and neuromuscular irritability.  

Brudzinski’s sign: Indicative of meningitis. It occurs when the patient is lying supine and when the neck is passively flexed it causes the patients hips and knees to flex due to an involuntary reaction to reduce stretch and strain on the inflamed meninges.  

More information: 

https://cks.nice.org.uk/topics/appendicitis/  

• Hepatic hydrothorax – This refers to a pleural effusion due to cirrhosis but does not explain the raised neutrophil count in ascitic fluid.
• Hepatorenal syndrome – This presents with acute kidney injury (AKI) in cirrhotic patients but does not cause peritoneal neutrophilia.
• Malignant ascites – Caused by peritoneal carcinomatosis, it leads to low SAAG (<1.1 g/dL) and is often associated with positive cytology for malignant cells.
• Budd-Chiari syndrome – This results from hepatic vein thrombosis, presenting with painful hepatomegaly, ascites, and liver dysfunction, but does not typically cause SBP-like neutrophilia.