12. KFP: Eye/Abdomen Flashcards
Differentials for non-traumatic causes of transient (<24h) monocular vision loss?
- Amaurosis fugax (usually minutes): usually embolic or thrombotic
- Migraine
- Papilloedema
- Impending central retinal vein occlusion
- Giant cell arteritis
- Glaucoma
- Large vessel occlusion or dissection
Differentials for acute persistent monocular vision loss?
Painless acute persistent loss of vision:
- Central retinal artery occlusion
- Central retinal vein occlusion
- Retinal detachment or haemorrhage
- Vitreous haemorrhage
- Optic or retrobulbar neuritis
- Internal carotid artery occlusion
Painful acute loss of vision:
- Acute glaucoma
- Endophalmitis
- Uveitis
- Keratoconus (vision can deteriorate rapidly and is associated with photophobia)
What is Marcus Gunn Pupil?
The Marcus Gunn Pupil can be detected by swinging a flashlight between both eyes.
Normally, if you flash light in one eye, both pupils will constrict.
It is a defect where, if one eye has a problem with detecting light (usually from a problem with the retina or optic nerve), there will be less constriction.
This can be seen in disease of the retina or optic nerve such as in retinal detachment, retinal ischaemia or optic neuritis, among other causes.
What is a chalazion vs a stye?
A chalazion is an inflammatory lump or cyst on the eyelid caused by the blockage of an oil gland/meibomian gland in the eyelid.
A stye is an infection at the base of an eyelash
What is the management for a chalazion?
- Face-washer or disposable makeup pad as a hot compress for several minutes 3-4 times a day
- Antibiotic drops, ointment or tablets are usually not necessary
- Massaging towards the lid margin and eyelashes after hot compresses
Differentials for a red eye?
Extra-ocular causes:
- Orbital cellulitis
- Cavernous sinus thrombosis
- Carotid-cavernous fistula
- Cluster headache
External eye disease causes:
- Eye lid disease
- Conjunctival disease
Internal eye disease causes:
- Iritis
- Glaucoma
Painless Red Eye:
- Diffuse (usually an eyelid abnormality because most conjunctivitis is painful): e.g. blepharitis, ectropion, trichiasis, entropion, eyelid lesion (e.g. tumour, stye)
- Localised: e.g. pterygium, corneal foreign body, ocular trauma, subconjunctival haemorrhage
Painful Red Eye:
- Abnormal cornea: e.g. herpes simplex keratitis, corneal ulcer, marginal keratitis, corneal abrasion
- Abnormal eyelid: e.g. chalazion/stye, acute blepharitis, herpes zoster ophthalmicus
- Diffuse conjunctival injection: e.g. viral conjunctivitis, allergic conjunctivitis, bacterial conjunctivitis, dry eyes, acute glaucoma
- Ciliary injection /scleral involvement: eg scleritis
- Anterior chamber involvement: eg acute anterior uveitis (iritis), hypopyon, hyphema
Clinical presentation of acute angle closure glaucoma?
Symptoms:
* Decreased vision
* Halos around lights
* Headache
* Severe eye pain
* Nausea and vomiting
Signs:
* Conjunctival redness
* Corneal oedema or cloudiness
* A shallow anterior chamber
* A mid-dilated pupil (4 to 6 millimetres) that reacts poorly to light
Medications that can predispose to acute angle closure glaucoma?
- OTC decongestants
- Motion sickness medications
- Adrenergic agents
- Antipsychotics
- Antidepressants
- Anticholinergics
What is ocular rosacea?
Rosacea is a common skin problem in which there is mid facial flushing, redness, prominent vascular shell, swelling, papules and /or pustules.
Ocular rosacea is a form of rosacea that involves the eyelids and the front of the eye. It includes:
- blepharitis
- conjunctival hyperemia
- rosacea associated keratitis
What are the signs of anterior blepharitis?
Anterior blepharitis involves a lid margin an lash line. Signs include:
* Swelling and thickening of lid margin
* Redness and dilated blood vessels
* Scaly debris at the base of the eyelashes
* Loss of eyelashes (madarosis) or misdirected eyelashes
What is posterior blepharitis commonly associated with?
Rosacea
What are the clinical signs of posterior blepharitis?
Posterior blepharitis involves obstruction of the ducts and loss of the Meibomian glands. This leads to:
* Conjunctival hyperemia (dilated conjunctival vessels)
* Cloudy secretions
* Papillary and follicular reactions to the tarsal plate
* Conjunctival scarring
* Chalazions (granulomatous Inflammatory lesions around meibomian glands)
* Hordeolum externum (stye, ie eyelash infection with Staphylococcus aureus)
What is the management of blepharitis?
Eyelid hygiene is a mainstay of therapy
- Warm compress is applied to the eyelids (with eyes closed) daily for two to five minutes to soften the cross followed by gentle scrubbing of the eyelashes
Anterior blepharitis:
- Consider adding chloramphenicol 1% eye ointment topically, applied to the eyelid margin of both eyes twice daily for one to two weeks
Posterior blepharitis:
- Doxycycline 100mg daily, reduced to 50mg daily after clinical improvement (usually after 2 to 4 weeks)
What is the management of ocular rosacea?
- Ocular lubricant
- Daily eyelid hygiene
- Firm eyelid massage towards the margins
- Antibiotics as for treatment of inflammatory papules and pustules in rose asia
What are some aspects on history and examination for you to suspect malignancy in eyelid lesions?
History:
* Risk factors: prior skin cancer, fair skin, previous radiation, immunosuppression
* Gradual enlargement
* Painless
Exam:
* Ulceration
* Induration
* Irregular or pearly borders
* Destruction of eyelid margin
* Loss of lashes (madarosis)
* Telangiectasia
* Reduced sensation
Differentials for benign eyelid lesions (non-tumours)?
- Cystic: Cyst of Moll, Cyst of Zeis, Epidermoid cyst
- Chalazion
- Hordeolum (stye)
- Molluscum contagiosum
- Xanthelasma
- Vascular malformation (port wine stain)
Differentials for benign eyelid tumours?
- Papillomas: seborrheic keratosis, squamous, viral wart
- Naevi
- Vascular: infantile haemangioma
Differentials for malignant eyelid tumours?
- Basil cell carcinoma: nodular, morphoeic, superficial, others
- Squamous cell carcinoma: actinic keratosis (pre-cancerous), in situ (Bowen’s), keratoacanthoma, invasive
- Sebaceous carcinoma
- Melanoma
What is the uvea?
The uvea is the middle layer of the eye between the sclera and the retina. It has 3 parts:
* Iris (the coloured part of the eye)
* Ciliary body (the part of the eye that helps the lens focus)
* Choroid (the part of the eye that connects the retina to the sclera)
What are the key features of uveitis?
- Photophobia
- Reduced vision
- Conjunctival and ciliary inflammation
- White cells in anterior chamber
- Irregular pupil from posterior synechiae
- History of autoimmune disease
What are some major to systemic disorders associated with uveitis?
- Behcet syndrome
- Inflammatory bowel disease
- Ankylosing spondylitis
When is a patient at moderate risk of developing colorectal cancer?
- Anyone first degree relative with colorectal cancer diagnosed before age 60
- One 1st degree relative AND one or more second degree relatives with colorectal cancer diagnose any age
- Two first degree relatives with colorectal cancer diagnosed at any age
What is recommended for patients at moderate risk of developing colorectal cancer?
- Colonoscopy should be offered every five years starting at 10 years younger than the earliest age of diagnosis of colorectal cancer in a first degree relative or age 50, whichever is earlier, to age 74
- Aspirin 100mg daily should be considered from age 45 to 70
What is the diagnostic criteria for irritable bowel syndrome?
At least six months of recurrent abdominal pain, which has occured at least one day per week for the last three months, and with at least two of the following in the last three months:
* Abdominal pain related to defecation
* Abdominal pain associated with a change in stool frequency
* Abdominal pain associated with the change in stool form (appearance)
What is the approach to treating irritable bowel syndrome?
The aetiology of IBS is multifactorial, so different aspects of disease may need to be addressed simultaneously; for example, diet, psychological health, gut microbiota and visceral hypersensitivity may all require attention
MDT approach:
* Patient support
* Psychiatric or psychological assessment
* Your modulation using antidepressant drugs
* Dietetic support
* Physiotherapy (e.g. pelvic floor physiotherapy)
What is the firstline dietary therapy for irritable bowel syndrome?
Patients should complete a food diary and be assessed for common triggers or food intolerance.
Common triggers of food intolerance include:
* Caffeine
* Alcohol
* Carbonated drinks
* Fatty food
* Fibre
* Lactose-containing food
* Wheat
* Spicy food
A food intolerance is suspected, use a trial of an exclusion diet. If there is no clear benefit from initial dietary therapy, consider referral to an accredited practising dietitian
What dietary therapy would you advise for irritable bowel syndrome?
- Gradually increase intake of fibre from freedom vegetables (aiming 25-35g total fibre daily)
- Avoid wheat bran and large quantities of other insoluble fibres that are slowly fermented, or soluble fibres that are rapidly fermented
- Trial a less fermentable soluble fibre supplement (e.g. psyllium). Psyllium is useful for both constipation and diarrhoea (acts as a bulking agent)
- If symptoms worsen with fibre supplement ation, a low fibre diet maybe trial to assess if this relieve symptoms
What is the cause and symptoms of lactose intolerance?
Lactose intolerance is usually due to a deficiency of the digestive enzyme lactase in the small bowel mucosa, resulting in lactose malabsorption. Incompletely absorbed lactose is subsequently fermented by bacteria in the large bowel.
Symptoms:
* Abdominal pain
* Bloating flat
* Flatulence
* Watery diarrhoea
* Nausea and vomiting occasionally
How is lactose intolerance diagnosed?
Lactose challenge test:
* Gastrointestinal upset after drinking 125 mils of full fat milk suggests lactose intolerance.
* To diagnose lactose intolerance, low fat milk should be used because fat can induce gastrointestinal symptoms independently of lactose
* Advise patients to avoid lactose containing foods for a few weeks and record their symptoms to see if they improve
What is the management of lactose intolerance?
- Reducing dietary lactose (<10g per day) - Small amounts if often tolerated so they do not need to avoid it completely
- Using low lactose and lactose free products where possible
- Consuming smaller quantities of lactose containing products more frequently over the day (rather than large quantities at a time)
- Using lactase enzyme drops or tablets before ingesting lactose containing products
Dx Triad: severe pain + nausea and vomiting + relative lack of abdominal signs?
Acute pancreatitis
What is the clinical presentation of acute pancreatitis?
Typical clinical features:
* Constant deep epigastric pain
* Pain may radiate to back
* Relieved by sitting forwards
Signs:
* Tender in epigastrium
* Fever, tachycardia +/- shock
Risk factors: precipitated by fatty foods and alcohol
What packing options are there for healing of open wounds?
- Hypertonic saline dressing
- Gelling fibre dressing
- Alginate fibre dressing
If empirical antibiotic therapy for acute infectious diarrhoea is indicated, what is the choice?
Ciprofloxacin 500mg Q12hourly PO for 3 days
What specific clinical features would indicate severe acute infectious diarrhoea and prompt microbiological testing and consideration of treatment?
- High fever
- Tachycardia
- Leucocytosis
- Abdominal tenderness or severe abdominal pain
- High volume diarrhoea with hypovolemia
- Bloody stool
- Prolonged symptoms
When is faecal testing, including for clostridium difficile, indicated?
- Bloody stools, moderate to severe disease or with prolonged symptoms
- Immunocompromised patients - also test for parasites and viral pathogens
- Situations of public health importance (e.g. outbreak in residential aged-care facilities, food handlers)
Causes of iron deficiency?
- Inadequate dietary intake of iron (eg toddlers or adolescence, people with a vegan or vegetarian diet, anorexia nervosa)
- Malabsorption (eg celiac disease, pernicious anaemia or after gastrectomy or bariatric surgery)
- Increased iron requirements (eg pregnancy or breastfeeding, during periods of rapid growth [toddlers/adolescents], heavy menstrual loss or chronic gastrointestinal blood loss)
What advice would you provide when advising a patient to take iron supplementation?
- Elemental iron 100 to 210 mg daily - daily dose can be administered in divided doses or every second day
- Iron supplement should be taken at least one hour before eating because it is best absorbed on an empty stomach
- Vitamin c is often given concurrently to optimise iron absorption
- Oral iron absorption is also reduced by calcium supplements, proton pump inhibitors, h2 receptor antagonists, antacids and tea
- One patient that oral iron supplements can cause black stools
What population groups should be offered screening for hepatitis c virus?
- People who inject drugs or have ever injected drugs
- People in custodial settings
- People with tattoos or body piercings
- People who received a blood transfusion organ transplant before 1990
- Children born to mothers who are hepatitis c virus positive
- People info with HIV or hepatitis b virus
- Sexual partners of a person who is hepatitis c virus positive
- People with evidence of liver disease (persistently elevated alanine aminotransferase level)
- People who have a needle stick injury
- Migrants from high prevalence regions
Can Hepatitis C virus be cleared without antivirals?
Yes, in a proportion of individuals, within 6 months
What methods exist to assess for liver fibrosis?
APRI index (aspartate aminotransferase to platelet ratio)/Hepascore:
* Score <0.5: fibrosis unlikely
* Score >1.0: significant fibrosis or cirrhosis is likely
Fibroscan (transient elastography)
What is pruritus ani And what can it be associated with?
It is characterised by Itching of the perianal skin.
It can be associated with a dermatosis, most commonly irritant dermatitis, followed by psoriasis, lichen sclerosus and lichen planus
Differentials for perianal itch?
- Pruritus ani
- Anal pathology (eg anal fissure, anal skin tags, haemorrhoids, fishers, warts)
- Crohn’s disease, perianal into epithelial neoplasia, extramammary Paget’s disease
- Worms (eg threadworms) an perianal streptococcal dermatitis, in children
- Tinea
In pruritus ani, what factors can exacerbate but do not cause it?
- Insufficient hygiene
- Faecal incontinence
- Manner of perianal area wiping
What is the management of pruritis ani?
Goal: break the itch-scratch cycle
General measures:
* Cleaning the perianal area gently using moistened cotton wool
* Using a soap substitute
* Applying a greasy emollient as a barrier
* Promoting a bulkier stool if bowel actions are loose and unformed (using bulk forming laxatives)
* Wearing loose fitting cotton underwear
If no treatable cause is found and general measures do not resolve the itch, treat with a topical corticosteroid:
* methylprednisolone aceponate 0.1% fatty ointment topically, once daily until skin is cleared and itch has resolved, or for up to four weeks
What is the treatment for lichenified perianal area?
If the perianal area is lichenified, use a potent topical corticosteroid, followed by a less potent topical steroid:
- Betamethasone dipropionate 0.05% ointment, daily until skin is clear and itch has resolved (may take up to 4 weeks)
- FOLLOWED BY
- Methylprednisolone aceponate 0.1% fatty ointment topically, once daily for up to four weeks
What are some reasonable initial tests for macrocytosis?
- Reticulocyte count
- Folate and vitamin b12 levels
- Thyroid stimulating hormone (TSH)
- Liver function tests
- HIV testing
What are the three most common causes of macrocytosis?
- Alcohol
- Hemolysis
- Vitamin b12 /folate deficiency
What is the recommended level of alcohol consumption?
No more than 10 standard drinks a week and no more than 4 standard drinks on any one day
What is the most common protozoal cause of chronic diarrhoea?
Giardia intestinalis
What is the treatment for giardia intestinalis?
- If aymptomatic and immunocompetent: nothing
- If symptomatic and immunocompetent: metronidazole 400 mg Q8hourly PO for five days
Which populations are at risk for giardia infection?
- Children who are not toilet trained
- Health care and child care workers
- International travellers, particularly to or from developing areas
- Hikers and campers
What are some symptoms of giardiasis and when do they usually appear?
The following signs and symptoms usually appear between 7 and 10 days after infection:
* Foul smelling greasy or watery diarrhoea
* Abdominal (stomach) cramps
* Nausea
* Fatigue
* Bloating
* Loss of appetite
In gallbladder polyps, what factors are concerning or increase the risk for gallbladder cancer?
- Larger than 1cm
- Have a wide base
- Are associated with focal thickening, distortion or mass of the gallbladder
- Age > 60 years
- Indian ethinicity
- Sessile gallbladder polyp with focal thickness of the gallbladder wall >4 mm
What do you do for a gallbladder polyp less than 10mm?
Repeat abdominal ultrasound every six months for two years
Multi-organ complications of iron overload from hereditary haemochromatosis?
Liver: liver fibrosis, liver cirrhosis, hepatocellular carcinoma
Cardiac: Cardiac arrhythmias, cardiomyopathy
Endocrine: diabetes, hypogonadism
Arthropathy: HH associated arthritis most usually affects the 2nd and 3rd metacarpophalangeal joints
Skin hyperpigmentation
What are the most useful tests for iron overload due to hereditary haemochromatosis?
- Transferrin saturation: >45% is sensitive and fairly specific for diagnosing HH
- Serum ferritin
What genetic mutation confers the highest risk of multi-organ complications from hereditary haemochromatosis?
C282Y homozygosity
How does diverticulitis usually present?
Diverticulitis usually presents with abdominal pain in the left lower quadrant and fever, often with an altered bowel habit.
How would you define complicated diverticulitis?
- Diverticulitis with a positive blood culture result
- Perforation
- Peritonitis
- Sepsis or septic shock
- An abscess larger than 5cm in diameter
What is the management of complicated diverticulitis?
- Bowel rest
- Intravenous fluids
- Intravenous antibiotic therapy
- Screening for colorectal cancer is recommended 6 to 8 weeks after an acute episode of complicated diverticulitis
When is antibiotic therapy appropriate for patients with uncomplicated diverticulitis and what would you use?
Indications:
* Immune compromise
* Right sided diverticulitis
* Failure to improve after 72 hours of conservative treatment
Choices:
* Amoxicillin plus clavulanate 875 + 125 mg oral, 12 hourly for five days
* Allergic to penicillin: Trimethoprim + sulfamethoxazole 160 + 800 mg oral, 12 hourly for five days PLUS metronidazole 400 mg oral, 12 hourly for five days
When is colorectal cancer screening recommended in patients with uncomplicated diverticulitis?
- Imaging abnormalities suggestive of malignancy (eg abscess, shouldering at the edges of the inflammatory mass, obstruction, or mesenteric or retroperitoneal lymphadenopathy)
- Atypical symptoms (eg bleeding, narrowed stools)
- Delayed recovery (eg symptoms that do not resolve after a few days)
What is the diagnostic criteria for opioid induced constipation?
New or worsening symptoms of constipation when initiating, changing, or increasing appeared therapy that must include two or more of the following:
* Straining during more than 25% of defecations
* Lumpy or hard stools during more than 25% of defecations
* Sensation of incomplete evacuation during more than 25% of defecations
* Sensation of anorectal obstruction or blockage during more than 25% of defecation’s
* Use of manual manoeuvres (eg digital evacuation, support of the pelvic floor) to facilitate more than 25% of the defecations
* Fewer than three spontaneous bowel movements per week
The management of opioid induced constipation in adults?
Consider prophylactic laxative therapy in high risk patients
Avoid fermentable osmotic laxatives (eg lactulose) and bulk forming laxatives: due to bloating and excess gas
Prucalopride has short term improvement in bowel function and quality of life in patients with opioid induced constipation associate with noncancer pain:
* Prucalopride 2mg daily PO. (for patients older than 65 years old, use 1mg)
