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Core clinical problems > 59. Abdominal distension > Flashcards

59. Abdominal distension Flashcards

1
Q

DDX abdominal distension

A

Gynaecological
Fibroids
Ovarian cyst
Ovarian cancer

Gastroenterology
Ascites
IBD
IBS

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2
Q

History abdominal distension

A
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3
Q

Examination abdominal distension

A
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4
Q

buffer card

A
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5
Q

buffer card

A
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6
Q

What are fibroids

A

Fibroids are benign smooth muscle tumours of the uterus.

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7
Q

Risk factors for fibroids

A

race, increasing age

Occur in around 20% of white women
Occur in 50% of black women

later reproductive years.

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8
Q

Typical history and exam fibroids

A

PC: menorrhagia, prolonged menstruation (>7days), abdominal pain worse during menstruation, bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, e.g. frequency, may occur with larger fibroids, subfertility, deep dyspareunia, reduced fertility

o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus

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9
Q

PC: may be asymptomatic, menorrhagia (may result in iron-deficiency anaemia)
bulk-related symptoms (lower abdominal pain, cramping pains, often during menstruation, bloating) urinary symptoms, frequency, subfertility

A

fibroids

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10
Q

investigation ?fibroids

A

Diagnosis
transvaginal ultrasound
hysteroscopy?

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11
Q

Management asymptomatic fibroids

A

no treatment is needed other than periodic review to monitor size and growth

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12
Q

Management of menorrhagia secondary to fibroids if fibroids <3cm

A
  1. levonorgestrel intrauterine system (LNG-IUS)
    - useful if the woman also requires contraception
    - cannot be used if there is distortion of the uterine cavity
  2. Non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid
  3. Hormonal: combined oral contraceptive pill or oral progestogen eg norethisterone
  4. injectable progestogen
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13
Q

Management of menorrhagia secondary to fibroids if fibroids >3cm

A
  1. Refer to secondary care
  2. In meantime : non-hormonal : NSAIDs e.g. mefenamic acid or tranexamic acid

Considered in secondary care:
1. levonorgestrel intrauterine system (LNG-IUS)
- useful if the woman also requires contraception
- cannot be used if there is distortion of the uterine cavity

  1. Medical treatment to shrink/remove fibroids
    - GnRH agonists may reduce the size of the fibroid but are typically used more for short-term treatment
  2. Surgical treatment to shrink/remove fibroids
    - myomectomy if wanting to preserve fertility
    - hysteroscopic endometrial ablation
    - hysterectomy
    - uterine artery embolization
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14
Q

Side effects of GnRH agonists

A

menopausal symptoms (hot flushes, vaginal dryness) and loss of bone mineral density

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15
Q

Examples of GnRH agonists

A

GoseRelin

leuprorelin (brand name Lupron) and triptorelin (brand name Decapeptyl), goserelin (zoladex)

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16
Q

Mechanism of action GnRH agonists

A

Prolonged activation of GnRH receptors by GnRH leads to desensitization and consequently to suppressed gonadotrophin secretion. This is the primary mechanism of action of agonistic GnRH analogues.

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17
Q

Prognosis and complications of fibroids

A
  • regress after menopause as estrogen driven
  • red degeneration particularly in pregnancy
  • subfertility
  • iron deficiency anemia
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18
Q

What are ovarian cysts?

A

A cyst is a fluid-filled sac. Functional ovarian cysts are related to the fluctuating hormones of the menstrual cycle, and are very common in premenopausal women.

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19
Q

typical history ovarian cyst

A

PC: asymptomatic, bloating, fullness in abdomen, pelvic pain (acutely severe pain in ovarian torsion, haemorrhage or rupture)

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20
Q

typical history ovarian cancer

A

PC: asymptomatic, bloating, fullness in abdomen, pelvic pain (acutely severe pain in ovarian torsion, haemorrhage or rupture)

Red flags: Abdominal bloating, Reduce appetite, Early satiety , Weight loss, Urinary symptoms, Pain, Ascites, Lymphadenopathy, change in bowel habit - symptoms of IBS

Risk factors: post menopausal, older age, BRCA 1 or BRCA 2, many ovulations (early menarche,late menopause, nulliparity), smoking, obesity
Protective factors: COCP, breast feeding, pregnancy

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21
Q

red flags for ovarian cancer

A

Red flags: Abdominal bloating, Reduce appetite, Early satiety , Weight loss, Urinary symptoms, Pain, Ascites, Lymphadenopathy, change in bowel habit - symptoms of IBS

22
Q

risk factors for ovarian cancer

A

Risk factors: post menopausal, older age, BRCA 1 or BRCA 2, many ovulations (early menarche,late menopause, nulliparity), smoking, obesity
Protective factors: COCP, breast feeding, pregnancy

23
Q

Plan ?ovarian pathology

A

1) Consider for 2ww, do CA-125 if post menopausal
Refer directly if physical exam reveals : ascites, pelvic mass, abdominal mass
If exam normal → measure CA-125 (particularly important if over 50 and red flags) → if > 35IU/ml → arrange urgent USS → if USS suggestive of ovarian ca → 2ww to gynae

1) USS if pre-menopausal and no red flags

24
Q

Management of ovarian pathology based of USS

A

Pre-menopausal with simple cyst <5cm don’t need any further investigation

Pre-menopausal with simple cyst 5-7 cm - routine referral to gynae for annual USS

Pre-menopausal with simple cyst>7cm - consider MRI or surgical evaluation

Women <40 with complex ovarian mass: test tumour markers for a possible germ cell tumour: lactate dehydrogenase (LDH), alpha-fetoprotein (a-FP), human chorionic gonadotrophin (HCG) → referral to gynae for biopsy and ?surgery

Postmenopausal simple cyst<5cm, USSmonitoring every 4-6 months

Complex cyst - biopsy

25
Q

USS ovaries : Multi-loculated

A

complex, could be ca –> biopsy

26
Q

USS ovaries : “Thin walls and no internal structures”

A

Likely benign follicular cyst

27
Q

USS ovaries: Solid tumour consisting of bundles of spindle shaped fibroblasts

A

ovarian fibroma

28
Q

USS ovaries “Signet ring”

A

Krukenberg tumour (metastasis from another site)

29
Q

What features suggest a malignant over a benign cystic neoplasm?

A

large cystic mass
thick irregular walls and septa
papillary projections
large soft tissue component
ascites
evidence of invasive spread or adenopathy

30
Q

Causes of raised CA-125

A

Ovarian cancer
Endometriosis
Fibroids
Adenomyosis
Pelvic infection
Liver disease
Pregnancy

31
Q

What is the risk of malignancy index

A

Menopausal status
Ultrasound findings
CA125 level

32
Q

Management of ovarian cancer

A

usually a combination of surgery and platinum-based chemotherapy

33
Q

what is the most common type of ovarian cyst

A

follicular cyst

34
Q

physiology and prognosis follicular cyst

A

Follicular cysts represent the developing follicle. When these fail to rupture and release the egg, the cyst can persist.
They typically disappear after a few menstrual cycles

35
Q

how do follicular cysts appear on USS

A

“Thin walls and no internal structures”

36
Q

what is a corpus luteum cyst?complication?

A

during the menstrual cycle if pregnancy doesn’t occur the corpus luteum usually breaks down and disappears. If this doesn’t occur the corpus luteum may fill with blood or fluid and form a corpus luteal cyst

more likely to present with intraperitoneal bleeding than follicular cysts

37
Q

what type of germ cell are you aware of?

A

dermoid/teratoma

38
Q

what is the most common benign ovarian tumour in women under 30

A

teratoma

39
Q

what is a teratoma

A

Most common benign ovarian tumour in women under 30
Lined with epithelial tissue so may contain skin, hair and teeth
More risk of torsion

40
Q

what are teratomas more at risk of compared with other ovarian cysts/tumours

A

torsion

41
Q

what types of benign epithelial ovarian tumors are you aware of

A
  • serous cystadenoma
  • mucinous cystadenoma
42
Q

what is a serous cystadenoma

A

Most common benign epithelial tumour which bears resemblance to most common type of ovarian ca (serous carcinoma)

43
Q

what is a mucinous cystadenoma

A

Second most common benign epithelial tumour
Typically large and become massive
IF rupture occurs, may cause pseudomyxoma peritonei

44
Q

what sex cord-stromal benign tumours are you aware of?

A

ovarian fibroma

45
Q

what is an ovarian fibroma

A

Benign sex cord-stromal tumour
Solid tumour consisting of bundles of spindle shaped fibroblasts)
Associated with Meig’s syndrome : triad of: ovarian fibroma, pleural effusion, ascites. Management involves removal of the tumour - causes resolution of effusion and ascites

46
Q

how does an ovarian fibroma appear on USS

A

Solid tumour consisting of bundles of spindle shaped fibroblasts

47
Q

what is meigs syndrome? management?

A

triad of: ovarian fibroma, pleural effusion, ascites.

Management involves removal of the tumour - causes resolution of effusion and ascites

48
Q

Most common origin of ovarian cancers

A

Around 90% of ovarian cancers are epitlelial

49
Q

most common type of ovarian cancer

A

serous carcinoma

50
Q

what are the stages of ovarian cancer

A

Stage 1
Tumour confined to ovary
Stage 2
Tumour outside ovary but within pelvis
Stage 3
Tumour outside pelvic but within abdomen
Stage 4
Distant metastasis

51
Q

examination findings fibroids

A

o/e: abdominal and bimanual exam may reveal palpable pelvic mass or an enlarged non-tender uterus

Core clinical problems (94 decks)

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