Abdo Flashcards
1
Q
Abdo Schpiel
A
Today I examined ___ abdomen and my main findings were ___ mass consistent with spleen/kidney/liver or multiple.
Given these findings I went to complete a renal/GI/haematological examination and my peripheral findings were ____.
This is consistent with a diagnosis of ____. But my differentials are ____.
2
Q
Causes of Massive Hepatomegaly
A
- MF
- MDS
- Liver mets/HCC
- CLD/ETOH with fatty infiltration
- TR (pulsatile)
*If CLD but liver big = hepatoma, haemochromotosis
3
Q
Causes of Moderate Hepatomegaly
A
- Haemochromotosis
- MDS
- CML, CLL
- Lymphoma
- NAFLD
- Infiltration
4
Q
Causes of marked splenomegaly (>7cm)
A
- Primary myelofibrosis
- CML
- MDS
- Myelofibrosis
- Malaria
- Kala azar
- Splenic lymphoma
5
Q
Causes of moderate splenomegaly (3-7cm)
A
- Lymphoma
- CLL
- PRV
- Portal Hypertension (with CLD but liver may be small)
- Leukaemia
- Thalassaemia
- Storage Disease
6
Q
Causes of mild splenomegaly (1-2cm) - *spleen has to be 2-3x its normal size to be palpable.
A
- PRV, ET
- Haemolytic anaemia, ITP, Thalassemia, Sickle cell disease
- Infection
- CTD
- Infiltration: Sarcoidosis, amyloidosis
- Portal Hypertension (with signs of CLD)
7
Q
Causes of hepato-splenomegaly
A
- CLD - fatty liver/NAFLD, ETOH
- Hepatitis
- Haemochromotosis
- HCC or infiltration
- Infiltration - lymphoma, amyloid, CTD
8
Q
Causes of massive hepato-splenomegaly
A
- MF
- MDS
- CML/CMML
9
Q
Causes of moderate hepato-splenomegaly
A
- CLL
- Lymphoma
10
Q
Abdo likely cases:
A
GIT:
- CLD +/- portal HTN (21%)
- Hepatomegaly undefined
- Splenomegaly
- Hepatomegaly metastatic disease
- Hepatosplenomegaly (others)
- Abdominal Mass (pancreatic cancer)
# Renal: - PCKD +/- Renal transplant (32%)
Haematology:
- Chronic Lymphocytic Leukaemia/Lymphoma (17%)
- Myelofibrosis/CML (16%)
- PRV (4%)
- Others (HIV, isolated splenomegaly, sarcoidosis)
11
Q
Abdo Inspection (10 things):
A
1) Patient’s age
2) Patient’s face (PCV, jaundice, drowsiness)
3) The rest of the body (does the patient look malnourished, cachectic)
4) Flanks
5) Umbilicus
6) Organs, liver, spleen, kidney’s
7) Scars (renal Tx)
8) Veins
9) Masses
10) Tubes/lines
12
Q
8 things to mention about the liver:
A
1) Span (MCL)
2) Shape/map out the edge (left vs right lobes)
3) Tender, non-tender
4) Consistency/feel, firm, hard, soft
5) Edge: regular, irregular, nodular
6) Surface: smooth, nodular
7) Pulsatile or non-pulsatile
8) Rubs or bruits
13
Q
Why spleen and not kidney? (5)
A
1) Comes down & medially with respiration
2) Has a notch
3) Can’t get above it
4) Dull over it & in Traub’s area
5) Not ballottable
14
Q
Spleen characteristics:
A
1) Why is it a spleen and not kidney
2) How big is it?
3) Consistency, firm
4) Tender, non-tender
5) Any rubs?
15
Q
Unilateral RIF mass with a scar?
A
Transplanted kidney…
16
Q
PCK (12) things to look for
A
1) Bilateral, maybe asymmetrical
2) Span of each, ability to get above mass
3) Surface, border
4) Tender or non-tender
5) Auscultation
6) Movement with respiration
7) Ballottable or non ballottable
8) Any differentials
9) Is there a current fistula - or an old one
10) Is there a renal Tx?
11) Are there signs of CKD?
12) Blood pressure
17
Q
*Must leave abdomen by 5 minutes!
A
*Must leave abdomen by 5 minutes!
18
Q
Abdo Gastro additional things you’d like to do:
A
- Temperature chart
- LNs (including inguinal)
- PN, cerebellar signs (ETOH, B12)
- Testes - atrophy
- CVS - CM
- Urine analysis (Urobilinogen)
- DRE
19
Q
Liver problem signs (4)
A
- Small liver - mild-moderate spleen
- Ascites
- Signs of CLD
- Dupytron’s, parotidomegaly
20
Q
Haematological problem signs (6)
A
- Splenomegaly only, hepatosplenomegaly, lymphadenopathy
- Pallor
- Jaundice (Haemolysis)
- Bruises
- Petechiae
- Pleural effusions
21
Q
Renal disease signs (5)
A
- PCK, renal Tx
- Finger urochrome stains
- Gouty Tophi
- AVF - ask for blood pressure (lying & standing)
- JVP - fluid status
22
Q
PCKD extra-renal manifestations:
A
- hepatomegaly/cysts
- MVP
- MCA aneurysm - CN 3, 4 and 6
23
Q
Abdo:
A
- inspect
- palpate
- percuss
- auscultate
24
Q
Liver
A
- can’t get above it
- moves inferiorly with inspiration
- dull (no overlying bowel)
25
Kidneys
- can get above
| - bimanually palpate
26
Spleen
- can't get above it
- notch
- moves inferiorly with inspiration
- not bimanually palpable
- dull
27
Mild hepatomegaly causes
- hepatitis
- biliary obstruction
- hydatid disease
- HIV infection
28
Hepato-splenomegaly causes:
- CLD with portal HTN
- Myeloproliferative disease, lymphoma, leukaemia, pernious anaemia, sickle cell anaemia
- Infection - acute viral hepatitis, infectious mononucleosis, CMV
- Infiltration - amyloidosis, sarcoid
- CTD
- Acromegaly
- Thyrotoxicosis
29
Hands (abdo) signs:
- Leuconychia, clubbing
- Palmar erythema
- Dupytren's contracture (ETOH)
- Arthropathy (CTD, haemochromotosis, Felty's sydnrome)
- Hepatic flap
30
Face (abdo) signs:
- Eyes: jaundice, anaemia, iritis, Kayser-Fleischer rings
- Parotids: (ETOH)
- Breath fetor hepaticus
- Lips: stomatitis, leukoplakia, ulceration, localised pigmentation, telangiectasia
- Gums: gingivitis, bleeding, hypertrophy, pigmentation
- Tongue: atrophic glossitis, leukoplakia, ulceration
- Tonsils
31
Legs (abdo) signs:
- Bruising
- Oedema - note this could be liver disease / hypoalbuminaemia / heart failure or obstruction from LNs
- Neurological signs (ETOH)
32
Myeloproliferative signs and causes:
- Splenomegaly
- +/- Hepatomegaly
- No nodes
- Leukonychia, conjunctival pallor, bruising
- DDx: CML/CMML, myelofibrosis, PV, ET
33
Lymphoproliferative signs and causes:
- As for myeloproliferative plus nodes. May be associated with tophaceous gout
DDx: CLL, lymphoma, infection (CMV, EBV, viral hepatitis, HIV, syphilis)
34
Cirrhosis causes
- ETOH
- Viral - HBV, HCV
- AI: PBC, PSC, auto immune hepatitis
- Metabolic: NASH, haemochromotosis, alpha-1 AT deficiency, Wilson's disease, CF
- Drugs: MTX, Isoniazid, Amiodarone
35
ETOH misuse signs:
- Cachexia
- Tremor
- Parotid enlargement
- Dupuytren's contracture
- Cerebellar syndrome
- Peripheral neuropathy
- Myopathy
36
Portal HTN consequences:
- Oesophageal varices
- Ascites
- Hyersplenism/thrombocytopenia
37
Liver dysfunction consequences:
- Coagulopathy
- Encephalopathy
- Jaundice
- Hypoalbuminaemia
38
Causes of decompensation in cirrhosis:
- Infection
- SBP
- Hypokalaemia
- GI bleed
- Sedatives
- HCC
39
Hepatic encephalopathy severity grades
Grade 1: insomnia/reversal of day-night sleep pattern
Grade 2: lethargy/disorientation
Grade 3: Confusion/somnolescence
Grade 4: Coma
40
Most common causes of ascites:
- Cirrhosis
- Malignancy
- Heart failure
- TB
- Pancreatitis
41
SA-AG
- Serum albumin - ascitic fluid albumin
- > 11g/L suggests transudative ascites
- < 11g/L suggests exudative ascites
42
Causes of hepatomegaly:
Malignancy
* Cirrhosis:
- ETOH
- NAFLD
- PBC
* Hepatic congestion
- RHF
- Constrictive pericarditis
- Restrictive cardiomyopathy
*ETOH hepatitis
* Infectious disease:
- Viral hepatitis
- Toxoplasmosis
- Hydatid disease
- Pyogenic liver abscess
- Amoebic liver abscess
* Infiltration:
- Amyloidosis
- Sarcoidosis
* Vascular liver disease:
- Budd-Chiari syndrome
Polycystic liver disease
43
Splenomegaly + anaemia without lymphadenopathy is most likely to be a myeloproliferative condition such as chronic myeloid leukaemia (CML).
Splenomegaly + anaemia without lymphadenopathy is most likely to be a myeloproliferative condition such as chronic myeloid leukaemia (CML).
44
Splenomegaly and lymphadenopathy is most likely to be a lymphoproliferative condition such as lymphoma or chronic lymphocytic leukaemia.
Splenomegaly and lymphadenopathy is most likely to be a lymphoproliferative condition such as lymphoma or chronic lymphocytic leukaemia.
45
Spleen characteristics
- enlarges towards the RIF
- possesses a medial notch
- is dull to percussion
- one cannot palpate 'above' a spleen
- the spleen is not balltoable
46
Causes of splenomegaly
- Portal HTN - 33%
- Haematological malignancy - 27%
- Infection - HIV, IE - 23%
- Congestion or inflammation - cardiac failure - 8%
- Primary splenic disease (splenic vein thrombosis - 4%
47
Renal Tx steps:
- Palpate the margins - often smooth
- Estimate the size (usually 8cm x 5cm)
- Comment on whether it is tender or non-tender
- Comment on consistency (often a firm mass)
- Percuss over the mass (usually a dull percussion note)
- Auscultate for bruits
48
Adequacy of RRT
- assess for fluid status
* clinical signs of uraemia:
- altered mental status
- asterixis (metabolic encephalopathy)
- excoriation marks (secondary to pruritis)
- tachypnoea (metabolic acidosis with respiratory compensation)
- pericardial rub (uraemic pericarditis)
49
Abdo immunosuppression consequences:
1) Infection stigmata
2) Presence of skin lesions (benign or malignant)
3) Complications relating to specific drugs:
Cyclosporin: gum hypertrophy, hirsutism, coarse tremor, hypertension, diabetes
Steroids: purpura, cushingoid features, diabetes
Tacrolimus: diabetes mellitus, tremor
50
Cause of renal failure:
- Diabetes - FPT, lipodystrophy, diabetic retinopathy
- HTN - BP
- Vasculitis - skin lesions, stigmata of rheumatological disease
- PCKD - palpable kidnies, nephrectomy scars
Alport's syndrome - hearing aid
Tuberous sclerosis - subungal fibromas
Membranoproliferative GN
51
Add ons to renal tx presentation:
- measure the BP
- check urinalysis - glycosuria, haematuria and proteinuria
- auscultate the heart for a pericardial rub (uraemic pericarditis)
52
Common cause of CKD
- Diabetes
- GN
- HTN
- PCKD
- Reflux nephropathy
- Analgesic nephropahy
53
PCKD extra steps:
- BP
- CVS: MVP, AR, LV heave
- Neuro: old stroke, CN 3 palsy/Berry aneurysm
54
Other causes of renal cysts:
- Multiple simple cysts
- Tuberous sclerosis
- Von Hippel Lindau Syndrome
55
Single palpable kidney ddx:
- PCKD with only 1 palpable kidney
- Hydronephrosis
- Hypertrophy of a single functioning kidney
- Renal cell carcinoma
56
Double palpable kidney ddx:
- Bilateral renal cysts
- Bilateral hydronephrosis
- Amyloidosis
- Bilateral RCC - VHL
57
Extra-renal manifestations of ADPKD:
- Cerebral aneurysms
- Liver cysts
- Pancreatic, splenic cysts
- Valvular heart disease: MVP, AR
58
Abdo Mass features:
- Size
- Consistency
- Border - inspection, percussion, palpation
- Tender/non-tender
- Attached to abdominal wall
- Movement with respiration
- Pulsastile
- Ballotable
- Percussion note: solid masses with a firm consistency will give a dull percussion note
- Auscultatory findings
59
*It is not possible to palpate above the liver or spleen.
*It is not possible to palpate above the liver or spleen.
60
Generalised lymphadenopathy causes (6):
- Lymphoma (rubbery and firm)
- Leukemia (CLL, ALL)
- Infections (CMV, EBV, HIV, TB, Syphilis, Toxo)
- CTD (RA, SLE)
- Infiltration (Sarcoidosis)
- Drugs (Phenytoin)
61
Localised lymphadenopathy causes (3):
- Local acute or chronic infection
- Metastases from carcinoma or other solid tumour
- Lymphoma (especially Hodgkin's lymphoma)
62
Liver disease: Chronicity not required
- Jaundice
- Ascites
- Coagulopathy
- Encephalopathy
*All may acute liver failure
62
Liver disease: Chronicity NOT required
- Jaundice
- Ascites
- Coagulopathy
- Encephalopathy
*All may acute liver failure
63
Liver disease: Chronicity REQUIRED
- Cachexia
- Spiders
- Gynaecomastia
- Most portal HTN
- Caput
- Clubbing
- Palmar erythema
- Testicular atrophy
64
High SA-AG causes (>11) - (4):
*Portal Hypertension: pre/intra/post hepatic:
- Cirrhosis
- ETOH hepatitis
- Cardiac ascites
- Budd-chiari
65
APKD NAILED:
- Polycystic kidney - may be massive
- Hepatic cysts, rare splenic cysts - may cause confusion
- Transplanted kidney (can be tricky)
- Look for a fistula
- BP - 75% hypertensive
- Anaemia (CRF, polycythaemia from high EPO) *Hb higher than expected for degree of renal failure
- CN3 palsy
- Listen to heart for MVP - may also have AR/LVH
- Urine - haematuria (haemorrhage into the cyst) and proteinuria (<2g/day)
66
Thrombophilia screen (unprovoked VTE, if young, recurrent, FHx, porto/hepatic/cerebral/mesenteric)
- APLS - LAC, ACL, B2 glycoprotein
- Factor 5 Leiden
- PT Gene mutation
- Protein C/S deficiency
- Anti-thrombin III deficiency
- MPN - JAK2/PNH
67
Complications of CKD
- Anaemia - Stage 3
- Electrolyte disturbance
- Bone health
- Malnutrition
- Oedema - Stage 4
- Lethargy/pruritis
- Uraemia
- CV risk
68
Complications of dialysis
- Sudden cardiac death
- Vascular disease
- Extravascular calcification
- Amyloidosis
69
Indications for dialysis
- A - acidosis (metabolic) - pH <7.1
- E - electrolytes - refractory - K>6.5
- I - intoxications - Salicylates, Lithium, Isopropanol, Methanol, Ethylene glycol
- O - overload - refractory to diuresis
- U - uraemia - pericarditis, encephalopathy, neuropathy, bleeding
70
Post renal transplant issues
- Diabetes
- HTN
- Cancer
- CVD
- Infections: CMV, BK, PJP, fungal
- OP
- Hchol
71
Abdominal distension (6 F's)
- Fat
- Fluid
- Flatus
- Faeces
- Fibroids
- Fetus
72
Extra-intestinal manifestations of UC (5)
- Liver - PSC, fatty liver, cirrhosis, carcinoma, amyloidosis
- Blood - VTE, anaemia
- Enteropathic arthropathy
- Skin - ulcers, pyoderma, EN
- Ocular - Uveitis, conjunctivitis, episcleritis
73
DDx colitis (7)
- IBD
- Infectious - pseudomembranous
- Radiation
- Ischemic colitis
- Microscopic/collagenous
- Toxic exposure
- Lymphocytic
74
Colitis infection ddx (9)
- Shigella
- Salmonella
- Yersinia
- E. coli 0157:H7
- Campylobacter
- CDT
- STI
- IC - herpes, CMV, cryptosporidium
- TB
75
Goals of management of CD (3)
- Induce remission
- Maintain remission
- Preventing/treating complications
76
MTx side effects (4)
- Hepatotoxic
- BM suppression
- Teratogenic
- Interstitial pneuomonitis
77
MTx side effects (4)
- Hepatotoxic
- BM suppression
- Teratogenic
- Interstitial pneumonitis
78
TTP (5)
- Fever
- Anaemia (MAHA)
- Thrombocytopenia
- Renal failure
- Neuro abnormalities
79
Splenectomy (4)
- Vaccinate: pneumococcus, Hib, group C meningococcus, flu vax, COVID 2-3/52 before splenectomy
- Booster every 5 years, annual flu, COVID
- Consider prophylactic penicillin V 250mg BD
- Alert braclet
80
Cx post renal Tx - 1-12 weeks (4)
- Acute rejection
- CNI toxicity
- Infection: CMV/BK virus
- Recurrence of disease
81
Cx post renal Tx - 12-52 weeks (6)
- Acute rejection
- CNI toxicity
- Infection CMV
- Recurrence of primary disease
- Chronic rejection
- BK
82
Cx post renal Tx - >1 year (7)
- IF-TA - chronic allograft nephropathy
- CVD
- Malignancy
- Infection
- BK
- Hypertensive nephrosclerosis
- Recurrence of disease
- Infection from over IS
83
Elevated Cr post Tx (6)
- Re-check
- Urine m/c/s
- Tac (CNI) level
- Medication adherence, hydration status
- USS renal tx doppler
- Biopsy
84
Cx post renal Tx (general) - (5)
- NODAT
- Increased malignancy risk - yearly skin, scopes every 2 years, PSA yearly, mamograms, cervical smear
- Infection risk: CMV, BK (usually after 6/12)
- CV risk - REMAINS - still have CKD
- CKD-MBD
85
SAAG <11 (4)
- Peritoneal carcinomatosis
- Peritoneal TB
- Pancreatitis
- Nephrotic syndrome
86
HBV Phases (4)
- Immune tolerance (monitor)
- Immune clearance (inflammation) - EAg+ to EAg- *Treat!
- Immune control - EAb+, low VL, normal LFTs - Monitor
- Immune escape - High VL, abnormal ALT -*Treat!
87
Cirrhosis Rx (5)
1. Rx cause of CLD
2. Prevent superimposed insults: vaccinate, avoid hepatotoxic drugs - e.g., statin
3. Rx and prevent Cx:
- nutrition, ETOH, low salt, FR, protein 1.5g/kg/d, adequate energy (counteract catabolism)
- hepatoma surveillance - USS + aFP every 6/12, all cirrhotics, or HBV
- ascites, varices, SBP, encephalopathy
4. Tx - at decompensation or MELD >10, <65YO, no major CI
5. general health maintenance: CVRF, exercise program, bone health, ACP
88
Ascites Rx (7)
1. Salt restriction
2. FR
3. diuretics: spiro (100-400mg), fruse 40-160mg)
4. LV paracentesis if Sx
5. Umbilical hernia repair
6. TIPPS but encephalopathy
7. Tx
89
Long Term post OLTx Rx (10)
- Infection risk
- Return to occupation (often <3 months)
- Post Tx renal failure
- Post Tx diabetes
- CV RF
- Bone health
- Malignancy risk - PTLD
- Disease recurrence
- Chronic rejection
- 90% 10-year survival
90
CKD-MBD - Ix/Rx (5)
- Ca/PO4/PTH/ALP
- PO4 binder
- Calcitriol
- Secondary/Tertiary PTH
- Cinacalcet
91
ESKD diet (6)
- Low K
- Low PO4
- Low Na
- Dietician
- Nutrition
- Adherence
92
Life on dialysis (5)
- Sleep - RLS/CTS/IDA
- Fertility/sexual fn
- Edu, employment, financial, logistics, travel
- Mood/depression/cognition
- QOL, impact on self, others, support
