Abdo Flashcards
Abdo Schpiel
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 ____.
Causes of Massive Hepatomegaly
- MF
- MDS
- Liver mets/HCC
- CLD/ETOH with fatty infiltration
- TR (pulsatile)
*If CLD but liver big = hepatoma, haemochromotosis
Causes of Moderate Hepatomegaly
- Haemochromotosis
- MDS
- CML, CLL
- Lymphoma
- NAFLD
- Infiltration
Causes of marked splenomegaly (>7cm)
- Primary myelofibrosis
- CML
- MDS
- Myelofibrosis
- Malaria
- Kala azar
- Splenic lymphoma
Causes of moderate splenomegaly (3-7cm)
- Lymphoma
- CLL
- PRV
- Portal Hypertension (with CLD but liver may be small)
- Leukaemia
- Thalassaemia
- Storage Disease
Causes of mild splenomegaly (1-2cm) - *spleen has to be 2-3x its normal size to be palpable.
- PRV, ET
- Haemolytic anaemia, ITP, Thalassemia, Sickle cell disease
- Infection
- CTD
- Infiltration: Sarcoidosis, amyloidosis
- Portal Hypertension (with signs of CLD)
Causes of hepato-splenomegaly
- CLD - fatty liver/NAFLD, ETOH
- Hepatitis
- Haemochromotosis
- HCC or infiltration
- Infiltration - lymphoma, amyloid, CTD
Causes of massive hepato-splenomegaly
- MF
- MDS
- CML/CMML
Causes of moderate hepato-splenomegaly
- CLL
- Lymphoma
Abdo likely cases:
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)
Abdo Inspection (10 things):
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
8 things to mention about the liver:
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
Why spleen and not kidney? (5)
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
Spleen characteristics:
1) Why is it a spleen and not kidney
2) How big is it?
3) Consistency, firm
4) Tender, non-tender
5) Any rubs?
Unilateral RIF mass with a scar?
Transplanted kidney…
PCK (12) things to look for
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
*Must leave abdomen by 5 minutes!
*Must leave abdomen by 5 minutes!
Abdo Gastro additional things you’d like to do:
- Temperature chart
- LNs (including inguinal)
- PN, cerebellar signs (ETOH, B12)
- Testes - atrophy
- CVS - CM
- Urine analysis (Urobilinogen)
- DRE
Liver problem signs (4)
- Small liver - mild-moderate spleen
- Ascites
- Signs of CLD
- Dupytron’s, parotidomegaly
Haematological problem signs (6)
- Splenomegaly only, hepatosplenomegaly, lymphadenopathy
- Pallor
- Jaundice (Haemolysis)
- Bruises
- Petechiae
- Pleural effusions
Renal disease signs (5)
- PCK, renal Tx
- Finger urochrome stains
- Gouty Tophi
- AVF - ask for blood pressure (lying & standing)
- JVP - fluid status
PCKD extra-renal manifestations:
- hepatomegaly/cysts
- MVP
- MCA aneurysm - CN 3, 4 and 6
Abdo:
- inspect
- palpate
- percuss
- auscultate
Liver
- can’t get above it
- moves inferiorly with inspiration
- dull (no overlying bowel)
Kidneys
- can get above
- bimanually palpate
Spleen
- can’t get above it
- notch
- moves inferiorly with inspiration
- not bimanually palpable
- dull
Mild hepatomegaly causes
- hepatitis
- biliary obstruction
- hydatid disease
- HIV infection
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
Hands (abdo) signs:
- Leuconychia, clubbing
- Palmar erythema
- Dupytren’s contracture (ETOH)
- Arthropathy (CTD, haemochromotosis, Felty’s sydnrome)
- Hepatic flap
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
Legs (abdo) signs:
- Bruising
- Oedema - note this could be liver disease / hypoalbuminaemia / heart failure or obstruction from LNs
- Neurological signs (ETOH)
Myeloproliferative signs and causes:
- Splenomegaly
- +/- Hepatomegaly
- No nodes
- Leukonychia, conjunctival pallor, bruising
- DDx: CML/CMML, myelofibrosis, PV, ET
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)
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
ETOH misuse signs:
- Cachexia
- Tremor
- Parotid enlargement
- Dupuytren’s contracture
- Cerebellar syndrome
- Peripheral neuropathy
- Myopathy
Portal HTN consequences:
- Oesophageal varices
- Ascites
- Hyersplenism/thrombocytopenia
Liver dysfunction consequences:
- Coagulopathy
- Encephalopathy
- Jaundice
- Hypoalbuminaemia
Causes of decompensation in cirrhosis:
- Infection
- SBP
- Hypokalaemia
- GI bleed
- Sedatives
- HCC
Hepatic encephalopathy severity grades
Grade 1: insomnia/reversal of day-night sleep pattern
Grade 2: lethargy/disorientation
Grade 3: Confusion/somnolescence
Grade 4: Coma
Most common causes of ascites:
- Cirrhosis
- Malignancy
- Heart failure
- TB
- Pancreatitis
SA-AG
- Serum albumin - ascitic fluid albumin
- > 11g/L suggests transudative ascites
- < 11g/L suggests exudative ascites
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
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).
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.
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
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%
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
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)
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
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
Add ons to renal tx presentation:
- measure the BP
- check urinalysis - glycosuria, haematuria and proteinuria
- auscultate the heart for a pericardial rub (uraemic pericarditis)
Common cause of CKD
- Diabetes
- GN
- HTN
- PCKD
- Reflux nephropathy
- Analgesic nephropahy
PCKD extra steps:
- BP
- CVS: MVP, AR, LV heave
- Neuro: old stroke, CN 3 palsy/Berry aneurysm
Other causes of renal cysts:
- Multiple simple cysts
- Tuberous sclerosis
- Von Hippel Lindau Syndrome
Single palpable kidney ddx:
- PCKD with only 1 palpable kidney
- Hydronephrosis
- Hypertrophy of a single functioning kidney
- Renal cell carcinoma
Double palpable kidney ddx:
- Bilateral renal cysts
- Bilateral hydronephrosis
- Amyloidosis
- Bilateral RCC - VHL
Extra-renal manifestations of ADPKD:
- Cerebral aneurysms
- Liver cysts
- Pancreatic, splenic cysts
- Valvular heart disease: MVP, AR
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
*It is not possible to palpate above the liver or spleen.
*It is not possible to palpate above the liver or spleen.
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)
Localised lymphadenopathy causes (3):
- Local acute or chronic infection
- Metastases from carcinoma or other solid tumour
- Lymphoma (especially Hodgkin’s lymphoma)
Liver disease: Chronicity not required
- Jaundice
- Ascites
- Coagulopathy
- Encephalopathy
*All may acute liver failure
Liver disease: Chronicity NOT required
- Jaundice
- Ascites
- Coagulopathy
- Encephalopathy
*All may acute liver failure
Liver disease: Chronicity REQUIRED
- Cachexia
- Spiders
- Gynaecomastia
- Most portal HTN
- Caput
- Clubbing
- Palmar erythema
- Testicular atrophy
High SA-AG causes (>11) - (4):
*Portal Hypertension: pre/intra/post hepatic:
- Cirrhosis
- ETOH hepatitis
- Cardiac ascites
- Budd-chiari
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)
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
Complications of CKD
- Anaemia - Stage 3
- Electrolyte disturbance
- Bone health
- Malnutrition
- Oedema - Stage 4
- Lethargy/pruritis
- Uraemia
- CV risk
Complications of dialysis
- Sudden cardiac death
- Vascular disease
- Extravascular calcification
- Amyloidosis
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
Post renal transplant issues
- Diabetes
- HTN
- Cancer
- CVD
- Infections: CMV, BK, PJP, fungal
- OP
- Hchol
Abdominal distension (6 F’s)
- Fat
- Fluid
- Flatus
- Faeces
- Fibroids
- Fetus
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
DDx colitis (7)
- IBD
- Infectious - pseudomembranous
- Radiation
- Ischemic colitis
- Microscopic/collagenous
- Toxic exposure
- Lymphocytic
Colitis infection ddx (9)
- Shigella
- Salmonella
- Yersinia
- E. coli 0157:H7
- Campylobacter
- CDT
- STI
- IC - herpes, CMV, cryptosporidium
- TB
Goals of management of CD (3)
- Induce remission
- Maintain remission
- Preventing/treating complications
MTx side effects (4)
- Hepatotoxic
- BM suppression
- Teratogenic
- Interstitial pneuomonitis
MTx side effects (4)
- Hepatotoxic
- BM suppression
- Teratogenic
- Interstitial pneumonitis
TTP (5)
- Fever
- Anaemia (MAHA)
- Thrombocytopenia
- Renal failure
- Neuro abnormalities
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
Cx post renal Tx - 1-12 weeks (4)
- Acute rejection
- CNI toxicity
- Infection: CMV/BK virus
- Recurrence of disease
Cx post renal Tx - 12-52 weeks (6)
- Acute rejection
- CNI toxicity
- Infection CMV
- Recurrence of primary disease
- Chronic rejection
- BK
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
Elevated Cr post Tx (6)
- Re-check
- Urine m/c/s
- Tac (CNI) level
- Medication adherence, hydration status
- USS renal tx doppler
- Biopsy
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
SAAG <11 (4)
- Peritoneal carcinomatosis
- Peritoneal TB
- Pancreatitis
- Nephrotic syndrome
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!
Cirrhosis Rx (5)
- Rx cause of CLD
- Prevent superimposed insults: vaccinate, avoid hepatotoxic drugs - e.g., statin
- 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 - Tx - at decompensation or MELD >10, <65YO, no major CI
- general health maintenance: CVRF, exercise program, bone health, ACP
Ascites Rx (7)
- Salt restriction
- FR
- diuretics: spiro (100-400mg), fruse 40-160mg)
- LV paracentesis if Sx
- Umbilical hernia repair
- TIPPS but encephalopathy
- Tx
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
CKD-MBD - Ix/Rx (5)
- Ca/PO4/PTH/ALP
- PO4 binder
- Calcitriol
- Secondary/Tertiary PTH
- Cinacalcet
ESKD diet (6)
- Low K
- Low PO4
- Low Na
- Dietician
- Nutrition
- Adherence
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
