Abdo/endocrine shorts Flashcards
Ddx Hepatomegaly (9)
- Malignancy (primary HCC or mets)
- Alcoholic fatty liver disease (AFLD)
- Non-alcoholic fatty liver disease (NAFLD) - obesity, diabetes, toxins
- Hepatobiliary:
. cirrhosis
. biliary obstruction
. primary biliary cholangitis - Haematological disease- CML, lymphoma, myeloproliferative disease
- Right heart failure with congestion
- Infiltrative:
. amyloidosis
. sarcoidosis
. haemochromatosis - Infection:
. hepatitis (viral, drugs)
. HIV infection
. hydatid disease
. tuberculosis - Ischemic.
Firm and irregular liver
Cirrhosis
Metastatic malignancy
Infection - hydatid cyst
Infiltration- granuloma, amyloid, lipoid (Gaucher’s)
DDX Tender liver (4)
- Hepatitis
Rapid liver enlargement- - RHF
- Budd-Chiari
- HCC
Pulsatile liver (2)
TR
HCC
Causes of Renal mass
Bilateral
- polycystic kidney
- acromegaly
- amyloid, lymphoma and other infiltration
Unilateral
- RCC
- hydronephrosis or pyonephrosis
- polycystic kidney
- acute renal vein thrombosis
- solitary kidney
Abdominal masses
- right iliac fossa
- left iliac fossa
- upper abdomen
RIF
- appendix abscess
- caecal cancer, carcinoid tumour
- crohn’s
- pelvic kidney
- ovarian tumour or cyst
- psoas abscess
LIF
- faeces
- sigmoid/descending colon ca
- diverticular dx
- ovarian tumor / cyst
- psoas abscess
Upper abdomen
- retroperitoneal lymphadenopathy (lymphoma, teratoma)
- abdominal aortic aneurysm (pulsatile)
- stomach ca
- pancreatic pseudocyst or tumour
- transverse colon carcinoma
Causes of Splenomegaly (>2cm below subcostal margin)
CHI3
Mod (11-20)
Massive (>20)
Chronic liver disease, with portal HTN
Haematological: CML, myeloproliferative (PRV, ET), myelofibrosis, lymphoproliferative (lymphoma, leukemia), anaemia (thalassaemia, haemolytic anaemia, megaloblastic anaemia)
Infection: malaria, EBV, infective endocarditis
Infiltration: amyloid, sarcoid, Gaucher’s disease
Inflammation: connective tissue disease (RA, SLE), vasculitis (PAN)
Classification:
Mod (11-20cm)
-Haematological (lymphoma, myeloproliferative, hemolytic anaemia)
-Infection (schistosomiasis, malaria, leischmaniasis, EBV)
-Inflammation (RA, SLE, sjogrens)
Massive (>20cm)
-Haematological (Myelofibrosis, CML)
5 features distinguishing SPLEEN from KIDNEY.
- Spleen no palpable upper border
- Spleen has notch
- Spleen moves inferomedially on inspiration
- Spleen not bimanually palpable (ballotable)
- Spleen might have friction rub heard.
Abdo EXAM: chronic liver disease
General
Skin
Hands
Face
Abdomen
Arterial systolic bruit
Friction rub
Venous hum
Ix:
Bloods
Ascitic fluid
Imaging
General:
- cachexia, muscle wasting
- poor dentition
- hair loss and testicular atrophy (men)
- gynaecomastia (men) + breast atrophy (women)
-tattoos
-pedal oedema
Skin:
- excoriation marks
- purpura
- spider naevi
Hands:
-clubbing
-palmar erythema
-leuconychia
-dupuytren’s contractures
Face:
-icterus
-parotid swelling
-pallor
Abdomen:
-caput medusae
-ascites
-hepatomegaly
-hepatic bruit
-splenomegaly
-previous ascitic tap/drains
Arterial systolic bruit:
- HCC
- Acute alcoholic hepatitis
Friction rub:
- tumour
- recent liver biopsy
- infarction (splenic rub = infarction)
- gonococcal perihepatitis
Venous hum = portal hypertension.
Ix:
Bloods: FBC, UnE, LFT + albumin, GGT, coagulation screen, hepatitis serology, ceruloplasmin, ferritin, autoantibodies (antimitochrondrial antibody AMA), anti-smooth muscle, anti-liver kidney microsomal (LKM), antinuclear antibody (ANA), alpha-fetoprotein (AFP), thyroid function tests (TFT), coeliac screen, alpha-1 antitrypsin level, glucose
Ascitic fluid: gram stain + cell count (>250 wcc = SBP), protein, culture
Imaging: US ?hepatosplenomegaly, ascites, dopper flow hepatic/portal vein: r/o thrombosis, CT abdo.
Ascitic fluid
Imaging
Causes of cirrhosis
ABC2I2
Autoimmune hepatitis
Biliary: PBC, PSC
Chronic liver disease: AFLD, NAFLD
Cardiac: RHF
Inherited: Haemochromatosis, A1AT deficiency, wilsons
Infection: hepatitis
CNS signs of alcoholism
Peripheral neuropathy
Proximal myopathy
Cerebellar syndrome
Wernicke’s encephalopathy (bilateral VI nerve palsies)
Korasakoff psychosis
ADPKD Ix to request
BP
Urine: haematuria (haemorrhage into cysts) + proteinuria (<2g/d)
Anaemia 2o CKD or polycythemia (high EPO levels)
Imaging:
. CTB: aneurysm
. Hepatic and splenic cyst
Echo: MVP / AR
Haemochromatosis (auto recessive)
Bronze skin pigment
Joint arthropathy, pseudogout
Testicular atrophy
Dilated cardiomyopathy
Liver cirrhosis
Diabetes
Causes of hepatosplenomegaly
ACHI2P
Acromegaly
Chronic liver disease with portal hypertension
Haematological:
-Lymphoproliferative: CLL, HL, NHL
-Myeloproliferative: CML, AML, PRV, ET
-Myelofibrosis
-Anaemia: thalassaemia, sick cell disease
Infection: hepatitis, EBV, CMV, HIV, Hep B/C, malaria, brucellosis, toxoplasmosis, leptospirosis
Infiltration: amyloid, sarcoid, glycogen storage disease
PCKD
Causes of generalised lymphadenopathy
Lymphoma (rubbery and firm)
Leukaemia (CLL, acute lymphoblastic leukaemia)
Malignancy (mets or reactive changes, asymmetrical and firm)
Infection- viral (CMV, HIV, infectious mono), bacterial (tuberculosis, brucellosis), protozoal (toxoplasmosis).
Connective tissue disease (RA, SLE)
Infiltration- sarcoid.
Drugs- phenytoin (pseudolymphoma).
Causes of diffuse goitre
Idiopathic
Puberty, pregnancy and postpartum
Iodine deficiency or excess
Drugs: lithium, amiodarone, immunotherapy
Hashimotos
Graves
Thyroiditis- subacute (tender), chronic fibrosing (rare)
Inherited: Pendreds (thyroid hormone synthesis error, auto recessive, nerve deafness)
Causes of thyrotoxicosis
Primary:
Graves
Toxic adenoma
Multinodular goitre
Iodine induced (Jod-basedown)
Excess thyroid hormone
Drugs: amiodarone, lithium
Thyroiditis: Hashimotos (early), subacute (transient), post-partum, granulomatous (painful) or lymphatic (painless)
Secondary
- Pituitary
- Ectopic TSH
HCG secreting hydatiform mole or choriocarcinoma
Struma Ovarii
Causes of hypothyroidism.
WITHOUT goitre.
- idiopathic atrophy
- agenesis or lingual thyroid
- iatrogenic (iodine, thyroidectomy)
WITH a goitre.
- Hashimotos
- Chronic fibrosing thyroiditis (late hashimotos, Riedel’s thyroiditis)
- Drugs (Lithium, amiodarone, iodine Jod-basedow)
- Iodine deficiency
- Enzyme deficiency (Pendreds)
SECONDARY = hyposecreting pituitary.
TERTIARY = hyposecreting hypothalamus.
TRANSIENT = thyroid hormone treatment withdrawn, subacute thyroiditis, postpartum thyroiditis.
Causes of anaemia in pts with hypothyroidism.
Chronic disease (direct or EPO mediated BM supression)
Folate deficiency (secondary to bacterial overgrowth)
Pernicious anaemia (associated with myxoedema)
Iron deficiency (menorrhagia)
Haemolysis (secondary to hypercholesterolaemia-induced spur-cell anaemia)
Neurological associations of hypothyroidism.
Common
- entrapment (carpal tunnel, tarsal tunnel)
- delayed relaxation of ankle jerks
- nerve deafness
Uncommon
- peripheral neuropathy
- proximal myopathy (normal CK)
- hypokalaemic periodic paralysis
- eaton-lambert syndrome OR deterioration / unmasking of myasthenia gravis
- cerebellar syndrome
- psychosis
- coma
- cerebrovascular disease
- high CSF protein
- muscle cramps
Causes of panhypopituitarism.
GH, FSH, LH -> TSH -> ACTH
Chromophobe adenoma (male, most common cause)
Space occupying lesion (craniopharyngioma, metastatic carcinoma, granuloma)
Iatrogenic (surgery, radiation)
Sheehan’s syndrome (postpartum necrosis)
Head injury
Idiopathic
Causes of hirsutism
Constitutional (normal endocrinology)
PCOS
Adrenal- cushing’s, congenital adrenal hyperplasia, virilising adrenal tumor
Ovarian- stromal ovarian cancer
Drugs- phenytoin, diazoxide, streptomycin, minoxidil, androen, glucocorticoids
Other- acromegaly, porphyria cutanea tarda
EXAM: Thyroid (neck)
GEN INSP.
-comfortable
-non-agitated
-dressed appropriately
NECK INSP.
-anterior enlargement.
-move up with swallow
-no move with tongue protrusion
PALPATION.
-symmetrical diffuse goitre / bilateral multinodular enlargement
-no single dominant nodule OR nodular enlargement
-non-tender
-lower edge: palpable OR non-palpable ?dullness to percussion (retrosternal extension)
AUSCULTATE.
-thyroid bruit.
LYMPH NODES.
-submental, submandibular, pre-auricular, post-auricular, posterior cervical, parotid, occipital or supraclavicular.
CAROTID ARTERY.
-malignant infiltration x if palpable
THYROID STATUS.
-Hyperthyroid
-Hypothyroid
Hyperthyroid state features.
Hands: tremor, clubbing, palmar erythema/sweating, tachycardia (irregular)
Arms: proximal myopathy, brisk reflexes
Face: exopthalmos, lid lag, opthalmoplegia
Legs: pretibial myxedema, prox myopathy, brisk reflexes
Cardiac: systolic flow murmur, AF, heart failure
Resp: pleural effusion
Hypothyroid state features.
Hands: dry, cold skin, bradycardia with peripheral cyanosis
Limbs (arms/legs): prox myopathy, delayed reflexes
Face: perioribital oedema, loss of eyebrow 1/3, slow speech
Cardiac: pericardial effusion
Resp: pleural effusion
DDx neck mass (5)
Goitre
Thyroglossal cyst
Branchial cyst
Lymphadenopathy
Vascular aneurysm
Abdo EXAM: Neck (Haematology)
-lymph nodes
-general
-face
-bone
-chest
-abdo
Ix:
-Bloods: FBC, LDH, blood film, viral screen, autoimmune screen, LFTs, lymph node biopsy, bone marrow aspirate and trephine, CXR, sputum for acid-fast bacilli
-CT/PET, LP
SUMMARY.
Generalised lymphadenopathy without evidence of cytopenias.
Lymph nodes.
-submental
-submandibular
-pre-auricular and post-auricular
-posterior cervical
-occipital
-supraclavicular
-axillary AND inguinal
-epitrochlear
General.
-evident lumps
-purpura
-pallor
-cachexia
Face.
-eyes: conjunctival pallor, scleral icterus, plethora (polycythemia)
-scratch marks (myeloproliferative disorder)
-petechiae
-echymoses
-enlarged tonsils
Bone (tenderness).
-sternum
-long bones
-arthritis
Chest.
-Hickman’s scar.
Abdo.
-Hepatosplenomegaly.
-inguinal lymph nodes
Endocrine EXAM: Acromegaly
SUMMARY.
Morphological features suggestive of acromegaly with visual field loss, nerve entrapment, cardiac sequelae, athropathy, proximal myopathy and diabetes.
Hands: spade like hands, sweaty palms with thick skin, carpal tunnel, ?finger prick for diabetes
Arms: prox myopathy, HTN
Axilla: skin tags, acanthosis nigricans
Face: frontal bossing, prominent supraorbital ridge, enlarged features with macroglossia, previous pituitary surgery (nose), hirsutism, protrusion of lower jaw, splaying of teeth
Eyes: visual field (bitemporal homonymous hemianopia), fundoscopy (optic atrophy, papilloedema), opthalmoplegia
Neck: goitre
Chest: gynaecomastia, cardiomegaly
Abdo: hepatosplenomegaly, other organomegaly
Legs: OA, common peroneal nerve entrapment (foot drop), heel pad thickening
Further: BP, U/A, fundoscopy (angioid streaks), headache, increasing ring or shoe size
INVESTIGATIONS: IGF1, glucose growth hormone suppression test, MRI pituitary, HbA1c, sleep study (OSA), echo, colonoscopy (bowel cancer)
EXAM: diabetes
-gen insp
-legs
-arms
-eyes
-mouth and ears
-neck
-chest
-abdo
-other
GEN INSP.
-weight (obesity)
-hydration
-endocrine facies (cushing, acromegaly)
-pigmentation (haemochromatosis)
LEGS.
-INSP: skin- necrobiosis, hair loss, infection, pigmented scars, atrophy, ulceration, injection sites, muscle wasting, joint destruction (charcots)
-PALPATE: temp feet (cold, blue owing to PVD)/
-Peripheral pulses: femoral, popliteal, posterior tibial, dorsalis pedis.
-Oedema
-neurological assessment, femoral nerve mononeuritis, peripheral neuropathy
ARMS.
-INSP: skin lesions
-Pulse / postural BP
EYES.
-Fundi: cataracts, retinal disease, CN 3 palsy
MOUTH and EARS.
-infection
NECK.
-carotid arteries, palpate and ascultate.
CHEST.
-signs of infection.
-cardiac disease
ABDO.
-liver: fat infiltration=NASH, rarely haemochromatosis
-fat hypertrophy - insulin injection sites
OTHER.
-urinalysis: glycosuria, ketones, proteinuria
-blood pressure and pulse: lying and standing
Endocrine EXAM: Cushings.
-gen insp
-arms
-face
-back
-legs
-mental state
-abdo
-other
Ix: 24hr urine free cortisol level, late night salivary cortisol level, FBC, UnE, serum BSL
-low dose dex suppression test
-8mg dex suppression test
-other tests: serum ATCH, petrosal sinus ACTH sampling, pituitary and adrenal imaging.
GEN INSP.
-central obesity and thin limbs
-skin bruising, atrophy
-pigmentation (ACTH tumour- rare, or bilateral adrenalectomy)
-poor wound healing
ARMS.
-purple striae proximally
-prox myopathy
-HTN
FACE.
-plethora, hirsutism, acne, telangiectasia
-moon shape
-eyes: visual fields (pituitary tumour), fundi (atrophy, papilloedema, signs of HTN or diabetes).
-mouth: thrush
-neck: supraclavicular fat pads, acanthosis nigricans
BACK.
-interscapular fat pad
-kyphoscoliosis (osteoporosis)
-tenderness of vertebrae (osteoporotic fracture)
LEGS.
-prox myopathy
-striae (thighs)
-bruising, oedema
MENTAL STATE.
-depression
-psychosis
-irritability
ABDO.
-purple striae
-adrenal masses, adrenalectomy scars, liver (tumour deposits)
OTHER.
-urine analysis (glycosuria, evidence renal stone disease)
-blood pressure (HTN)
-signs of ectopic tumour (e.g. lung small cell caarcinoma or carcinoid)- rare
Causes and mx of chronic liver disease (5)
Alcohol: parotid swelling, cachexia, dupuytren’s contracture
Mx: alcohol avoidance, diuretics, vit B compound, thiamine, oesophagogastroduodenoscopy (AGD) ?oesophageal varices.
Viral hepatitis: tattoos, injection sites
Mx Hep C: antiviral agents
Wilson’s disease: kayser-fleischer rings, parkinsonism, cognitive impairment, heart failure
Mx: chelation, penicillamine, trientine
Haemochromatosis: slate-gray pigmentation, diabetes, heart failure, arthritis
Mx: venesection (aim ferr <50ug/L)
Alpha-1 antitrypsin deficiency: SOB, hyperinflated chest, cor-pulmonale, clubbing (bronchiectasis)
Mx: supportive, avoid smoking, alpha-1 antitrypsin replacement optional.
Consider liver transplant.
Signs of decompensated chronic liver disease
Jaundice
Portal HTN
1. Hepatic encephalopathy
2. Ascites
3. Varices
Hepatorenal syndrome
Ascites investigation
Protein level (serum ascites-albumin gradient) = serum albumin - ascites albumin.
SAAG >11 (transudate) = cirrhosis and hepatic failure, alcoholic hepatitis, cardiac failure, budd-chiari, portal vein thrombosis, veno-occlusive disease, myxoedema, fatty liver of pregnancy
SAAG <11 (exudate) = peritoneal cancer, peritonitis, pancreatitis, bowel obstruction, biliary obstruction, , post-op lymphatic leak, serositis (CTD)
Neuts, mcs for SBP (neut >250)
Amylase (pancreatitis)
Cytology (malignancy)
Abdo EXAM: hepatosplenomegaly
-General
-Peripheral
-Abdomen
-Investigations
-Management
General:
-purpura
-pallor
-jaundice
Peripheral:
-enlarged tonsils
-lymphadenopathy
-features of CLD
Abdomen:
-splenomegaly, hepatomegaly
-ascites
-inguinal LN
Investigations:
-Bloods: FBC, LDH, blood film, viral screen, autoimmune screen, LFT, renal function, serum and urine electrophhoresis
-Imaging: abdo US, CT/PET scan
-Invasive: LN bx, BM aspirate and trephine, other bx site (renal bx for amyloidosis).
Abdo EXAM: multiple abdominal scars
DDx: IBD
Ix:
-stool mcs, c.diff toxin
-bloods: fbc, crp, lfts, autoimmune hepatitis PBC
-faecal calprotectin
-AXR r/o toxic megacolon
-sigmoidoscopy/colonoscopy and bx
-MRI small bowel or bowel US ?SB strictures
Mx:
-medical: immunosuppression, steroids, 5-ASA, DMARDs (AZA, mercaptopurine, MTX and biological agents).
-surgical: fistulae, strictures, failure to respond to medical therapy
-nutritionla support and elemental and low-residue diets
-psychological support
General: cachexia, cushingoid, nutritional state.
Peripheral: oral ulcers, pallor, finger-pricks, gum hypertrophy, HTN (ciclosporin)
Abdomen: surgical scar (midline), stoma sites (past/current), evidence previous PD catheter exit site or removal (RRT) or repeated ascitic drainage
Extra: rectal exam (fistualae, abscess).
Abdo EXAM: palpable kidneys
General: anaemia, HTN, RRT
Hands: tremor
Arms: AV fistula, graft
Face: gum hypertrophy, anaemia, alopecia
Chest/neck: dialysis cath scars
Abdomen: enlarged kidneys, hepatosplenomegaly (ADPKD), renal transplant, nephrectomy scars.
Legs: oedema
Autosomal dominant polycystic kidney disease (ADPKD)
ADPKD
Other manifestations:
-cystic disease (liver, spleen, pancreas)
-berry aneurysm
-pain/haematuria (cyst rupture, infection, stone or RCC)
-RCC
-valve disease: MVP or AR
-HTN: LVH
-GI: colonic diverticulum formation, herniae
Indications for nephrectomy:
-recurrent infection
-chronic pain
-recurrent haematuria
-GI pressure (early satiety)
-size/creating space for transplant
Ix:
-urinalysis: haematuria, proteinuria, signs of infection
-US abdomen: renal size, cysts, obstruction, liver cysts
-CT abdo: ?malignancy
-MRI: renal size/volume
-echo: MVP, AR and LVEF
-cerebral angiogram: berry aneurysms, if first degree relative with ADPKD had SAH or bleed.
-genetic test: ADPKD 1 and 2.
Mx:
-counselling and Ix first degree relatives.
-monitoring
. renal function
. HTN
. CKD
. complications
-nephrectomy
-vasopressin antagonists (tolvaptan) inhibits vasopressin binding to V2 receptors, reduce cell proliferation, cyst formation and fluid excretion (rapidly progressive disease).
-RRT
Abdo exam: RRT / renal transplant.
SUMMARY: scar in the RIF overlying a mass, likely in keeping with a renal transplant with no evidence of graft failure. There are cushingoid features and evidence of immunosuppression side effects as well as previous RRT with left upper arm AV fistula.
(salient finding, current graft function, complications of treatment, previous RRT ?aetiology).
-general
-hands
-arms
-face
-abdomen
-salient
.renal transplant
.function
.RRT
.fluid status (JVP, peripheral oedema)
.immunosuppression
.cause
General: cushingoid
Hands:
-finger prick test (diabetes, cause or NODAT).
-fine tremor (tacrolimus)
Arms:
-AV fistula (feel for thrill, listen for bruit, fresh puncture)
. radiocephalic (wrist)
. brachiocephalic (antecubital fossa)
. brachiobasilic (medial from ACF)
-AV fistula = thrill + bruit
-Synthetic graft = bruit, no thrill.
Face: corneal arcus, gum hypertrophy (ciclosporin)
Neck/chest: IJV cath, tunnelled-catheter exit site scar, parathyroidectomy scar
Abdomen:
-peritoneal dialysis cath or scar
-midline laparotomy scar or posterior subcostal scar (previous nephrectomy, kidney/pancreas transplant)
-LIF renal transplant ?pancreas transplant simultaneous
Salient:
-renal transplant
-functioning, no recent dialysis or fluid overload
-RRT current and past
-fluid status (JVP, peripheral oedema)
-immunosuppression:
. ciclosporin: gum hypertrophy
. corticosteroids: cushingoid features
. skin lesions: previous skin cancer removal (SCC/BCC)
-?cause
1. Diabetes (lipodystrophy, fingertip pinprick)
2. Glomerulonephritis
3. ADPKD (bilateral ballotable masses)
4. HTN
Note. Alport’s syndrome (hearing aids)
