Abdo/endocrine shorts

Question 1

Ddx Hepatomegaly (9)

Answer 1

1. Malignancy (primary HCC or mets)
2. Alcoholic fatty liver disease (AFLD)
3. Non-alcoholic fatty liver disease (NAFLD) - obesity, diabetes, toxins
4. Hepatobiliary:
   . cirrhosis
   . biliary obstruction
   . primary biliary cholangitis
5. Haematological disease- CML, lymphoma, myeloproliferative disease
6. Right heart failure with congestion
7. Infiltrative:
   . amyloidosis
   . sarcoidosis
   . haemochromatosis
8. Infection:
   . hepatitis (viral, drugs)
   . HIV infection
   . hydatid disease
   . tuberculosis
9. Ischemic.

Question 2

Firm and irregular liver

Answer 2

Cirrhosis
Metastatic malignancy
Infection - hydatid cyst
Infiltration- granuloma, amyloid, lipoid (Gaucher’s)

Question 3

DDX Tender liver (4)

Answer 3

1. Hepatitis
   Rapid liver enlargement-
2. RHF
3. Budd-Chiari
4. HCC

Question 4

Pulsatile liver (2)

Answer 4

TR
HCC

Question 5

Causes of Renal mass

Answer 5

Bilateral
- polycystic kidney
- acromegaly
- amyloid, lymphoma and other infiltration

Unilateral
- RCC
- hydronephrosis or pyonephrosis
- polycystic kidney
- acute renal vein thrombosis
- solitary kidney

Question 6

Abdominal masses
- right iliac fossa
- left iliac fossa
- upper abdomen

Answer 6

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

Question 7

Causes of Splenomegaly (>2cm below subcostal margin)
CHI3
Mod (11-20)
Massive (>20)

Answer 7

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)

Question 8

5 features distinguishing SPLEEN from KIDNEY.

Answer 8

1. Spleen no palpable upper border
2. Spleen has notch
3. Spleen moves inferomedially on inspiration
4. Spleen not bimanually palpable (ballotable)
5. Spleen might have friction rub heard.

Question 9

Abdo EXAM: chronic liver disease
General
Skin
Hands
Face
Abdomen
Arterial systolic bruit
Friction rub
Venous hum

Ix:
Bloods
Ascitic fluid
Imaging

Answer 9

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

Question 10

Causes of cirrhosis
ABC2I2

Answer 10

Autoimmune hepatitis
Biliary: PBC, PSC
Chronic liver disease: AFLD, NAFLD
Cardiac: RHF
Inherited: Haemochromatosis, A1AT deficiency, wilsons
Infection: hepatitis

Question 11

CNS signs of alcoholism

Answer 11

Peripheral neuropathy
Proximal myopathy
Cerebellar syndrome
Wernicke’s encephalopathy (bilateral VI nerve palsies)
Korasakoff psychosis

Question 12

ADPKD Ix to request

Answer 12

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

Question 13

Haemochromatosis (auto recessive)

Answer 13

Bronze skin pigment
Joint arthropathy, pseudogout
Testicular atrophy
Dilated cardiomyopathy
Liver cirrhosis
Diabetes

Question 14

Causes of hepatosplenomegaly
ACHI2P

Answer 14

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

Question 15

Causes of generalised lymphadenopathy

Answer 15

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).

Question 16

Causes of diffuse goitre

Answer 16

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)

Question 17

Causes of thyrotoxicosis

Answer 17

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

Question 18

Causes of hypothyroidism.

Answer 18

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.

Question 19

Causes of anaemia in pts with hypothyroidism.

Answer 19

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)

Question 20

Neurological associations of hypothyroidism.

Answer 20

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

Question 21

Causes of panhypopituitarism.

GH, FSH, LH -> TSH -> ACTH

Answer 21

Chromophobe adenoma (male, most common cause)
Space occupying lesion (craniopharyngioma, metastatic carcinoma, granuloma)
Iatrogenic (surgery, radiation)
Sheehan’s syndrome (postpartum necrosis)
Head injury
Idiopathic

Question 22

Causes of hirsutism

Answer 22

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

Question 23

EXAM: Thyroid (neck)

Answer 23

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

Question 24

Hyperthyroid state features.

Answer 24

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

Question 25

Hypothyroid state features.

Answer 25

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

Question 26

DDx neck mass (5)

Answer 26

Goitre
Thyroglossal cyst
Branchial cyst
Lymphadenopathy
Vascular aneurysm

Question 27

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

Answer 27

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

Question 28

Endocrine EXAM: Acromegaly
SUMMARY.
Morphological features suggestive of acromegaly with visual field loss, nerve entrapment, cardiac sequelae, athropathy, proximal myopathy and diabetes.

Answer 28

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)

Question 29

EXAM: diabetes
-gen insp
-legs
-arms
-eyes
-mouth and ears
-neck
-chest
-abdo
-other

Answer 29

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

Question 30

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.

Answer 30

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

Question 31

Causes and mx of chronic liver disease (5)

Answer 31

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.

Question 32

Signs of decompensated chronic liver disease

Answer 32

Jaundice
Portal HTN
1. Hepatic encephalopathy
2. Ascites
3. Varices
Hepatorenal syndrome

Question 33

Ascites investigation

Answer 33

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)

Question 34

Abdo EXAM: hepatosplenomegaly
-General
-Peripheral
-Abdomen
-Investigations
-Management

Answer 34

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).

Question 35

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

Answer 35

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).

Question 36

Abdo EXAM: palpable kidneys

Answer 36

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

Question 37

Autosomal dominant polycystic kidney disease (ADPKD)

Answer 37

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

Question 38

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

Answer 38

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)