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DPD > abdo interactive cases > Flashcards

abdo interactive cases Flashcards

1
Q

inspection in abdo exam

A

o Arms – needle marks, excoriations, Acanthosis nigricans– malignancy/insulin, fistula (renal replacement therapy CKD), bruising, tattoos
o Hands - chronic liver disease
o Eyes – jaundice (upper eye lid), pallor
o Neck – lymphadenopathy
o Cachexia
o Chest – spider naevi, gynecomastia,
o Abdo – scars, organomegaly, tenderness
hair loss
oral - pigmentation/gum hypertrophy

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2
Q

inspection of hands

A 
o	A-E
o	Asterixis – liver failure 
o	Bruising 
o	Clubbing 
o	Dupuytren’s contracture 
o	Erythema 
o	Leukonychia
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3
Q

why would you get gum hypertrophy

A

if on medication eg ciclosporine after renal transplant

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4
Q

chest inspection

A

Gynaecomastia
Hair loss
Excoriation marks
Spider naevi

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5
Q

what do you look for on abdominal inspection

A

abdo distension
caput medusae
scars

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6
Q

describe caput medusae

A

distended superficial abdominal veins

direction of flow in the veins below the umbilicus is towards the legs.

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7
Q

scars on the abdomen

A

Right subcostal (Kocher’s) incision (biliary surgery)
Mercedes-Benz incision (liver transplant)
Midline laparotomy incision (GI or any major abdominal surgery)
McBurney’s (Gridiron) incision (appendicectomy)
J-shaped/ ‘hockey stick’ incision (renal transplant)
Low transverse (Pfannenstiel) incision (gynaecological procedures)
Inguinal incision (hernia repair, vascular access)
Loin incision (nephrectomy)

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8
Q

where do you palpate the kidneys

A

in renal angle not in the flanks one hand under the pt close to the spine
• Renal angle – between spine and ribs ie not peripheral

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9
Q

how do you get the pt to move when assessing shifting dullness

A

get them to role towards you

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10
Q

IPPA abdo

A

Palpation & Percussion for masses & organomegaly (liver, spleen, kidneys)

Percussion: shifting dullness

Percussion: bladder

Auscultation

lymphadenopathy in neck and axillae at end to collect thoughts

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11
Q

causes of hepatomegaly

A 
Cancer (primary or secondary deposits)
Cirrhosis (early, usually alcoholic - in late cirrhosis liver shrinks)
Cardiac: 
Congestive cardiac failure
Constrictive pericarditis

Infiltration:
Fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases

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12
Q

causes of liver disease

A 
o	Autoimmune 
o	Alcohol
o	Drugs 
o	Viral
o	biliary disease
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13
Q

causes of splenomegaly

A

H (portal Hypertension) - high pressure in the portal vein
H (Haematological) - lymphoma, leukaemia
Infection - malaria, IE, TB
Inflammation - sarcoid, connective tissue disorders

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14
Q

RF for viral disease

A

IV drug
travel
tattoos

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15
Q

75 year old man
Epigastric pain
Back pain

PR: 130 bpm
BP: 80/50 mm Hg
most likely dx

A

ruptured aortic aneurysm
: could be pancreatitis or ruptured aortic aneurysm
o Pain going to back, hypotensive – got to think AAA
o Pancreatititis differential
o Got to exclude AAA as an emergency
o Anyone unwell could become hypotensive systemically, chance is higher with ruptured aneurysm
o Scan to differentiate
Hb low in rupture, but if alcoholic and prev GI bleed Hb also low - not black and white

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16
Q

constant abdo pain

A

inflammatioon

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17
Q

colicky abdo pain

A

obstruction

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18
Q

epigastric pain

A 
Stomach:
Peptic ulcer (?NSAID use)
GORD (better with antacids)
Gastritis (retrosternal, ETOH)
Malignancy
Pancreas:
Acute Pancreatitis
(?Gallstones, high amylase)
above, below, R: 
MI
ruptured AAA
cholecystitis
hepatitis
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19
Q

characteristics/blood of acute pancreatitis

A

pain

high amylase

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20
Q

characteristics of chronic pancreatitis

A

Pain, wt loss
Loss of exocrine function - digestion
Loss of endocrine function - dm

Normal amylase
Faecal elastase present in stool

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21
Q

RUQ pain

A

Gall bladder:
Cholecystitis
Cholangitis
Gallstones

Liver:
Hepatitis
Abscess

Above: (lungs)
Basal pneumonia
Below: (appendix)
Appendicitis
Left: (Stomach, pancreas)
Peptic ulcer, Pancreatitis
Right: (kidney)
pyelonephritis
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22
Q

pain in cholecystitis

A

constant - inflammation

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23
Q

pain in gallstones

A

colicky

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24
Q

when would you get appendicitis presenting with RUQ pain

A

retrocecal appendix (very long) and pregnancy

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25
Q

RIF pain

A 
GI:
Appendicitis
Mesenteric adenitis
Colitis (IBD)
Malignancy

Gynaecological:
Ovarian cyst rupture, twist, bleed
Ectopic pregnancy

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26
Q

suprapubic pain

A

cystitis

urinary retention

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27
Q

LIF pain

A

GI:
Diverticulitis
Colitis (IBD)
Malignancy

Gynaecological:
Ovarian cyst rupture, twist, bleed
Ectopic pregnancy

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28
Q

diffuse abdominal pain

A

Obstruction

Infection: Peritonitis, Gastroenteritis

Inflammation: IBD

Ischaemia: Mesenteric ischaemia

Medical causes:
DKA
Addison’s
Hypercalacemia
Porphyria
Lead poisoning
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29
Q

features of addisonian crisis

A 
nausea
vom
abdo pain 
hyponatraemia 
hyperkalaemia

hyperpigmentation at pressure points

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30
Q

does cushings cause hyperpigmentation

A

• If malignancy producing a lot of ACTH in cushings – hyperpigmented because of excess ACTH – otherwise doesn’t

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31
Q

what do the mesenteric arteries supply

A

celiac - stomach, spleen, liver, gallbladder, duodenum
SMA - SI, R colon
IMA - L colon
iliac artery - rectum (top of anal canal is IMA)

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32
Q

mesenteric ischemia

A

cause blockage in the mesenteric arteries = pain = angina after eating

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33
Q

65 year old man
AAA repair 2 days ago
Diffuse abdominal pain

PR: 120 bpm
RR: 30
His blood tests are likely to show:

A

high amylase
o Pt with acute abdo – tachycardiac, AAA repair – worried about leak and ischemia – lactate would go up – be acidotic so bicarb would be high
o Amylase up in any cause of acute abdo, leakage if abdo inflammation – marginally high amylase isn’t necessarily pancreatitis

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34
Q 
55 year old man
Excess ETOH use
Cirrhosis
Confused
Abdominal pain
Abdominal distension

O/E: Ascites, liver flap
what is consistent with spontaneous bacterial peritonitis (SBP)

A

Ascites neut ≥ 250 cells/mm3

SBP may have precipitated encephalopathy and confusion

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35
Q

causes of abdo distension

A 
fluid 
flatus 
fat
faeces
fetus
36
Q

clues of fluid causing distension

A

ascites - shifting dullness

features of liver disease

37
Q

clues of flatus causing distension

A 
Obstruction
Nausea, vomiting
Not opened bowel
High-pitched tinkling BS
?Previous surgery (adhesions)
?Tender irreducible femoral hernia in the groin
38
Q

summarise transudate and exudate classifications of ascites

A

o Transudate – less protein – failures – heart, liver and kidneys
o Exudate – infection, inflam, malig – more protein

39
Q

causes of transudate ascites

A

Cirrhosis
Cardiac failure
Nephrotic syndrome

40
Q

causes of exudate ascites

A

Malignancy (abdominal, pelvic, peritoneal mesothelioma)
Infection: e.g. TB, pyogenic
Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis

41
Q 
50 year old man
Jaundice
RUQ pain
Dark urine
Pale stool

cause of pale stool

A

low stercobilinogen

42
Q

classifications of jaundice

A

pre-hepatic
hepatic
post hepatic

43
Q

pre-hepatic causes of jaundice

A

haemolysis

defective conjugation

44
Q

hepatic causes of jaundice

A

hepatitis

45
Q

post-hepatic causes of jaundice

A

CBD obstruction

46
Q

BR

A

red blood cells broken down = unconjugated BR
conjugated in liver
excrete it
turned into stercobilinogen (brown) by bacteria

47
Q

summarise pre-hepatic jaundice

A

haemolysis - pts will be pale and jaundice because breaking down RBC
Gilbert’s syndrome - defective glucuronidation

48
Q

summarise hepatic jaundice

A

hepatitis - alcohol, autoimmune, drugs, viruses

conjugated BR leaks out of hep – into urine to be excreted = dark urine

49
Q

summarise post-hepatic jaundice

A

Eg gallstone/stricture/head of panc cancer – obstruct the flow of bile – not getting into bowel = pale stool (steatorrhea, no stercobilinogen) – dark urine – conjugated BR in urine leaked out of hep
(• Stone needs to be in CBD to obstruct the flow of bile )

50
Q

pruritis and jaundice

A

related to endogenous opioids

51
Q 
50 year old man
Painless Jaundice
Wt loss
Dark urine
Pale stool

O/E trousseau’s sign of malignancy

His blood tests are most likely to show elevated:

A

ALP and CA19-9
o Painless jaundice – panc cancer
o Enzyme elevated in obstructive jaundice – ALP and GGT
o Ca19-99 marker of pancreatic cancer

52
Q

markers elevated in hepatic jaundice

A

ALT and AST

53
Q

what is a-fetoprotein

A

hepatocellular ca marker

54
Q

erythema nodosum

A

purple nodules on skin

55
Q

ddx for bloody diarrhoea

A 
infective colitis 
inflammatory colitis 
ischemic colitis 
diverticulitis 
malignancy
56
Q

causes of infective colitis

A 
CHESS 
Campylobacter
Haemorrhagic E coli
Entamoeba histolytica
Salmonella
Shigella
57
Q

when do you think inflammatory colitis

A

Young, Extra-GI manifestations: episcleritis, uveitis, eyrthema nodosum

58
Q

when do you think ischemic colitis

A

elderly

59
Q

when do you think diverticulitis/malignancy

A

change of bowel habit and PR blood

60
Q

what is ca125

A

ovarian cancer marker

61
Q

time frame of bloody diarrhoea

A 
infective colitis - acute 
inflammatory - acute on chronic
ischemic - acute 
malignancy - chronic 
diverticular disease - chronic 
diverticulitis - acute
62
Q

thickening of colon wall, thumb printing and thickening of haustral folds on AXR

A

inflammation

63
Q

lead pipe featureless colon

A

UC

64
Q

toxic megacolon >6cm

A

– associated with systemic illness – tachy, hypo, WCC up

• Acute exacerbation of UC – got to do abdo XR – see if evidence of toxic megacolon – would need urgent surgical input

65
Q

treatment of diarrhoa with fecal impaction on AXR

A

it is overflow diarrhoea

treatment of diarrhoea is to treat the constipation

66
Q

management of an acute GI bleed

A 
o	ABC 
o	Iv access
o	NBM 
o	Fluid 
o	G&S (identify blood groups) Xmatch 
o	OGD
67
Q

management of acute abdomen

A 
o	NBM 
o	IV fluids
o	Analgesics
o	Anti-emetics – can get nausea, inc medications you give 
o	Consider AB 
o	Consult surgeons 
o	Monitor vitals and UO
68
Q

management of variceal bleed

A

o Broad spectrum AB eg tazocin
o Terlipressin – vasoconstriction of splanchnic vessels
• SBP = translocation of bacteria - increased mortality with varicieal bleed – reduce mortality with broad spectrum AB

69
Q

investigations for an acute abdo

A 
FBC (anaemia, raised WCC if infection), U&Es (renal func), LFTs (hepatitis/obstruction), CRP (inflammation), Clotting, G&S, X-match
Erect CXR (air under the diaphragm - perforation)
CT
70
Q

investigations if jaundice

A

Bloods: FBC, LFTs, CRP
Abdominal USS
after a fast (gallstones better visualized in a distended, bile-filled gallbladder)

71
Q

investigations if dysphagia and weight loss

A

OGD and biospy

72
Q

investigations of PR bleed and weight loss

A

colonoscopy

73
Q

treatment of ascites

A

Diuretics (spironolactone ± furosemide if peripheral oedema)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin - because haemodynamic shift, remove lots of fluid so pt hypotensive - so give IV albumin )

74
Q

classification of ascites

A

SAG = serum-ascites gradient
SAG = serum albumin - ascites albumin
>11g/L:
Cirrhosis (not making albumin so ascites albumin low - transudate state), Cardiac failure

<11 g/L:
TB (protein in ascites high), Cancer, (Nephrotic syndrome - serum albumin low because losing in urine) - more albumin in ascites so gradient is lower

75
Q

nephrotic syndrome

A

– lose protein in urine – low albumin in blood – dm, amyloidosis, sle

76
Q

nephritic syndrome

A

glomerular nephritis - see blood and protein in the urine

77
Q

treatment of encephalopathy

A

lactulose - effect gut transit time = less time to make ammonia
o Phosphate enemas
o Avoid sedation
o Treat infections
exclude GI bleed because digest on blood so acts as a protein meal - precipitate encephalopathy

78
Q

signs of wound infection

A

erythematous

discharge

79
Q

signs of anastomotic leak

A

diffuse abdo tenderness
guarding
rigidity
hypotensive/tachycardic

80
Q

signs of pelvic abscess eg post-appendectomy

A

pain
fever
sweats
mucus diarrhoea

81
Q

perianal abscess

A

Tender, red swelling

Incision & drainage

82
Q

anal fissure

A

Rectal pain (defaecation)
Stool coated with blood
Advice re diet (fluids, fibre)
GTN cream

83
Q

presentation of IBS

A

Recurrent abdo pain, bloating
Improves with defecation
Change in the frequency/form of stool

No PR bleed, anaemia, wt loss or nocturnal symptoms (IBD will wake you up at night IBS unlikely), exclude Coeliac

84
Q

treatment of IBS

A 
Diet &amp; Lifestyle modification
Symptomatic treatment:
Abdo pain: antispasmodics
Laxatives for constipation
Anti-diarrhoeals
85
Q

Courvoisier sign

A

In presence iof jaundice – enlarged gall bladder likely ca of pancreas not GS. – cant palpate call bladder with stones – gallbladder with stone chronically fibrosed and cant enlarge

DPD (38 decks)

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