abdo interactive cases Flashcards
inspection in abdo exam
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
inspection of hands
o A-E o Asterixis – liver failure o Bruising o Clubbing o Dupuytren’s contracture o Erythema o Leukonychia
why would you get gum hypertrophy
if on medication eg ciclosporine after renal transplant
chest inspection
Gynaecomastia
Hair loss
Excoriation marks
Spider naevi
what do you look for on abdominal inspection
abdo distension
caput medusae
scars
describe caput medusae
distended superficial abdominal veins
direction of flow in the veins below the umbilicus is towards the legs.
scars on the abdomen
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)
where do you palpate the kidneys
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
how do you get the pt to move when assessing shifting dullness
get them to role towards you
IPPA abdo
Palpation & Percussion for masses & organomegaly (liver, spleen, kidneys)
Percussion: shifting dullness
Percussion: bladder
Auscultation
lymphadenopathy in neck and axillae at end to collect thoughts
causes of hepatomegaly
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
causes of liver disease
o Autoimmune o Alcohol o Drugs o Viral o biliary disease
causes of splenomegaly
H (portal Hypertension) - high pressure in the portal vein
H (Haematological) - lymphoma, leukaemia
Infection - malaria, IE, TB
Inflammation - sarcoid, connective tissue disorders
RF for viral disease
IV drug
travel
tattoos
75 year old man
Epigastric pain
Back pain
PR: 130 bpm
BP: 80/50 mm Hg
most likely dx
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
constant abdo pain
inflammatioon
colicky abdo pain
obstruction
epigastric pain
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
characteristics/blood of acute pancreatitis
pain
high amylase
characteristics of chronic pancreatitis
Pain, wt loss
Loss of exocrine function - digestion
Loss of endocrine function - dm
Normal amylase
Faecal elastase present in stool
RUQ pain
Gall bladder:
Cholecystitis
Cholangitis
Gallstones
Liver:
Hepatitis
Abscess
Above: (lungs) Basal pneumonia Below: (appendix) Appendicitis Left: (Stomach, pancreas) Peptic ulcer, Pancreatitis Right: (kidney) pyelonephritis
pain in cholecystitis
constant - inflammation
pain in gallstones
colicky
when would you get appendicitis presenting with RUQ pain
retrocecal appendix (very long) and pregnancy
RIF pain
GI: Appendicitis Mesenteric adenitis Colitis (IBD) Malignancy
Gynaecological:
Ovarian cyst rupture, twist, bleed
Ectopic pregnancy
suprapubic pain
cystitis
urinary retention
LIF pain
GI:
Diverticulitis
Colitis (IBD)
Malignancy
Gynaecological:
Ovarian cyst rupture, twist, bleed
Ectopic pregnancy
diffuse abdominal pain
Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric ischaemia
Medical causes: DKA Addison’s Hypercalacemia Porphyria Lead poisoning
features of addisonian crisis
nausea vom abdo pain hyponatraemia hyperkalaemia
hyperpigmentation at pressure points
does cushings cause hyperpigmentation
• If malignancy producing a lot of ACTH in cushings – hyperpigmented because of excess ACTH – otherwise doesn’t
what do the mesenteric arteries supply
celiac - stomach, spleen, liver, gallbladder, duodenum
SMA - SI, R colon
IMA - L colon
iliac artery - rectum (top of anal canal is IMA)
mesenteric ischemia
cause blockage in the mesenteric arteries = pain = angina after eating
65 year old man
AAA repair 2 days ago
Diffuse abdominal pain
PR: 120 bpm
RR: 30
His blood tests are likely to show:
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
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)
Ascites neut ≥ 250 cells/mm3
SBP may have precipitated encephalopathy and confusion
causes of abdo distension
fluid flatus fat faeces fetus
clues of fluid causing distension
ascites - shifting dullness
features of liver disease
clues of flatus causing distension
Obstruction Nausea, vomiting Not opened bowel High-pitched tinkling BS ?Previous surgery (adhesions) ?Tender irreducible femoral hernia in the groin
summarise transudate and exudate classifications of ascites
o Transudate – less protein – failures – heart, liver and kidneys
o Exudate – infection, inflam, malig – more protein
causes of transudate ascites
Cirrhosis
Cardiac failure
Nephrotic syndrome
causes of exudate ascites
Malignancy (abdominal, pelvic, peritoneal mesothelioma)
Infection: e.g. TB, pyogenic
Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
50 year old man Jaundice RUQ pain Dark urine Pale stool
cause of pale stool
low stercobilinogen
classifications of jaundice
pre-hepatic
hepatic
post hepatic
pre-hepatic causes of jaundice
haemolysis
defective conjugation
hepatic causes of jaundice
hepatitis
post-hepatic causes of jaundice
CBD obstruction
BR
red blood cells broken down = unconjugated BR
conjugated in liver
excrete it
turned into stercobilinogen (brown) by bacteria
summarise pre-hepatic jaundice
haemolysis - pts will be pale and jaundice because breaking down RBC
Gilbert’s syndrome - defective glucuronidation
summarise hepatic jaundice
hepatitis - alcohol, autoimmune, drugs, viruses
conjugated BR leaks out of hep – into urine to be excreted = dark urine
summarise post-hepatic jaundice
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 )
pruritis and jaundice
related to endogenous opioids
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:
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
markers elevated in hepatic jaundice
ALT and AST
what is a-fetoprotein
hepatocellular ca marker
erythema nodosum
purple nodules on skin
ddx for bloody diarrhoea
infective colitis inflammatory colitis ischemic colitis diverticulitis malignancy
causes of infective colitis
CHESS Campylobacter Haemorrhagic E coli Entamoeba histolytica Salmonella Shigella
when do you think inflammatory colitis
Young, Extra-GI manifestations: episcleritis, uveitis, eyrthema nodosum
when do you think ischemic colitis
elderly
when do you think diverticulitis/malignancy
change of bowel habit and PR blood
what is ca125
ovarian cancer marker
time frame of bloody diarrhoea
infective colitis - acute inflammatory - acute on chronic ischemic - acute malignancy - chronic diverticular disease - chronic diverticulitis - acute
thickening of colon wall, thumb printing and thickening of haustral folds on AXR
inflammation
lead pipe featureless colon
UC
toxic megacolon >6cm
– 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
treatment of diarrhoa with fecal impaction on AXR
it is overflow diarrhoea
treatment of diarrhoea is to treat the constipation
management of an acute GI bleed
o ABC o Iv access o NBM o Fluid o G&S (identify blood groups) Xmatch o OGD
management of acute abdomen
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
management of variceal bleed
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
investigations for an acute abdo
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
investigations if jaundice
Bloods: FBC, LFTs, CRP
Abdominal USS
after a fast (gallstones better visualized in a distended, bile-filled gallbladder)
investigations if dysphagia and weight loss
OGD and biospy
investigations of PR bleed and weight loss
colonoscopy
treatment of ascites
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 )
classification of ascites
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
nephrotic syndrome
– lose protein in urine – low albumin in blood – dm, amyloidosis, sle
nephritic syndrome
glomerular nephritis - see blood and protein in the urine
treatment of encephalopathy
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
signs of wound infection
erythematous
discharge
signs of anastomotic leak
diffuse abdo tenderness
guarding
rigidity
hypotensive/tachycardic
signs of pelvic abscess eg post-appendectomy
pain
fever
sweats
mucus diarrhoea
perianal abscess
Tender, red swelling
Incision & drainage
anal fissure
Rectal pain (defaecation)
Stool coated with blood
Advice re diet (fluids, fibre)
GTN cream
presentation of IBS
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
treatment of IBS
Diet & Lifestyle modification Symptomatic treatment: Abdo pain: antispasmodics Laxatives for constipation Anti-diarrhoeals
Courvoisier sign
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
