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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
RIF pain
``` GI: Appendicitis Mesenteric adenitis Colitis (IBD) Malignancy ``` Gynaecological: Ovarian cyst rupture, twist, bleed Ectopic pregnancy
26
suprapubic pain
cystitis | urinary retention
27
LIF pain
GI: Diverticulitis Colitis (IBD) Malignancy Gynaecological: Ovarian cyst rupture, twist, bleed Ectopic pregnancy
28
diffuse abdominal pain
Obstruction Infection: Peritonitis, Gastroenteritis Inflammation: IBD Ischaemia: Mesenteric ischaemia ``` Medical causes: DKA Addison’s Hypercalacemia Porphyria Lead poisoning ```
29
features of addisonian crisis
``` nausea vom abdo pain hyponatraemia hyperkalaemia ``` hyperpigmentation at pressure points
30
does cushings cause hyperpigmentation
• If malignancy producing a lot of ACTH in cushings – hyperpigmented because of excess ACTH – otherwise doesn’t
31
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)
32
mesenteric ischemia
cause blockage in the mesenteric arteries = pain = angina after eating
33
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
34
``` 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
35
causes of abdo distension
``` fluid flatus fat faeces fetus ```
36
clues of fluid causing distension
ascites - shifting dullness | features of liver disease
37
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 ```
38
summarise transudate and exudate classifications of ascites
o Transudate – less protein – failures – heart, liver and kidneys o Exudate – infection, inflam, malig – more protein
39
causes of transudate ascites
Cirrhosis Cardiac failure Nephrotic syndrome
40
causes of exudate ascites
Malignancy (abdominal, pelvic, peritoneal mesothelioma) Infection: e.g. TB, pyogenic Budd–Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
41
``` 50 year old man Jaundice RUQ pain Dark urine Pale stool ``` cause of pale stool
low stercobilinogen
42
classifications of jaundice
pre-hepatic hepatic post hepatic
43
pre-hepatic causes of jaundice
haemolysis | defective conjugation
44
hepatic causes of jaundice
hepatitis
45
post-hepatic causes of jaundice
CBD obstruction
46
BR
red blood cells broken down = unconjugated BR conjugated in liver excrete it turned into stercobilinogen (brown) by bacteria
47
summarise pre-hepatic jaundice
haemolysis - pts will be pale and jaundice because breaking down RBC Gilbert's syndrome - defective glucuronidation
48
summarise hepatic jaundice
hepatitis - alcohol, autoimmune, drugs, viruses | conjugated BR leaks out of hep – into urine to be excreted = dark urine
49
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 )
50
pruritis and jaundice
related to endogenous opioids
51
``` 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
52
markers elevated in hepatic jaundice
ALT and AST
53
what is a-fetoprotein
hepatocellular ca marker
54
erythema nodosum
purple nodules on skin
55
ddx for bloody diarrhoea
``` infective colitis inflammatory colitis ischemic colitis diverticulitis malignancy ```
56
causes of infective colitis
``` CHESS Campylobacter Haemorrhagic E coli Entamoeba histolytica Salmonella Shigella ```
57
when do you think inflammatory colitis
Young, Extra-GI manifestations: episcleritis, uveitis, eyrthema nodosum
58
when do you think ischemic colitis
elderly
59
when do you think diverticulitis/malignancy
change of bowel habit and PR blood
60
what is ca125
ovarian cancer marker
61
time frame of bloody diarrhoea
``` infective colitis - acute inflammatory - acute on chronic ischemic - acute malignancy - chronic diverticular disease - chronic diverticulitis - acute ```
62
thickening of colon wall, thumb printing and thickening of haustral folds on AXR
inflammation
63
lead pipe featureless colon
UC
64
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
65
treatment of diarrhoa with fecal impaction on AXR
it is overflow diarrhoea | treatment of diarrhoea is to treat the constipation
66
management of an acute GI bleed
``` o ABC o Iv access o NBM o Fluid o G&S (identify blood groups) Xmatch o OGD ```
67
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 ```
68
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
69
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 ```
70
investigations if jaundice
Bloods: FBC, LFTs, CRP Abdominal USS after a fast (gallstones better visualized in a distended, bile-filled gallbladder)
71
investigations if dysphagia and weight loss
OGD and biospy
72
investigations of PR bleed and weight loss
colonoscopy
73
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 )
74
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
75
nephrotic syndrome
– lose protein in urine – low albumin in blood – dm, amyloidosis, sle
76
nephritic syndrome
glomerular nephritis - see blood and protein in the urine
77
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
78
signs of wound infection
erythematous | discharge
79
signs of anastomotic leak
diffuse abdo tenderness guarding rigidity hypotensive/tachycardic
80
signs of pelvic abscess eg post-appendectomy
pain fever sweats mucus diarrhoea
81
perianal abscess
Tender, red swelling | Incision & drainage
82
anal fissure
Rectal pain (defaecation) Stool coated with blood Advice re diet (fluids, fibre) GTN cream
83
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
84
treatment of IBS
``` Diet & Lifestyle modification Symptomatic treatment: Abdo pain: antispasmodics Laxatives for constipation Anti-diarrhoeals ```
85
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

DPD (38 decks)

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