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PACES 2024 > Abdomen > Flashcards

Abdomen Flashcards

1
Q

General inspection findings in chronic liver disease?

A
  • Jaundice
  • Bruising (thrombocytopenia)
  • Scratch marks (pruritus)
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2
Q

Hand findings in chronic liver disease?

A

Asterixis
Clubbing
Dupuytren’s contracture
Palmar erythema
Leukonychia (white spots due to hypoalbuminaemia)

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3
Q
A

Terry nails secondary to hypoalbuminaemia
- causes: Liver cirrhosis, CKD, Heart failure, protein-losing enteropathy, iron deficiency anaemia

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4
Q

Face findings in chronic liver disease?

A
  • Scleral icterus
  • Parotid enlargement (2’ alcoholism)
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5
Q

Chest findings in chronic liver disease?

A
  • Gynaecomastia
  • Spider naevi (5 or >)
  • Scanty axillary hair
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6
Q

Why does gynaecomastia occur in liver disease or cirrhosis?

A
  • increased production of androstenedione by adrenal glands
  • increased aromatisation of androstenedione -> oestrogens
  • loss of clearance of adrenal androgens by the liver
  • rise in SHBG
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7
Q
A

Leukonychia

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8
Q

Abdominal findings in chronic liver disease?

A

Hepatomegaly (may be small in advanced cirrhosis)
Splenomegaly 2’ portal hypertension
Kidneys not ballotable
Shifting dullness +ve (ascites)
Caput medusae 2’ portal hypertension

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9
Q

Lower limb findings in chronic liver disease?

A

bilateral oedema (2’ hypoalbuminaemia)

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10
Q

After abdominal examination in chronic liver disease, how to complete examination?

A
  • examine genitalia for testicular atrophy (in males)
  • perform a DRE
  • examine cervical and inguinal lymph nodes
  • look at vital signs including temperature
  • take a full history (including history of ethanol ingestion, hep B/C infection)
  • take a drug history (drug causes: methotrexate, amiodarone, methyldopa)
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11
Q

Complications of chronic liver disease?

A

(A) portal hypertension: splenomegaly, ascites, varices
(B) hypoalbuminaemia: leukonychia, pitting oedema
(C) coagulopathy
(D) hepatic encephalopathy
(E) SBP: tender abdomen
(F) HCC: lymphadenopathy, cachexia
(G) Hepatorenal syndrome

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12
Q

Important negatives to present in chronic liver disease patient?

A

no evidence of:
- hepatic encephalopathy: coherent with no asterixis
- SBP: non tender abdomen, afebrile
- HCC/ mets: no lymphadenopathy

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13
Q

Examination findings for chronic liver disease to suggest hep C/B?

A

Tattoos
Needle track marks e.g. IVDU

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14
Q

Examination findings in chronic liver disease patient suggesting alcoholism as cause?

A
  • Dupuytrens contractures
  • Parotidomegaly
  • Rhinophyma
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15
Q

Examination findings in chronic liver disease patient suggesting Wilson’s disease as cause?

A

Kayser Fleischer rings
Chorea-athetoid movements

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16
Q
A

Kayser-Fleischer rings
in Wilson’s disease

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17
Q

Aetiology of chronic liver disease?

A
  1. Alcohol
  2. Hep B/ C
  3. NAFLD

Inherited:
4. Wilson’s disease
5. Hereditary haemochromatosis (AR)
6. alpha 1 antitrypsin deficiency

Autoimmune
7. Autoimmune hepatitis
8. PBC

  1. Drug induced
  2. Cryptogenic
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17
Q

Aetiology of chronic liver disease?

A
  1. Alcohol
  2. Hep B/ C
  3. NAFLD

Inherited:
4. Wilson’s disease
5. Hereditary haemochromatosis (AR)
6. alpha 1 antitrypsin deficiency

Autoimmune
7. Autoimmune hepatitis
8. PBC

  1. Drug induced
  2. Cryptogenic
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18
Q

Causes of decompensated liver cirrhosis?

A

infection
bleeding GI tract
dehydration
electrolyte imbalance e.g. hypoNa
drugs: diuretics, barbiturates
constipation

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19
Q

investigations in chronic liver disease?

A

FBC: macrocytic anaemia, thrombocytopenia
Renal panel
LFT: albumin, bilirubin, transaminitis
Coagulation profile INR

Imaging
US HBS: to confirm cirrhosis, evaluate for splenomegaly, ascites or elevated portal pressures

Determine aetiology:
Hep B/ C screen
Autoimmune workup
Serum caeruloplasmin

Surveillance/ evaluate for complications:
Endoscopic evaluation for varices
US HBS for suspicious nodules + AFP -> KIV triphasic CT liver/ MRI liver or biopsy

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20
Q

Management of chronic liver disease?

A

Treat underlying cause: e.g. Stop drinking
Hep A and B vaccinations
Prevent constipation and decompensation: lactulose
B blockers for varices: carvedilol

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21
Q

Treatment of Hepatitis B

A

Entecavir, lamivudine, adefovir

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22
Q

Treatment of Hepatitis C

A

Ribavarin (oral antiviral 500mg BD) + pegylated alpha IFN (180mcg sc weekly)
- 24 or 48 week course

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23
Q

Treatment of autoimmune hepatitis

A

steroids, azathioprine

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24
Q

Treatment of Wilson’s disease?

A

penicillamine, traimeterene, zinc

25
Q

treatment of haemochromatosis

A

venesection

26
Q

Mx of BGIT in cirrhotic patients?

A

ABC, urgent fluid and blood products resus

Urgent endoscopy for diagnostic and therapeutic purposes: variceal band ligation
-> if fails x2, for TIPS

Correct coagulopathy: PCT/ Plt/ FFP transfusions (aim Hb 8-9, not too high as will elevate portal pressure), IV Vit K

Lower portal pressure by decreasing splanchnic circulation: IV somatostatin, octreotide or terlipressin

Prevent encephalopathy: ensure BO 3x/day

IV ceftriaxone - prophylaxis for SBP from gut translocation of bacteria

IV PPI

27
Q

Indication for treatment of hepatitis B infection?

A
  • serum Hep B virus DNA level > 10^5 copies/mL + ALT >2 xULN
  • if cirrhosis present: just HBV DNA level > 10^5 copies/ mL
28
Q

Treatment end point for Hepatitis B infection?

A
  • virological: HBeAg seroconversion + reduction of HBV DNA level to < 10^5 copies/mL
  • biochemical: normalisation of ALT values
29
Q

Indication for treatment of chronic hepatitis C?

A
  • proven Hepatitis C infection (Anti HCV Ab/ HCV RNA)
  • abnormal LFTs
  • evidence of chronic hepatitis on liver biopsy
  • no contraindications (eg. clinical decompensated liver disease 2’ hep C, organ transplant)
30
Q

HBsAg, Anti-HBs, Anti-HBc negative

A

susceptible individual - should get vaccination

31
Q

HBsAg negative, Anti-HBs + Anti-HBc positive

A

Immune due to previous infection

32
Q

HBsAg + Anti-HBc negative, Anti-HBs positive

A

Immune due to hepatitis B vaccination

33
Q

HBsAg +, Anti-HBs -, Anti-HBc +, IgM anti-HBc +

A

Acute Hep B infection

34
Q

HBsAg +, Anti-HBs -, Anti-HBc +, IgM anti-HBc -

A

Chronic Hep B infection

35
Q

HBsAg -, Anti-HBs -, Anti-HBc +

A

Four possibilities:
1. Resolved infection (most common)
2. False-positive anti-HBc, thus susceptible
3. “Low level” chronic infection (thus HBsAg -)
4. Resolving acute infection

36
Q

Markers of synthetic function of the liver?

A

albumin
INR
bilirubin

37
Q

Causes of normal ratio transaminitis e.g. ALT»AST

A
  1. acute viral hep A/B/C/E
  2. drug induced including TCM
  3. Autoimmune: raised IgM, globulin fraction
  4. Ischaemic
  5. Acute alcohol intoxication
38
Q

Causes of reversed ratio transaminitis e.g. AST> ALT

A
  1. Alcoholism: also with raised GGT
  2. Liver cirrhosis
  3. Infiltrative disease: e.g. infiltrative HCC, cholangioCa
39
Q

why screen for HIV in hepatitis C patients?

A

co-infection increases risk of early cirrhosis

40
Q

How to complete examination after differential diagnosis of liver mets on examination?

A
  • DRE: rectal or prostate primary
  • examine lymph nodes
  • Respiratory examination (lung primary)
  • Breast examination in female
  • examine for lumbosacral spinal tenderness (to suggest bony involvement)
41
Q

Hepatomegaly (irregular), cachexia, no peripheral stigmata of chronic liver disease?

A

Liver mets (most commonly 2’ spread followed by liver primary)

42
Q

Most common primary sources of liver mets?

A

colorectal
stomach
lungs
breast

43
Q

differential diagnosis of irregular, hard liver

A

polycystic liver - also look for ballotable kidneys!

44
Q

General inspection findings in patient with a transplanted kidney?

A

Cushingoid appearance
Hirsutism (cyclosporin)
Pallor

45
Q

Arm examination findings in kidney transplant?

A

AVF - working?
Bruises, thin skin, proximal myopathy (2’ steroids)
Leukonychia, nail bed pallor (anaemia)
Uraemic flap
Fine tremor (cyclosporin)

46
Q

Head/face examination findings of kidney transplant patient?

A

Gum hypertrophy (cyclosporin)
Oral thrush (immunocompromised)
Uraemic fetor
Eyes: conjunctival pallor

47
Q

Neck examination findings of kidney transplant patient?

A

JVP - look for fluid overload

48
Q

Chest examination findings of kidney transplant patient?

A
  • previous scars from tunnelled dialysis catheter
  • parathyroidectomy scar
49
Q

Abdominal examination findings in kidney transplant patient?

A
  • Transplant scar + palpable superficially placed mass in RIF/LIF (firm, smooth, non tender, bruit?)
  • Nephrectomy scar (e.g. when removing PCK)
  • previous TK catheter scar for PD (usually periumbilical/ infraumbilical)
  • Ballotable kidneys (polycystic kidneys)
  • hepatomegaly (PCKD)
  • insulin injection marks, lipodystrophy (DM)
  • purple striae (2’ steroids)
50
Q
A

Kidney transplant
- reverse J scar

+ right infraumbilical scar from previous Tenkhoff catheter

51
Q

Leg examination findings in kidney transplant patient?

A
  • peripheral oedema
  • diabetic dermopathy
  • amputations (PVD in DM)
52
Q

How to complete examination after conducting abdominal examination in a kidney transplant patient

A
  • cardiovascular examination for pericardial rub
  • respiratory examination for bibasal crepitations to suggest fluid overload
  • examine for lymphadenopathy (post transplant lymphoproliferative disease)
  • look at vitals (Blood pressure)
  • full history taking (e.g. symptoms of uraemia, family history of PCKD)
  • urinalysis for haematuria
  • ? fundoscopy for hypertensive or diabetic retinopathy
53
Q

important negatives to present for patient with kidney transplant?

A
  • pt clinically not uraemic (no asterixis/ rub) or overloaded (euvolamic)
  • transplant non tender
54
Q

Complications of ESRF

A
  • hypoalbuminaemia (leukonychia)
  • anaemia (conjunctival pallor)
  • fluid overload
  • uraemia
55
Q

complications of drug therapy for kidney transplant patients?

A
  • steroid use: cushingoid appearance, purple striae, proximal myopathy, thin skin
  • cyclosporin: fine tremors, gum hypertrophy, hirsutism
  • tacrolimus: fine tremor
  • infection (fever)
56
Q

aetiology of ESRF?

A

1) diabetes
- most common cause of ESRF locally
2) PCKD
- ballotable kidneys
3) HTN - 2nd most common cause
4) Glomerulonephritis

57
Q

how to complete the examination in patient with polycystic kidneys?

A
  • cardiovascular examination for pericardial rub, raised JVP, associated valvular problems (e.g. MVP, AR)
  • respiratory examination for bibasal creps
  • neuro exam: for cranial nerve palsies or long tract signs to suggest intracranial berry aneurysm
  • vitals: BP
  • urine dip for haematuria/ proteinuria
  • family history of similar disease
58
Q

causes of pain over polycystic kidneys?

A
  • Rupture of cyst
  • bleed into cyst
  • infection of cyst/ UTI
  • renal stones
  • malignant transformation into RCC

-> investigate with CT scan

59
Q

Renal and extra renal complications of polycystic kidney disease?

A

renal: ESRF, RCC, infection, hypertension
Extra renal: cysts in liver/ spleen/ pancreas/ ovaries,
cardiac with MVP/ AR
CNS: intracranial berry aneurysm -> SAH

60
Q

differentials of bilateral ballotable kidneys

A
  • obstructive uropathy 2’ bladder outlet obstruction with bilateral hydronephrosis
  • amyloidosis
  • bilateral renal cell carcinoma
  • tuberous sclerosis with angiomyolipoma
  • Von Hippel Lindau disease

PACES 2024 (14 decks)

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