Abdomen Flashcards
What is the marker of pancreatic cancer
Ca19 -9
How classify ascites?
- High gradient serum: ascites albumin (>11g/L) (hepatic + cardiac causes)
- low gradient serum: ascites albumin (<11g/L) (peritoneal causes)
Name 4 causes high saag ascites
Liver+cardiac causes
HOLM
- heart disease: heart failure, constrictive pericarditis
- obstruction of hepatic veins: Budd chiari syndrome
- Liver disease: cirrhosis, hepatitis, fatty liver, portal vein thrombosis
- malignancy: massive liver metastasis
Name 3 causes low saag ascites
Peritoneal causes
HIM
- hypoalbuminaemia: nephrotic syndrome, protein-losing enteropathy, malnutrition; hypothyroid
- inflammation: pancreatic disease, Tb, infective peritonitis
- malignancy: ovarian, pancreatic cancer, peritoneal metastasis
Name 3 causes hypoalbuminaemia
- nephrotic syndrome,
- protein-losing enteropathy,
- malnutrition
Define budd- chiari syndrome
Occlusion of hepatic vein
Name 3 causes budd- chiari syndrome
Hypercoagulable states.
- Pregnancy + postpartum + oral contraceptives
- polycythaemia Vera
- cancer
Name the clinical triad of budd- chiari syndrome
- Abdominal pain
- ascites
- hepatomegaly
Also: jaundice, spleen enlargement
(Occlusion of hepatic veins)
Name 6 differentials for abdominal distension
6 Fs
- fat
- faeces
- flatus
- foetus
- fluid
- fatal growth
Treatment ascites? (3)
- Spironolactone 100 - 300 mg oral. For rapid results add Lasix (furosemide) 40mg.
- paracentesis if diuretics don’t provide relief.
- surgical tipss (transjugular intrahepatic portosystemic shunt) for refractory ascites
Gold standard to diagnose ascites?
Ultrasound
How calculate SAAG
Serum - ascites albumin gradient = serum albumin - ascites albumin
Nb complication of ascites
Spontaneous bacterial peritonitis
(Neutrophils on ascitic fluid > 0,25 X 10^9/L)
How assess splenomegaly (3)
- Palpate from umbilicus upwards ( enlarge down + medial toward umbilicus)
- percuss Traube’s space: percuss across from medial to lateral. Should remain resonant unless enlarged. Borders = 6th rib MCL medically to 9th rib mal
- percuss over Castell spot: lowest left intercostal space in anterior axillary line. Pt deep breaths. Dull during inspiration if enlarged
Can’t get above it, moves with inspiration towards RIQ, may feel palpable notch on medial side
How Assess hepatomegaly if ascites
Scratch test
Approach to splenomegaly? (7)
MIMIC OH
- = massive splenomegaly
Malignancy
- leukemia * (myeloproliferative)
- Lymphoma (lymphoproliferative)
Infective
- bacterial: endocarditis, sepsis, tb, brucellosis, salmonella
- viral: hepatitis, ebV, CMV
- protozoan: malaria *, leishmaniasis *, trypanosomiasis
- fungal: histoplasmosis
Metabolic (lysosomal storage diseases)
- Gaucher’s disease
- Niemann pick disease
Inflammatory/granulomatous disorders
- Felty’s syndrome in rheumatoid arthritis
- Sarcoidosis
- SLE
Congestive
- portal ht: cirrhosis, hepatic vein occlusion, portal vein thrombosis, stenosis/malformation of portal/splenic vein
- cardiac: chronic CHF, constrictive pericarditis
Other
- cysts, haemophagocytic syndromes
- amyloid
- Thyrotoxicosis
Haematological
- Red cell disorders: megaloblastic anaemia, hb-opathies, hereditary spherocytosis
- autoimmune haemolytic anaemias
- myeloproliferative disorders : myelofibrosis *, polycythaemia rubra Vera, essential thrombocythaemia, chronic myeloid leukemia *
Signs of cholecystitis?
Murphy’s sign
Take in and hold deep breath while palpate r subcostal area. Pain on inspiration = positive
What is Courvoisier’s law
Gallbladder enlarged + jaundice = probably carcinoma of pancreas / lower biliary tree resulting in obstructive jaundice. Unlikely gallstones.
Causes hepatosplenomegaly? (7)
ITCH ABC
- infiltration: amyloid, sarcoid
- thyrotoxicosis
- chronic liver disease with portal hypertension
- Haem: myeloproliferative disease, leukemia, lymphoma, pernicious anaemia, sickle cell anaemia
- acromegaly
- bugs: acute viral hepatitis, infectious mononucleosis, CMV
- Connective tissue disease: SLE
Define ascites
Abnormal accumulation of fluid in peritoneal cavity
What is a negative clinical predictor of ascites
Bipedal oedema
What will ascitic fluid show in cirrhosis (3)
- Clear fluid
- high saag
- transudative: total protein < 2,5 g/ dl
What will ascitic fluid show in spontaneous bacterial peritonitis (2)
- Cloudy
- neutrophils > 250 / mm3
- low total protein < 1,1 g/ dL
What will ascitic fluid show in heart failure (2)
- High saag
- exudative - total protein > 2,5 G / dl
Treatment spontaneous bacterial peritonitis? (2)
- Cefotaxime (third gen) 2g Iv TDS for 5-7 days (cover G+ and G-)
- albumin 1 g/kg iv
(Often a complication of cirrhosis)
Criteria for acute pancreatitis prognosis?
Atlanta criteria
(also Ranson’s criteria, but outdated)
Diagnosis chronic pancreatitis? (4)
Imaging
- Ultrasound / ct: pancreatic calcifications confirm diagnosis
- mrcp + ercp: check if choledocholithiasis, malignancy, strictures, obstruction
- AXR: speckled calcification
Bloods
- glucose (endocrine function)
Breath tests eg 13C hiolien
Diagnosis acute pancreatitis? (5)
Bloods
- lipase best! Raised
- raised amylase > 1000 u /ml or 3x upper limit
- CRP > 150 mg/l at 36h after admission = predict severe pancreatitis
Imaging
- AXR: no psoas shadow (increased retroperitoneal fluid), “sentinel loop” of proximal jejunum from ileum ( solitary air filled dilatation )
- Ct assess severity and complications
- ercp if LFTs worsen
Name 3 causes greatly elevated transaminases X5 ULN
- Viral hepatitis
- drug induced hepatitis
- ischaemia
Name causes elevated alp and GGT (6)
Obstructive
- stones
- strictures: pBC /psc, prior surgery, recurrent pancreatitis
- malignancy: cCA, HcC, compression of bile duct by tumour eg pancreas, gallbladder , ampullary ca
Non obstructive / infiltrative
- drugs (alcohol high GGT)
- infiltrative malignancies (primary = HCC, CCA; secondary = lymphoma, Met’s)
- viral infection: EBV, CMV
Which markers indicate acute hepatitis B
- Hbv DNA +
- hbsag +
- anti HBC IGM +
- anti HBC ig G -
- hbeag +
- anti HBs -
- anti HBe -
Which markers indicate chronic hepatitis B
- Hbv DNA ++ (high)
- hbsag +
- anti HBC IGM -
- anti HBC ig G +
- hbeag +
- anti HBs - (only positive if immune)
- anti HBe - (only positive if immune)
Approach to hepatosplenomegaly? (6)
Massive splenomegaly, splenic rub = haematologic disorder
- lymphadenopathy → lymphoma, lymphocytic leukaemia
- no lymphadenopathy → myeloproliferative disease, non-lymphocytic leukaemia
Signs of chronic liver disease eg spider naevi, jaundice, gynaecomastia, testicular atrophy
- with ascites → advanced cirrhosis, budd-chiari syndrome, hepatoma
- without → stable cirrhosis, PBC, haemochromatosis, chronic active hepatitis
