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Internal Medicine > Abdomen > Flashcards

Abdomen Flashcards

1
Q

What is the marker of pancreatic cancer

A

Ca19 -9

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2
Q

How classify ascites?

A
  • High gradient serum: ascites albumin (>11g/L) (hepatic + cardiac causes)
  • low gradient serum: ascites albumin (<11g/L) (peritoneal causes)
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3
Q

Name 4 causes high saag ascites

A

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
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4
Q

Name 3 causes low saag ascites

A

Peritoneal causes

HIM

  • hypoalbuminaemia: nephrotic syndrome, protein-losing enteropathy, malnutrition; hypothyroid
  • inflammation: pancreatic disease, Tb, infective peritonitis
  • malignancy: ovarian, pancreatic cancer, peritoneal metastasis
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5
Q

Name 3 causes hypoalbuminaemia

A
  • nephrotic syndrome,
  • protein-losing enteropathy,
  • malnutrition
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6
Q

Define budd- chiari syndrome

A

Occlusion of hepatic vein

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7
Q

Name 3 causes budd- chiari syndrome

A

Hypercoagulable states.

  • Pregnancy + postpartum + oral contraceptives
  • polycythaemia Vera
  • cancer
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8
Q

Name the clinical triad of budd- chiari syndrome

A
  • Abdominal pain
  • ascites
  • hepatomegaly

Also: jaundice, spleen enlargement

(Occlusion of hepatic veins)

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9
Q

Name 6 differentials for abdominal distension

A

6 Fs

  • fat
  • faeces
  • flatus
  • foetus
  • fluid
  • fatal growth
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10
Q

Treatment ascites? (3)

A
  • 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
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11
Q

Gold standard to diagnose ascites?

A

Ultrasound

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12
Q

How calculate SAAG

A

Serum - ascites albumin gradient = serum albumin - ascites albumin

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13
Q

Nb complication of ascites

A

Spontaneous bacterial peritonitis

(Neutrophils on ascitic fluid > 0,25 X 10^9/L)

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14
Q

How assess splenomegaly (3)

A
  • 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

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15
Q

How Assess hepatomegaly if ascites

A

Scratch test

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16
Q

Approach to splenomegaly? (7)

A

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 *
17
Q

Signs of cholecystitis?

A

Murphy’s sign

Take in and hold deep breath while palpate r subcostal area. Pain on inspiration = positive

18
Q

What is Courvoisier’s law

A

Gallbladder enlarged + jaundice = probably carcinoma of pancreas / lower biliary tree resulting in obstructive jaundice. Unlikely gallstones.

19
Q

Causes hepatosplenomegaly? (7)

A

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
20
Q

Define ascites

A

Abnormal accumulation of fluid in peritoneal cavity

21
Q

What is a negative clinical predictor of ascites

A

Bipedal oedema

22
Q

What will ascitic fluid show in cirrhosis (3)

A
  • Clear fluid
  • high saag
  • transudative: total protein < 2,5 g/ dl
23
Q

What will ascitic fluid show in spontaneous bacterial peritonitis (2)

A
  • Cloudy
  • neutrophils > 250 / mm3
  • low total protein < 1,1 g/ dL
24
Q

What will ascitic fluid show in heart failure (2)

A
  • High saag
  • exudative - total protein > 2,5 G / dl
25
Q

Treatment spontaneous bacterial peritonitis? (2)

A
  • Cefotaxime (third gen) 2g Iv TDS for 5-7 days (cover G+ and G-)
  • albumin 1 g/kg iv

(Often a complication of cirrhosis)

26
Q

Criteria for acute pancreatitis prognosis?

A

Atlanta criteria
(also Ranson’s criteria, but outdated)

27
Q

Diagnosis chronic pancreatitis? (4)

A

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

28
Q

Diagnosis acute pancreatitis? (5)

A

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
29
Q

Name 3 causes greatly elevated transaminases X5 ULN

A
  • Viral hepatitis
  • drug induced hepatitis
  • ischaemia
30
Q

Name causes elevated alp and GGT (6)

A

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
31
Q

Which markers indicate acute hepatitis B

A
  • Hbv DNA +
  • hbsag +
  • anti HBC IGM +
  • anti HBC ig G -
  • hbeag +
  • anti HBs -
  • anti HBe -
32
Q

Which markers indicate chronic hepatitis B

A
  • Hbv DNA ++ (high)
  • hbsag +
  • anti HBC IGM -
  • anti HBC ig G +
  • hbeag +
  • anti HBs - (only positive if immune)
  • anti HBe - (only positive if immune)
33
Q

Approach to hepatosplenomegaly? (6)

A

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

Internal Medicine (20 decks)

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