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DPD interactive cases > Abdomen (3) > Flashcards

Abdomen (3) Flashcards

1
Q

What are the ABCDEFGHIJL of liver disease?

A 
Asterixis 
Bruising
Clubbing/Caput Medusae
Dupuytren's Contracture
Erythema/Excoriaiton marks
Fetor
Gynaecomastia
Hair loss 
Icterus
Jaundice 
Leuconychia
Spider Naevi (will refill from centre)
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2
Q

What is Dupuytren’s contracture caused by?

A

It is thickening of the palmar fascia and it is associated with alcoholic liver disease (CLD, ETOH, Familial)

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3
Q

What is leuconychia a sign of?

A

Hypoalbuminaemia (decreased liver function)

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4
Q

What abdominal condition/treatment can cause gum hypertrophy?
What other thing can you find in the mouth?

A

Ciclosporine (following renal transplant)

Pigmentation

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5
Q

6 Fs of abdominal distension

A 
Fat 
Flatus
Fetus
Fluid 
Faeces
Fucking cancer (Foreign obstruction?)
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6
Q

What is caput medusa? How do you differentiate from IVC obstruction?

A

Distended superficial umbilical veins due to portal hypertension
If it is occluded and released, direction of blood flow in the dilated veins below the umbilicus is towards the legs and towards head if above umbilius (sun)
IVC: opposite flow

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7
Q

Right Subcostal (Kocher’s)(surgical incision) is made for what operation?

A

Biliary surgery

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8
Q

Mercedez-Benz (surgical incision) is made for what operation?

A

Liver transplant

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9
Q

Midline Laparotomy (surgical incision) is made for what operation?

A

GI/Major abdominal surgery/vascular

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10
Q

McBurney’s (Gridiron)(surgical incision) is made for what operation?

A

Appendicectomy

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11
Q

J-shaped (surgical incision) is made for what operation?

A

Renal transplant

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12
Q

Pfannenstiel (low transverse) (surgical incision) is made for what operation?

A

Gynaecological procedures

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13
Q

Inguinal (surgical incision) is made for what operation?

A

Hernia repair

Vascular access

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14
Q

Loin (surgical incision) is made for what operation?

A

Nephrectomy

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15
Q

Describe how you would complete the abdominal examination of a patient.

A

Full history
DRE
Urinalysis
Examination of hernial orifices and external genitalia

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16
Q

List some causes of hepatomegaly.

A

Cancer
Cirrhosis (early stage; alcoholic)
Cardiac – congestive cardiac failure, constrictive pericarditis
Infiltration – fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis and lymphoproliferative disease

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17
Q

Broadly speaking, what are the common aetiologies of liver disease?

A 
Alcohol
Autoimmune 
Virus 
Drugs 
Biliary disease
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18
Q

List some causes of splenomegaly.

Mnemonic: HHII

A

Portal Hypertension (e.g. in chronic liver disease)

Haematological (e.g. haemolytic anaemia,
leukaemia, lymphoma, myeloma)

Infection (e.g. malaria, schistosomiasis, glandular fever, TB, leishmaniasis, infective endocarditis)

Inflammation

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19
Q

What are the two most common differentials for epigastric pain?

A

Pancreatitis

Peptic ulcer disease

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20
Q

What is an important condition to consider in a patient with epigastric pain, radiating to the back who is also tachycardic and hypotensive?

A

Ruptured aortic aneurysm

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21
Q

What are the two types of abdominal pain?

A

Constant – due to inflammation

Colicky – due to obstruction of viscus

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22
Q

What organs can cause abdominal pain? (6)

A

Stomach (Gastritis - ETOH, retrosternal pain)
Pancreas (Acute pancreatitis - consider gallstones and alcohol consumption); if loss of function: exocrine (steatorrhea, malabsorption), endocrine: DM
Heart (MI)
Aorta (Ruptured AAA)
Liver (Hepatitis)
Gallbladder (Cholecystitis)

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23
Q

Stomach related abdominal pain causes

A

Peptic ulcer disease (NSAID use)

GORD (better with antacids)

Gastritis (retrosternal, history of alcohol abuse)

Malignancy

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24
Q

What is a key difference between acute pancreatitis and chronic pancreatitis?

A

In chronic pancreatitis, serum amylase is NORMAL

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25
Q

What presenting symptom do you find in chronic pancreatitis that is unlikely to occur in acute pancreatitis?

A

Weight loss

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26
Q

List features of chronic pancreatitis that distinguish it from acute pancreatitis.

A

Chronic pancreatitis causes loss of endocrine and exocrine function
Weight loss
Steatorrhoea
Diabetes mellitus

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27
Q

What is the diagnostic test for chronic pancreatitis?

A

Faecal elastase – low in chronic pancreatitis

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28
Q

How can appendicitis cause RUQ pain?

A

Retrocaecal appendix

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29
Q

List causes of RUQ pain that 7 organs:

A

Gallbladder

  • Cholecystitis
  • Cholangitis
  • Gallstones (normal CRP)

Liver

  • Hepatitis
  • Abscess (Bacterial, malignant)

Lungs
- Basal pneumonia

Appendix

  • Appendicitis
  • Retrocaecal appendicitis (going up and backwards, inflamed).

Stomach and Pancreas

  • Peptic ulcer disease
  • Pancreatitis

Kidney
- Pyelonephritis (also causes extreme tenderness over the renal angle - when percussing)

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30
Q

List some GI causes of RIF pain

A 
Appendicitis 
Mesenteric adenitis (particularly important in children) - US to look at LN
Colitis (IBD)
Malignancy 
IBS
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31
Q

List some gynaecological causes of RIF/LIF pain.

A

Ovarian cyst rupture, torsion or bleed
Ectopic pregnancy
Salpingitis

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32
Q

List two main causes of Suprapubic pain.

A

Cystitis (UTI)

Urinary retention

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33
Q

List some GI causes of LIF pain.

A

Diverticulitis
Colitis (IBD)
Malignancy
Faecal impaction

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34
Q

List the differential diagnosis of a patient with diffuse abdominal pain.

A 
Obstruction 
Infection – peritonitis, gastroenteritis 
Inflammation – IBD 
Ischaemic – (mesenteric ischaemia)
Medical
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35
Q

List medical causes of diffuse abdominal pain

A 
DKA
Addison’s disease 
Hypercalcaemia 
Porphyria
Lead poisoning
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36
Q

What is porphyria?

A

One of a group of rare disorders due to inborn errors of metabolism in which there are deficiencies in the enzymes involved in the biosynthesis of haem. The accumulation of the enzyme’s substrate gives rise to symptoms.
(Acute abdo pain, muscle weakness)

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37
Q

When do patients with mesenteric ischaemia tend to experience diffuse abdominal pain?

A

Post-prandial

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38
Q

Draw the mesenteric arteries.

A

Pic

Blockage = ischaemia

39
Q

What can cause a high amylase?

A

Any cause of acute abdomen

40
Q

How is spontaneous bacterial peritonitis (SBP) diagnosed?

A

Ascites neutrophils > 250/mm3

41
Q

What are the three main signs of decompensated liver disease?

A

Ascites
Encephalopathy
Jaundice

42
Q

What is the main sign of ascites on examination?

A

Shifting dullness

43
Q

Describe some features of obstruction on examination.

A

Nausea/vomiting
Not opening bowels
High-pitched tinkling bowel sounds

44
Q

Why is it important to ask a patient with suspected bowel obstruction about previous abdominal surgery?

A

Previous abdominal surgery increases the risk of adhesions forming, which can cause obstruction

45
Q

What cause abdominal distension? (6F)

A 
Flatus (due to obstruction; tender irreducible femoral hernia in the groin)
Fat 
Fluid
Fetus
Faeces
“Fatal growth” (often a neoplasm)
46
Q

What was the old way of differentiating between causes of ascites?

A

Transudate vs Exudate

47
Q

What is the new way of differentiating between causes of ascites?

A

Based on albumin gradient

Albumin gradient = serum albumin – ascites albumin

48
Q

List causes of ascites that has a HIGH albumin gradient (> 11 g/L).

A 
Portal hypertension
Constrictive pericarditis 
Cardiac failure 
Cirrhosis (decreased albumin production)
Budd Chiari Syndrome (hepatic/portal vein thrombosis)

Ascites albumin is low
Increased hydrostatic pressure –> fluid leaves into peritoneal cavity

49
Q

List causes of ascites that has a LOW albumin gradient (< 11 g/L).

A

Indicates a high protein level in ascites - inflammatory proteins

Nephrotic syndrome (serum albumin is lost, so gradient is low)
TB
Pancreatitis 
Cancer 
Peritonitis
50
Q

What gives faeces its brown colour?

A

Stercobilinogen

51
Q

Which enzyme conjugates bilirubin?

A

Glucuronyl transferase

52
Q

What happens to bilirubin after it has been conjugated?

A

It is excreted into the bile

It moves to the intestines where it gets converted to urobilinogen and stercobilinogen

53
Q

State two causes of unconjugated hyperbilirubinaemia.

A

Haemolysis

Gilbert’s syndrome (defective conj)

54
Q

Explain why patients with hepatocellular jaundice will produce dark urine.

A

The damage to the liver cells leads to leakage of conjugated bilirubin from the hepatocytes
The conjugated bilirubin is soluble and excreted in the urine, causing dark urine

55
Q

List some causes of hepatitis.

A

Alcohol
Autoimmune
Drugs
Viruses

56
Q

Explain why patients with post-hepatic jaundice will have pale stools and dark urine.

A
  • Obstruction means that conjugated bilirubin cannot be excreted into the duodenum
  • Conjugated bilirubin leaks into the circulation and is renally excreted, producing dark urine
  • Conjugated bilirubin does NOT reach the intestines and, so, is not converted to stercobilinogen so the stools are pale (BR is metabolised into S by GI bacteria)
57
Q

List some causes of post-hepatic jaundice.

A

Gallstones in the common bile duct
Stricture
Cancer of the head of the pancreas

58
Q

State Courvoisier’s law.

A

A palpable gallbladder in the presence of painless jaundice is unlikely to be due to gallstones (more likely due to cancer)

59
Q

The elevation of which liver enzymes suggest pathology in the biliary tree?

A

ALP + GGT

60
Q 
What is the tumour marker for the following cancers:
Pancreatic
Colorectal
Liver
Ovarian
A

Pancreatic: CA19-9
Colorectal: CEA
Liver: a-fetoprotein
Ovarian: CA125

61
Q

What is Trousseau’s sign of malignancy?

A

Episodes of thrombophlebitis that are recurrent or appearing in different locations over time
It can be an early sign of gastric or pancreatic malignancy

62
Q

List the 5 causes of bloody diarrhoea.

A 
Infective colitis 
Inflammatory colitis 
Ischaemic colitis 
Diverticulitis 
Malignancy
63
Q

What are the main pathogens associated with infective colitis?
CHESS

A 
Campylobacter jejuni
Haemorrhagic E. coli
Entamoeba histolytica
Salmonella
Shigella
64
Q

List some extra-gastrointestinal manifestations of inflammatory bowel disease.

A

Eyes: episcleritis, scleritis, uveitis
Skin: erythema nodosum, pyoderma gangrenosum

65
Q

List two common causes of bloody diarrhoea in the elderly.

A

Ischaemic colitis

Diverticulitis

66
Q

What causes leadpipe sign on AXR?

A

Inflammatory bowel disease (featureless colon)

67
Q

What is the diameter of the colon in a patient with toxic megacolon?

A

More than 6 cm

Also systemically unwell - TC, htn, fever

68
Q

What is another name for overflow diarrhoea?

A

Spurious diarrhoea

Faecal impaction/loading

69
Q

What may elderly patients with constipation present with?

A

Confusion

70
Q

Describe the management of an acute GI bleed.

A 
ABC 
IV access 
Fluids 
Group &amp; Save/Crossmatch 
OGD – find the underlying cause
71
Q

What additional measures will be used for variceal bleeds?

A

Antibiotics (e.g. tazocin, ciprofloxacin) – because of bacterial translocation –> improves mortality
Terlipressin – causes splanchnic vasoconstriction

72
Q

Describe the management of acute abdomen.

A 
NBM
Fluids 
Analgesia
Anti-emetics 
Antibiotics - cover Anaerobes (Metronidazole, Cef)
Monitor vitals and urine output
73
Q

Which two antibiotics are commonly used in the management of acute abdomen?

A 
A cephalosporin (e.g. cefuroxime)
Cover anaerobes (metronidazole)
74
Q

What other investigations are important in patients with acute abdomen?

A

FBC – raised WCC suggests infective process
U&Es – allow assessment of renal function and hydration status
CRP – marker of inflammation
Clotting – surgeons need to know about bleeding tendency before an operation
Erect CXR – check for air under the diaphragm

75
Q

List some important investigations for patients with jaundice.

A

FBC – low Hb may be due to haemolytic anaemia
LFTs – important if liver pathology is suspected
Abdominal ultrasound – performed after fasting because gallstones are better visualised in a distended, bile-filled gallbladder. Dilatation of the ducts would suggest obstruction.

76
Q

Describe the investigations that will be undertaken in a patient presenting with dysphagia and weight loss.

A

OGD and biopsy

77
Q

Describe the investigations that will be undertaken in a patient presenting with PR bleeding and weight loss.

A

Colonoscopy

78
Q

What is Pabrinex and what is it given for?

A

Water-soluble vitamin supplements given in chronic liver disease
It contains thiamine, which is necessary to prevent Wernicke’s encephalopathy

79
Q

Summarise the management of ascites.

A

Ascitic Tap and send to lab for WCC –> SBP?
Diuretics (spironolactone, + furosemide if periph oe)
Dietary sodium restriction
Fluid restriction in patients with hyponatraemia
Monitor weight daily
Therapeutic paracentesis (with IV 2% human albumin)

80
Q

Explain how cirrhosis leads to secondary hyperaldosteronism.

A

Cirrhosis causes vasodilation, which results in the body producing more renin and aldosterone to promote fluid retention
Spironolactone and furosemide helps counteract this effect

81
Q

Describe the management of a patient with hepatic encephalopathy.

A

Lactulose
Phosphate enemas
Avoid sedation (e.g. benzodiazepines)
Treat infections (e.g. SBP)
Exclude GI bleed (an occult GI bleed can precipitate encephalopathy)
Treat non-liver causes (constipation, drug)

82
Q

Why is lactulose used in patients with hepatic encephalopathy?

A

It is an osmotic laxative that reduces GI transit time such that bacteria doesn’t have enough time to produce toxic metabolites that can be absorbed and cause encephalopathy

83
Q

What would you expect the urea of an alcoholic patient to be?

A

Alcoholic patients tend to have low urea (~ 1 mmol/L)

Urea=7 is significant for patient with CLD (increased due to protein meal e.g. digesting GI Bleed)

84
Q

What could cause urea to rise?

A

Digestion of red blood cells (due to a GI bleed)

85
Q

List three major complications of abdominal surgery and describe their features.

A 
Wound infection – erythematous, discharge 
Anastomotic leak – diffuse abdominal tenderness, guarding, rigidity, hypotensive/tachycardic
Pelvic abscess (e.g. post-appendicectomy) – pain, fever, sweats, mucus diarrhoea
86
Q

Describe the appearance of a perianal abscess and state how you would treat it.

A

Tender, red swelling around the anus

Treated with incision and drainage

87
Q

Describe the presenting symptoms of an anal fissure and state how you would treat it.

A

Rectal pain during defecation
Stool coated with blood
Treatment: advice regarding diet (increase fluids and fibre), GTN cream (analgesic)

88
Q

Describe the presentation of IBS.

A 
Recurrent abdominal pain 
Bloating 
Relief with defecation 
Change in frequency/form of stool 
Can be diarrhoea predominant or constipation predominant
89
Q

What is a key difference between the pattern of symptoms of IBD and IBS?

A

IBS patients will not have rectal bleeding, anaemia, weight loss or nocturnal symptoms

90
Q

Describe the treatment of IBS.

A 
Diet and lifestyle modification 
Symptomatic treatment:
- Abdo pain – antispasmodics
- Laxatives for constipation 
- Anti-diarrhoeals (loperamide 2mg oral PO)
91
Q

How should Coeliac disease be excluded?

A

Tissue transglutaminase (tTG) test

92
Q

What could you see if the patient was on Renal Replacement Therapy?

A

AV Fistulae

93
Q

What causes thumbprinting?

A

Inflammation of BW (IBD), shows mucosal oedema

94
Q

Prescribe for non-bleeding ulcer, H Pylori -ve

A

Omeprazole 20mg oral 3x/day

2nd line: H2 antagonist - cimetidine, ranitidine (-dine)

DPD interactive cases (8 decks)

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