Abdomen (3) Flashcards
What are the ABCDEFGHIJL of liver disease?
Asterixis Bruising Clubbing/Caput Medusae Dupuytren's Contracture Erythema/Excoriaiton marks Fetor Gynaecomastia Hair loss Icterus Jaundice Leuconychia Spider Naevi (will refill from centre)
What is Dupuytren’s contracture caused by?
It is thickening of the palmar fascia and it is associated with alcoholic liver disease (CLD, ETOH, Familial)
What is leuconychia a sign of?
Hypoalbuminaemia (decreased liver function)
What abdominal condition/treatment can cause gum hypertrophy?
What other thing can you find in the mouth?
Ciclosporine (following renal transplant)
Pigmentation
6 Fs of abdominal distension
Fat Flatus Fetus Fluid Faeces Fucking cancer (Foreign obstruction?)
What is caput medusa? How do you differentiate from IVC obstruction?
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
Right Subcostal (Kocher’s)(surgical incision) is made for what operation?
Biliary surgery
Mercedez-Benz (surgical incision) is made for what operation?
Liver transplant
Midline Laparotomy (surgical incision) is made for what operation?
GI/Major abdominal surgery/vascular
McBurney’s (Gridiron)(surgical incision) is made for what operation?
Appendicectomy
J-shaped (surgical incision) is made for what operation?
Renal transplant
Pfannenstiel (low transverse) (surgical incision) is made for what operation?
Gynaecological procedures
Inguinal (surgical incision) is made for what operation?
Hernia repair
Vascular access
Loin (surgical incision) is made for what operation?
Nephrectomy
Describe how you would complete the abdominal examination of a patient.
Full history
DRE
Urinalysis
Examination of hernial orifices and external genitalia
List some causes of hepatomegaly.
Cancer
Cirrhosis (early stage; alcoholic)
Cardiac – congestive cardiac failure, constrictive pericarditis
Infiltration – fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis and lymphoproliferative disease
Broadly speaking, what are the common aetiologies of liver disease?
Alcohol Autoimmune Virus Drugs Biliary disease
List some causes of splenomegaly.
Mnemonic: HHII
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
What are the two most common differentials for epigastric pain?
Pancreatitis
Peptic ulcer disease
What is an important condition to consider in a patient with epigastric pain, radiating to the back who is also tachycardic and hypotensive?
Ruptured aortic aneurysm
What are the two types of abdominal pain?
Constant – due to inflammation
Colicky – due to obstruction of viscus
What organs can cause abdominal pain? (6)
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)
Stomach related abdominal pain causes
Peptic ulcer disease (NSAID use)
GORD (better with antacids)
Gastritis (retrosternal, history of alcohol abuse)
Malignancy
What is a key difference between acute pancreatitis and chronic pancreatitis?
In chronic pancreatitis, serum amylase is NORMAL
What presenting symptom do you find in chronic pancreatitis that is unlikely to occur in acute pancreatitis?
Weight loss
List features of chronic pancreatitis that distinguish it from acute pancreatitis.
Chronic pancreatitis causes loss of endocrine and exocrine function
Weight loss
Steatorrhoea
Diabetes mellitus
What is the diagnostic test for chronic pancreatitis?
Faecal elastase – low in chronic pancreatitis
How can appendicitis cause RUQ pain?
Retrocaecal appendix
List causes of RUQ pain that 7 organs:
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)
List some GI causes of RIF pain
Appendicitis Mesenteric adenitis (particularly important in children) - US to look at LN Colitis (IBD) Malignancy IBS
List some gynaecological causes of RIF/LIF pain.
Ovarian cyst rupture, torsion or bleed
Ectopic pregnancy
Salpingitis
List two main causes of Suprapubic pain.
Cystitis (UTI)
Urinary retention
List some GI causes of LIF pain.
Diverticulitis
Colitis (IBD)
Malignancy
Faecal impaction
List the differential diagnosis of a patient with diffuse abdominal pain.
Obstruction Infection – peritonitis, gastroenteritis Inflammation – IBD Ischaemic – (mesenteric ischaemia) Medical
List medical causes of diffuse abdominal pain
DKA Addison’s disease Hypercalcaemia Porphyria Lead poisoning
What is porphyria?
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)
When do patients with mesenteric ischaemia tend to experience diffuse abdominal pain?
Post-prandial
Draw the mesenteric arteries.
Pic
Blockage = ischaemia
What can cause a high amylase?
Any cause of acute abdomen
How is spontaneous bacterial peritonitis (SBP) diagnosed?
Ascites neutrophils > 250/mm3
What are the three main signs of decompensated liver disease?
Ascites
Encephalopathy
Jaundice
What is the main sign of ascites on examination?
Shifting dullness
Describe some features of obstruction on examination.
Nausea/vomiting
Not opening bowels
High-pitched tinkling bowel sounds
Why is it important to ask a patient with suspected bowel obstruction about previous abdominal surgery?
Previous abdominal surgery increases the risk of adhesions forming, which can cause obstruction
What cause abdominal distension? (6F)
Flatus (due to obstruction; tender irreducible femoral hernia in the groin) Fat Fluid Fetus Faeces “Fatal growth” (often a neoplasm)
What was the old way of differentiating between causes of ascites?
Transudate vs Exudate
What is the new way of differentiating between causes of ascites?
Based on albumin gradient
Albumin gradient = serum albumin – ascites albumin
List causes of ascites that has a HIGH albumin gradient (> 11 g/L).
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
List causes of ascites that has a LOW albumin gradient (< 11 g/L).
Indicates a high protein level in ascites - inflammatory proteins
Nephrotic syndrome (serum albumin is lost, so gradient is low) TB Pancreatitis Cancer Peritonitis
What gives faeces its brown colour?
Stercobilinogen
Which enzyme conjugates bilirubin?
Glucuronyl transferase
What happens to bilirubin after it has been conjugated?
It is excreted into the bile
It moves to the intestines where it gets converted to urobilinogen and stercobilinogen
State two causes of unconjugated hyperbilirubinaemia.
Haemolysis
Gilbert’s syndrome (defective conj)
Explain why patients with hepatocellular jaundice will produce dark urine.
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
List some causes of hepatitis.
Alcohol
Autoimmune
Drugs
Viruses
Explain why patients with post-hepatic jaundice will have pale stools and dark urine.
- 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)
List some causes of post-hepatic jaundice.
Gallstones in the common bile duct
Stricture
Cancer of the head of the pancreas
State Courvoisier’s law.
A palpable gallbladder in the presence of painless jaundice is unlikely to be due to gallstones (more likely due to cancer)
The elevation of which liver enzymes suggest pathology in the biliary tree?
ALP + GGT
What is the tumour marker for the following cancers: Pancreatic Colorectal Liver Ovarian
Pancreatic: CA19-9
Colorectal: CEA
Liver: a-fetoprotein
Ovarian: CA125
What is Trousseau’s sign of malignancy?
Episodes of thrombophlebitis that are recurrent or appearing in different locations over time
It can be an early sign of gastric or pancreatic malignancy
List the 5 causes of bloody diarrhoea.
Infective colitis Inflammatory colitis Ischaemic colitis Diverticulitis Malignancy
What are the main pathogens associated with infective colitis?
CHESS
Campylobacter jejuni Haemorrhagic E. coli Entamoeba histolytica Salmonella Shigella
List some extra-gastrointestinal manifestations of inflammatory bowel disease.
Eyes: episcleritis, scleritis, uveitis
Skin: erythema nodosum, pyoderma gangrenosum
List two common causes of bloody diarrhoea in the elderly.
Ischaemic colitis
Diverticulitis
What causes leadpipe sign on AXR?
Inflammatory bowel disease (featureless colon)
What is the diameter of the colon in a patient with toxic megacolon?
More than 6 cm
Also systemically unwell - TC, htn, fever
What is another name for overflow diarrhoea?
Spurious diarrhoea
Faecal impaction/loading
What may elderly patients with constipation present with?
Confusion
Describe the management of an acute GI bleed.
ABC IV access Fluids Group & Save/Crossmatch OGD – find the underlying cause
What additional measures will be used for variceal bleeds?
Antibiotics (e.g. tazocin, ciprofloxacin) – because of bacterial translocation –> improves mortality
Terlipressin – causes splanchnic vasoconstriction
Describe the management of acute abdomen.
NBM Fluids Analgesia Anti-emetics Antibiotics - cover Anaerobes (Metronidazole, Cef) Monitor vitals and urine output
Which two antibiotics are commonly used in the management of acute abdomen?
A cephalosporin (e.g. cefuroxime) Cover anaerobes (metronidazole)
What other investigations are important in patients with acute abdomen?
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
List some important investigations for patients with jaundice.
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.
Describe the investigations that will be undertaken in a patient presenting with dysphagia and weight loss.
OGD and biopsy
Describe the investigations that will be undertaken in a patient presenting with PR bleeding and weight loss.
Colonoscopy
What is Pabrinex and what is it given for?
Water-soluble vitamin supplements given in chronic liver disease
It contains thiamine, which is necessary to prevent Wernicke’s encephalopathy
Summarise the management of ascites.
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)
Explain how cirrhosis leads to secondary hyperaldosteronism.
Cirrhosis causes vasodilation, which results in the body producing more renin and aldosterone to promote fluid retention
Spironolactone and furosemide helps counteract this effect
Describe the management of a patient with hepatic encephalopathy.
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)
Why is lactulose used in patients with hepatic encephalopathy?
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
What would you expect the urea of an alcoholic patient to be?
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)
What could cause urea to rise?
Digestion of red blood cells (due to a GI bleed)
List three major complications of abdominal surgery and describe their features.
Wound infection – erythematous, discharge Anastomotic leak – diffuse abdominal tenderness, guarding, rigidity, hypotensive/tachycardic Pelvic abscess (e.g. post-appendicectomy) – pain, fever, sweats, mucus diarrhoea
Describe the appearance of a perianal abscess and state how you would treat it.
Tender, red swelling around the anus
Treated with incision and drainage
Describe the presenting symptoms of an anal fissure and state how you would treat it.
Rectal pain during defecation
Stool coated with blood
Treatment: advice regarding diet (increase fluids and fibre), GTN cream (analgesic)
Describe the presentation of IBS.
Recurrent abdominal pain Bloating Relief with defecation Change in frequency/form of stool Can be diarrhoea predominant or constipation predominant
What is a key difference between the pattern of symptoms of IBD and IBS?
IBS patients will not have rectal bleeding, anaemia, weight loss or nocturnal symptoms
Describe the treatment of IBS.
Diet and lifestyle modification Symptomatic treatment: - Abdo pain – antispasmodics - Laxatives for constipation - Anti-diarrhoeals (loperamide 2mg oral PO)
How should Coeliac disease be excluded?
Tissue transglutaminase (tTG) test
What could you see if the patient was on Renal Replacement Therapy?
AV Fistulae
What causes thumbprinting?
Inflammation of BW (IBD), shows mucosal oedema
Prescribe for non-bleeding ulcer, H Pylori -ve
Omeprazole 20mg oral 3x/day
2nd line: H2 antagonist - cimetidine, ranitidine (-dine)
