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MD2 Core Conditions > Abdomen > Flashcards

Abdomen Flashcards

1
Q

Causes of ascites

A

Infection (esp TB)
Malignancy
Increased hydrostatic pressure: CCF, pericarditis
Decreased oncotic pressure: cirrhosis, nephrotic syndrome
Myxoedema (severe hypothyroidism)
With portal HTN: cirrhosis, portal nodes, Budd-Chiari syndrome, IVC or portal vein thrombosis

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2
Q

Causes of splenomegaly

A

Infective: septicaemia, malaria, IE, hepatitis, EBV, TB, CMV, HIV, rheumatic fever
Haematological: sickle cell, thalassaemia, pernicious anaemia, paraproteinaemia, hypereosinophilia, myelofibrosis
AI: vasculitis (Behcet’s), Sjogren’s syndrome, RA, SLE
Malignancy: leukaemias, lymphoma, secondaries (rare)

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3
Q

Irreducible hernia

A

Cannot be pushed back into abdomen (does not necessarily mean they are obstructed or strangulated)

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4
Q

Incarcerated hernia

A

Contents of hernial sac are stuck inside by adhesions

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5
Q

Obstructed hernia

A

Bowel contents cannot pass through the hernia

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6
Q

Strangulated hernia

A

Ischaemic occurs

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7
Q

Types of abdominal herniae and RFs

A 
Inguinal: men, chronic cough, constipation, urinary obstruction, heavy lifting, ascites
Femoral: women
Umbilical: obesity, ascites
Epigastric
Incisional: post-surgery, obesity
Spigelian
Lumbar
Obturator: pain along medial thigh in thin woman
Sciatic (rare)
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8
Q

Appearance of femoral hernia vs inguinal hernia

A

Femoral: inferolateral to pubic tubercle
Inguinal: superomedial to pubic tubercle

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9
Q

DDx of medial thigh mass

A 
Femoral hernia
Inguinal hernia
Saphena varix
Enlarged Cloquet's node (suggests superficial or deep inguinal involvement)
Lipoma
Femoral aneurysm
Psoas abscess
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10
Q

Indirect vs direct inguinal hernia

A

Indirect: more common, hernia passes trough internal inguinal ring and, if large, out through external ring
Direct: push directly through the posterior wall of inguinal canal into defect in adominal wall

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11
Q

Relations of inguinal canal

A

Floor: inguinal ligament and lacunar ligamenta
Roof: fibres of transversalis and IO
Anterior: EO aponeurosis + IO for lateral 1/3
Posterior: laterally transversalis fascia, medially conjoint tendon

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12
Q

Identifying internal ring

A

Mid-point of inguinal ligament (1.5cm above femoral pulse)

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13
Q

Identifying external ring

A

Split in EO aponeurosis just superior and medial to pubic tubercle

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14
Q

Mid-inguinal point vs mid-point of inguinal ligament

A

Mid-inguinal point: halfway between ASIS and public symphisis (femoral artery crosses here)
Mid-point of inguinal ligament: halfway between ASIS and public tubercles (location of deep internal ring)

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15
Q

Contents of inguinal canal in male

A 
External spermatic fascia (from EO), cremasteric fascia (from IO and transversus abdominus) and internal spermatic fascia (from transversalis fascia) covering the cord
Spermatic cord (round ligament of uterus in female): vas deferans, obliterated processus vaginalis, lymphatics, arteries to vas/cremaster/testes, venous plexus, genital branch of genitofemoral nerve, sympathic nerves
Ilioinguinal nerve
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16
Q

Mx of inguinal hernia

A

Diet
Surgical: mesh techniques
FU: 4/52 rest, return to manual work and driving after less than 2 weeks if all is well and the pt is comfortable

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17
Q

Achalasia

A

Lower oesophageal sphincter fails to relax due to degeneration of myenteric plexus

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18
Q

Mx of achalasia

A

Endoscopic balloon dilatation or Heller’s cardiomyotomy with fundoplication (+ PPI)
Non-invasive options: botox injection, CCBs, nitrates

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19
Q

Ix for achalasia

A

CXR: fluid level in dilated oesophagus

Barium swallow: dilated tapering oesophagus

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20
Q

Mx of dyspepsia

A

If less than 55: “test and treat” (test for H. pylori, give PPI)
If >55 (and new dyspepsia not from NSAID use and persisting for >4-6/52) or ALARM Sx: refer for urgent endoscopy

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21
Q

What is more common: GU or DU?

A

DU (4x)

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22
Q

Rx for dyspepsia

A

Lifestyle: decrease alcohol and tobacco, reduce stress, avoid aggravating foods
H. pylori eradication: triple therapy (PAC: PPI, amoxicillin, clarithromycin)
Drugs to reduce acid: PPI, H2 blockers
If drug-induced ulcer, cease drug if possible and give PPI

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23
Q

Testing for H. pylori

A 
Urea breath test (best; PPI will give a false negative so stop 2/52 before)
Stool Ag (PPI will give a false negative so stop 2/52 before)
Serology
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24
Q

Mx of Barrett’s oesophagus

A

Pre-malignant/high grade dysplasia: oesophageal resection or eradicative mucosectomy (partial thickness resection of bowel wall) if young and fit (less invasive options e.g. targeted mucosectomy, laser ablation, used in others)
Low grade dysplasia: annual endoscopy
No pre-malignant changes: surveillance endoscopy + biopsy every 1-3 years and anti-reflux measures in interim
NB Those with long-standing GORD (e.g. >5 years, esp if over 50) should have one-off screening endoscopy

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25
Most common site for gastric cancer
Gastro-oesophageal junction
26
Acute mesenteric ischaemic
Almost always involves small bowel May follow SMA thrombosis or embolism, mesenteric vein thrombosis or non-occlusive disease (trauma, vasculitis, radiotherapy, strangulation e.g. hernia)
27
Presentation of acute mesenteric ischaemia
Acute severe abdominal pain (constant, central or around RIF) No abdominal signs Rapid hypovolaemia leading to shock
28
Ix for acute mesenteric ischaemia
Increased WCC Persistent metabolic acidosis AXR: "gasless" abdomen Angiography (probably wouldn't if high clinical suspicion, just progress to laparotomy)
29
Complications of acute mesenteric ischaemia
Septic peritonitis Progression of systemic inflammatory response syndrome (SIRS) into multi-organ dysfunction syndrome (MODS; mediated by bacterial translocation across dying gut wall)
30
Rome criteria for constipation
Fewer than 3 BMs per week For >25% of BMs: Straining Lumpy or hard stools Tenesmus Sensation of anorectal obstruction or blockage Manual manoeuvres to facilitate (e.g. digital evacuation, support of pelvic floor)
31
Mx of constipation
Bulking agents: increase faecal mass and stimulate movement e.g. bran Stimulant laxatives: increase intestinal motility (do not use in obstruction or acute colitis) e.g. bisacodyl (Dulcolax), senna Stool softeners: e.g. liquid paraffin, particularly useful for painful anal conditions Osmotic laxatives: retain fluid in bowel e.g. lactulose, macrogol AKA Movicol (disaccharides), Mg2+ salts, phosphate enemas (useful for rapid bowel evacuation pre-op)
32
Diverticulosis
Presence of diverticula (outpouchings of gut wall, usually at sites of entry of perforating arteries)
33
Diverticular disease
Diverticulosis which is symptomatic
34
Diverticulitis
Inflammation of diverticulum
35
Pathogenesis of diverticulosis
Most occur in sigmoid colon Lack of dietary fibre is thought to lead to high intraluminal pressures which force the mucosa to herniate through the muscle layers of the gut at weak points adjacent to penetrating vessels
36
Ix for diverticulitis
Pyrexia Raised WCC Raised CRP/ESR Erect CXR, AXR: can detect perforation, free fluid, collections (CT with contrast enema is more accurate)
37
Mx of diverticulitis
Analgesia NBM IVFs IV Abx (e.g. cefuroxime + metronidazole)
38
Complications of diverticulitis
``` Perforation Haemorrhage Fistulae: enterocolic, colovaginal, colovesical Abscesses Post-infective strictures: in sigmoid ```
39
Hartmann's procedure
Temporary colostomy + partial colectomy
40
Mx of perforation secondary to diverticulitis
Hartmann's procedure
41
Mx of fistulae (esp colicovesical) secondary to diverticulitis
Surgical (e.g. colonic resection)
42
Angiodysplasia
Submucosal AVMs that typically present as fresh PR bleeding in elderly (underlying cause unknown)
43
Mx of angiodysplasia
Embolisation Endoscopic laser electrocoagulation Resection
44
Ix of angiodysplasia
Mesenteric angiography: also allows therapeutic embolisation (CT angiography is a non-invasive option) Tc radionuclide-labelled red-cell imaging during active bleeding
45
Meckel's diverticulum
Distal ileum contains embryonic remnants of gastric and pancreatic tissue; TRUE diverticulum (all layers of wall) May be gastric acid secretion, causing GI pain and occult bleeding or malaena
46
Rule of 2s for Meckel's diverticulum
2% (of the population) 2 feet (proximal to the ileocecal valve) 2 inches (in length) 2 types of common ectopic tissue (gastric and pancreatic) 2 years is the most common age at clinical presentation 2:1 male:female ratio
47
Red-currant jelly stool
Intussusception (mucus and malaena)
48
Rectal prolapse
Mucosa (partial/type 1) or all layers (complete/type 2), may protrude through anus Causes incontinence
49
Causes of rectal prolapse
Lax sphincter, prolonged straining | Related to chronic neurological or psychological disorders
50
Mx of rectal prolapse
Rectopexy (to fix rectum to sacrum) +/- mesh insertion +/0 rectosigmoidectomy
51
Types of anal cancers
``` Squamous cell (85%) Rarely basaloid, melanoma or adenocarcinoma ```
52
Anal margin vs anal canal tumours
Margin: usually well-differentiated, keratinising, good prognosis, spread to inguinal LNs Canal: above dentate line, spread to pelvic LNs, poorly differentiated, non-keratinising, poor prognosis
53
Associations with anal cancer
``` Perianal warts Leukoplakia Lichen sclerosis Bowen's disease Crohn's disease ```
54
Signs of decompensated liver failure
Jaundice Ascites Encephalopathy
55
Common liver secondaries
Breast and uterine Bronchus GIT
56
Leading causes of HCC
``` HBV HCV AI hepatitis Cirrhosis (alcohol, haemachromatosis, PBC) NASH ```
57
Ix for HCC
4-phase CT: delayed wash-out of contrast in suspected mass MRI Biopsy
58
Mx of HCC
``` Resection of solitary tumours under 3cm Liver transplant Percutaneous ablation Tumour embolisation Sorafenib ```
59
Cholangiocarcinoma
Biliary tree cancer | ~10% of liver primaries
60
Causes of cholangiocarcinoma
``` Flukes PSC Biliary cysts HBV HCV DM ```
61
Mx of cholangiocarcinoma
70% unsuited to surgery (and many recur anyway) Stenting improves quality of life Transplant rarely indicated
62
Prognosis of cholangiocarcinoma
~5/12
63
Liver tumour DDx
``` Malignancy (primary or secondary) Haemangioma (don't require treatment; avoid biopsy!) Adenoma (treat if symptomatic or >5cm) Cysts Focal nodular hyperplasia Fibroma ```
64
Causes of liver adenoma
Anabolic steroids OCP Pregnancy
65
AI hepatitis
Inflammatory liver disease of unknown cause; autoAbs against hepatocyte surface Ags Predominantly affects young or middle-aged women ~40% present with acute hepatitis (remainder with gradual jaundice or are asymptomatic)
66
Dx of AIH
Diagnosis of exclusion Based on increased IgG levels, +ive autoAbs and histology from biopsy (mononuclear infiltrate of portal and periportal areas, piecemeal necrosis +/- fibrosis or cirrhosis)
67
Type I AIH
80% Anti-smooth muscle Abs (ASMA), may have ANA Good response to immunosuppression
68
Type II AIH
Commoner in Europe, more often seen in children More commonly progresses to cirrhosis, less treatable Anti-liver/kidney microsomal type 1 Abs (LKM1) ASMA and ANA -ive
69
Type III AIH
Like type I but ASMA and ANA -ive | Abs against soluble liver Ag (SLA) or liver-pancreas Ag
70
Mx of AIH
Prednisolone 30mg/d PO for 1/12, decreasing by 5mg/month to maintenance dose of 5-10mg/d Can sometimes be stopped after 2 years but relapse may occur Azathioprine can be used as steroid-sparing agent Liver transplant if decompensated cirrhosis or failure to respond to medical therapy (but recurrence may occur)
71
Associations of AIH
``` Pernicious anaemia UC Glomerulonephritis AI thyroiditis AI haemolysis DM PSC ```
72
PBC
Interlobular bile ducts are damaged by chronic AI granulomatous inflammation causing cholestasis which may lead to fibrosis, cirrhosis and portal HTN
73
Dx of PBC
AMA (anti-mitochondrial Abs) are hallmark
74
Complications of PBC
Cirrhosis OP Fat-soluble vitamin malabsorption due to cholestasis HCC
75
Mx of PBC
Colestyramine for pruritis UCDA (secondary bile acid) End-stage: liver transplantation (once jaundice develops, survival is
76
PSC
Progressive cholestasis with bile duct inflammation and strictures
77
Complications of PSC
Increased risk of cancers: bile duct, gall bladder, liver, colon (do yearly colonoscopy + U/S)
78
Ix for PSC
AMA -ive ANA, SMA, ANCA may be +ive ERCP: many strictures with characteristic "beaded' appearance Biopsy: fibrous, obliterative cholangitis
79
Mx of PSC
Liver transplant for end-stage UCDA (may protect against colon cancer, improve LFT) Colestyramine for pruritis Abx for bacterial cholangitis
80
Overlap syndrome of AIH
PSC, IBD
81
Hydatid
Cystic hydatid disease is a zoonosis caused by eating eggs of dog parasite e.g. Echinococcus granulosus
82
Sx of hydatid cysts
Liver: hepatomegaly, obstructive jaundice, cholangitis Lung: dyspnoea, chest pain, haemoptysis, anaphylaxis CNS: space-occupying lesions Bone: osteolytic
83
Hydatid cyst Mx
Surgical referral to excise/drain cysts (some favour hepatic resection) with PAIR approach (puncture, aspirate, inject hypertonic saline, re-aspirate) Albendazole pre- and post-drainage
84
Amoebic liver abscess
Often single mass in R lobe containing "anchovy-sauce" pus
85
Dx of amoebic liver abscess
Increased WCC LFT normal or cholestatic picture PCR U/S or CT +/- aspiration (don't rely on microscopy)
86
Mx of amoebic liver abscess
Metronidazole for acute amoebic abscess | Diloxanide furoate for 10 days to destroy gut cysts or in chronic disease
87
Causes of liver abscess
Pyogenic: streptococcus, staphylococcus, gut microbes Amoebic Fungal NB Can occur following haematogenous spread of bacteria through portal vein post-abdominal infection (e.g. appendicitis, diverticulitis)
88
Toxic megacolon
Acute form of colonic distension Characterised by a very dilated colon (megacolon), accompanied by abdominal distension, and sometimes fever, abdominal pain, or shock Caused by IBD, infection (e.g. C. diff, Entamoeba histolytica, Shigella)
89
Mx of toxic megacolon
``` NGT for bowel decompression IVFs Steroids if IBD is underlying cause Consider Abx to prevent sepsis If decompression is not achieved or the patient does not improve within 24 hrs: colectomy ```

MD2 Core Conditions (12 decks)

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