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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
Q

Most common site for gastric cancer

A

Gastro-oesophageal junction

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26
Q

Acute mesenteric ischaemic

A

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)

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27
Q

Presentation of acute mesenteric ischaemia

A

Acute severe abdominal pain (constant, central or around RIF)
No abdominal signs
Rapid hypovolaemia leading to shock

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28
Q

Ix for acute mesenteric ischaemia

A

Increased WCC
Persistent metabolic acidosis
AXR: “gasless” abdomen
Angiography (probably wouldn’t if high clinical suspicion, just progress to laparotomy)

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29
Q

Complications of acute mesenteric ischaemia

A

Septic peritonitis
Progression of systemic inflammatory response syndrome (SIRS) into multi-organ dysfunction syndrome (MODS; mediated by bacterial translocation across dying gut wall)

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30
Q

Rome criteria for constipation

A

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)

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31
Q

Mx of constipation

A

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)

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32
Q

Diverticulosis

A

Presence of diverticula (outpouchings of gut wall, usually at sites of entry of perforating arteries)

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33
Q

Diverticular disease

A

Diverticulosis which is symptomatic

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34
Q

Diverticulitis

A

Inflammation of diverticulum

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35
Q

Pathogenesis of diverticulosis

A

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

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36
Q

Ix for diverticulitis

A

Pyrexia
Raised WCC
Raised CRP/ESR
Erect CXR, AXR: can detect perforation, free fluid, collections (CT with contrast enema is more accurate)

37
Q

Mx of diverticulitis

A

Analgesia
NBM
IVFs
IV Abx (e.g. cefuroxime + metronidazole)

38
Q

Complications of diverticulitis

A 
Perforation
Haemorrhage
Fistulae: enterocolic, colovaginal, colovesical
Abscesses
Post-infective strictures: in sigmoid
39
Q

Hartmann’s procedure

A

Temporary colostomy + partial colectomy

40
Q

Mx of perforation secondary to diverticulitis

A

Hartmann’s procedure

41
Q

Mx of fistulae (esp colicovesical) secondary to diverticulitis

A

Surgical (e.g. colonic resection)

42
Q

Angiodysplasia

A

Submucosal AVMs that typically present as fresh PR bleeding in elderly (underlying cause unknown)

43
Q

Mx of angiodysplasia

A

Embolisation
Endoscopic laser electrocoagulation
Resection

44
Q

Ix of angiodysplasia

A

Mesenteric angiography: also allows therapeutic embolisation (CT angiography is a non-invasive option)
Tc radionuclide-labelled red-cell imaging during active bleeding

45
Q

Meckel’s diverticulum

A

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
Q

Rule of 2s for Meckel’s diverticulum

A

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
Q

Red-currant jelly stool

A

Intussusception (mucus and malaena)

48
Q

Rectal prolapse

A

Mucosa (partial/type 1) or all layers (complete/type 2), may protrude through anus
Causes incontinence

49
Q

Causes of rectal prolapse

A

Lax sphincter, prolonged straining

Related to chronic neurological or psychological disorders

50
Q

Mx of rectal prolapse

A

Rectopexy (to fix rectum to sacrum) +/- mesh insertion +/0 rectosigmoidectomy

51
Q

Types of anal cancers

A 
Squamous cell (85%)
Rarely basaloid, melanoma or adenocarcinoma
52
Q

Anal margin vs anal canal tumours

A

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
Q

Associations with anal cancer

A 
Perianal warts
Leukoplakia
Lichen sclerosis
Bowen's disease
Crohn's disease
54
Q

Signs of decompensated liver failure

A

Jaundice
Ascites
Encephalopathy

55
Q

Common liver secondaries

A

Breast and uterine
Bronchus
GIT

56
Q

Leading causes of HCC

A 
HBV
HCV
AI hepatitis
Cirrhosis (alcohol, haemachromatosis, PBC)
NASH
57
Q

Ix for HCC

A

4-phase CT: delayed wash-out of contrast in suspected mass
MRI
Biopsy

58
Q

Mx of HCC

A 
Resection of solitary tumours under 3cm
Liver transplant
Percutaneous ablation
Tumour embolisation
Sorafenib
59
Q

Cholangiocarcinoma

A

Biliary tree cancer

~10% of liver primaries

60
Q

Causes of cholangiocarcinoma

A 
Flukes
PSC
Biliary cysts
HBV
HCV
DM
61
Q

Mx of cholangiocarcinoma

A

70% unsuited to surgery (and many recur anyway)
Stenting improves quality of life
Transplant rarely indicated

62
Q

Prognosis of cholangiocarcinoma

A

~5/12

63
Q

Liver tumour DDx

A 
Malignancy (primary or secondary)
Haemangioma (don't require treatment; avoid biopsy!)
Adenoma (treat if symptomatic or >5cm)
Cysts
Focal nodular hyperplasia
Fibroma
64
Q

Causes of liver adenoma

A

Anabolic steroids
OCP
Pregnancy

65
Q

AI hepatitis

A

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
Q

Dx of AIH

A

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
Q

Type I AIH

A

80%
Anti-smooth muscle Abs (ASMA), may have ANA
Good response to immunosuppression

68
Q

Type II AIH

A

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
Q

Type III AIH

A

Like type I but ASMA and ANA -ive

Abs against soluble liver Ag (SLA) or liver-pancreas Ag

70
Q

Mx of AIH

A

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
Q

Associations of AIH

A 
Pernicious anaemia
UC
Glomerulonephritis
AI thyroiditis
AI haemolysis
DM
PSC
72
Q

PBC

A

Interlobular bile ducts are damaged by chronic AI granulomatous inflammation causing cholestasis which may lead to fibrosis, cirrhosis and portal HTN

73
Q

Dx of PBC

A

AMA (anti-mitochondrial Abs) are hallmark

74
Q

Complications of PBC

A

Cirrhosis
OP
Fat-soluble vitamin malabsorption due to cholestasis
HCC

75
Q

Mx of PBC

A

Colestyramine for pruritis
UCDA (secondary bile acid)
End-stage: liver transplantation (once jaundice develops, survival is

76
Q

PSC

A

Progressive cholestasis with bile duct inflammation and strictures

77
Q

Complications of PSC

A

Increased risk of cancers: bile duct, gall bladder, liver, colon (do yearly colonoscopy + U/S)

78
Q

Ix for PSC

A

AMA -ive
ANA, SMA, ANCA may be +ive
ERCP: many strictures with characteristic “beaded’ appearance
Biopsy: fibrous, obliterative cholangitis

79
Q

Mx of PSC

A

Liver transplant for end-stage
UCDA (may protect against colon cancer, improve LFT)
Colestyramine for pruritis
Abx for bacterial cholangitis

80
Q

Overlap syndrome of AIH

A

PSC, IBD

81
Q

Hydatid

A

Cystic hydatid disease is a zoonosis caused by eating eggs of dog parasite e.g. Echinococcus granulosus

82
Q

Sx of hydatid cysts

A

Liver: hepatomegaly, obstructive jaundice, cholangitis
Lung: dyspnoea, chest pain, haemoptysis, anaphylaxis
CNS: space-occupying lesions
Bone: osteolytic

83
Q

Hydatid cyst Mx

A

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
Q

Amoebic liver abscess

A

Often single mass in R lobe containing “anchovy-sauce” pus

85
Q

Dx of amoebic liver abscess

A

Increased WCC
LFT normal or cholestatic picture
PCR
U/S or CT +/- aspiration (don’t rely on microscopy)

86
Q

Mx of amoebic liver abscess

A

Metronidazole for acute amoebic abscess

Diloxanide furoate for 10 days to destroy gut cysts or in chronic disease

87
Q

Causes of liver abscess

A

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
Q

Toxic megacolon

A

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
Q

Mx of toxic megacolon

A 
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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