Abdomen Flashcards
Abdomen History
Presenting Hx
Abdomenal pain - SOCRATES, particularly with food/defecation
Distension - Fat, Fluid, Faeces, Flatus, Fetus
Nausea/Vomiting - numerous causes. Timing, relation to meals, amount, content
Haematemesis - frequency, liquid/solid, bile/blood (colour), neoplasia, NSAIDs/warfarin, surgery, smoking
Dysphagia - at what level, onset, intermittent, progressive, pain
Indigestion/reflux - in relation to meals
Change in bowel habit - consider neoplasia
Diarrhoea or constipation
Rectal bleeding or melaena - pain, mucus, colour, is it mixed with stool or on surface or on paper
Appetite or weight change - intentional
Jaundiced - itch, dark urine, pale stools
Past Hx Peptic ulcer disease Carcinoma Jaundice Hepatitis Blood transfusions Tattoos Previous operations ?Last menstrual period Dietary changes
Drug Hx Steroids NSAIDs Abx Anti-coags
Family Hx IBS IBD Peptic ulcer Polyps Cancer Jaundice
Social Hx Smoking Alcohol IVDU Travel Contact/Exposures Sexual history
Abdomen pain sites
Epigastric - pancreatitis, gastritis/duodenitis, peptic ulcer, gallbladder, aortic aneurysm, or refered from MI
L hypochondrium - peptic ulcer, gastric or (splenic flexure) cancer, splenic rupture, subphrenic or perinephric abscess, renal (colic, pyelonephritis)
R hypochondrium - cholecystitis, biliary colic, hepatitis, peptic ulcer, hepatic flexure cancer, renal (colic, pyelonephritis), subphrenic/perinephric abscess
Loin - renal (), renal tumour, perinephric abscess
L iliac fossa - diverticulitis, volvulus, colon cancer, pelvic abscess, IBD, hip pathology, renal colic, UTI, gynae: ovarian cyst, salpingitis, ectopic pregnancy. Herpes Zoster
R iliac fossa - all causes of LIF pain plus: appendicitis, Crohn’s ileitis
Pelvic - Urological: UTI, retention, stones. Gynae: menstruation, pregnancy, endometriosis, salpingitis, endometritis, ovarian cyst
Generalised - gastroenteritis, IBS, peritonitis, constipation
Centralised - mesenteric ischaemia, aortic aneurysm, pancreatitis
Alcoholism
CAGE ?Cutting down ?Annoyed by people criticising your drinking ?Guilty about drinking ?Eye-opener in the morning
How much? How long? When stopped?
NB Holt’s Law and denial, be sure to ask relatives
1 unit = 8g ethanol = 1 shot = 1/2 glass of wine = 1/3 pint
Investigations Increase: gammaGT30 (liver enzyme) ALT MCV
AST:ALT>2
Decrease:
Urea
Platelets
Effects
1) Liver
Fatty liver (if >8units/day), acute and reversible, and may progress to cirrhosis if drinking continues.
Pathophysiology - 1) Increased hepatic glycerol 3-phosphate (3-GP) after ethanol ingestion, related to an increase in the ratio NAD+:NADH in the liver. A higher concentration of 3-GP results in enhanced esterification of fatty acids. 2) Enhance lipolysis through direct stimulation of the adrenal-pituitary axis. 3) Inhibition of oxidation of fatty acids in the liver and release of VLDL into the blood.
Alcoholic hepatitis - malaise, increased TPR, anorexia, D&V, tender hepatomegaly +/- jaundice, bleeding, ascites, encephalopathy if severe
Management - catheter and CVP monitoring, screen for infection, ascites tap, treat for SBP, stop alcohol, optimise nutrition with vitamins, potentially steroids
Cirrhosis - (see specific) 5y survival 48% if continue drinking, 77% if stop
2) CNS
self neglect, decrease cognition and memory, cortical atrophy, retrobulbar neuropathy, fits, falls
3) Gut
Obesity, D&V, gastric erosion, ulcers, varices, pancreatitis
4) Blood
Increase MCV anaemia, GI bleeding, haemolysis
5) Heart
Arrhythmias, increase BP, cardiomyopathy, sudden death
6) Reproduction
Testicular atrophy, decrease testosterone/progesterone
Fetal alcohol syndrome - decreased IQ, palpebral fissure, absent philtrum, small eyes
Withdrawal
10-72h since last drink
Increased pulse, decrease pressure, tremor, confusion, fits, hallucinations (DT - delirium tremens)
Management - NB out-patient services
Chlordiazepoxide 10-50mg/6h
Prevention techniques, and getting them onboard
Relapse
50%
Acamprosate may help
Ascites
Def: fluid in the peritoneal cavity. Transudative or exudative.
Cause:
Anything leading to portal hypertension - liver pathology, Budd-Chiari syndrome (clot in portal vein)
Other reasons e.g. pancreatitis, malignancy
Management: restrict fluid - 1.5L/d low salt diet - 40-100mM/d weigh daily - aim for 0.5kg loss/d diuretic - 100mg OD spironolactone, add furosemdie <120mg OD
U&E watching for Na
Complications:
SOB - compression, can then lead to pleural obstruction
SBP
Hepatorenal syndrome
Cirrhosis
Def: irreversible liver damage with histological finding of loss of architecture, bridging fibrosis, nodular regeneration
Causes: Chronic alcohol abuse HBV or HCV Genetic - Haemochromatosis, alpha 1 antitrypsin, Wislons Hepatic vein events NASH (non-alcoholic steatohepatitis) Autoimmune - PBC, PSC, autoimmune hep Drugs - amiodarone, methyldopa, methotrexate
Signs: Leuconychia Clubbing Palmar erythema Dupuytren's Spider nivae Xanthelasma Gynaecomastia Hair loss Organomegaly Ascites
Tests:
LFTs
bilirubin may increase
Increase - AST, ALT, ALP, gammaGT and PT or INR
Decrease - albumin, platelets & WBC (hypersplenism)
Looking for the cause: Ferritin, iron and TIBC Hepatitis serology Immunoglobulins Abs - ANA, AMA, SMA Alpha-fetoprotein Caeruloplasmin A1AT
Radiology
US and duplex
MRI - increase caudate lobe, smaller islands of regenerating nodules, right posterior hepatic notch
Ascitic tap
Biopsy
Management
General - nutrition, alcohol abstinence avoid NSAIDs/sedatives/opiates
Specific - treat cause
Transplant - see indications
Complications:
Liver failure - coagulopathy, encephalopathy, oedema, sepsis, SBP, hypoglycaemia
Portal hypertension - ascites, splenomegaly, portosystemic shunt (leading to upper varices and potentially bleeds), caput medusae
Decompensation due to Dehydration Constipation Alcohol Infection Opiates GI bleed
Kidney or spleen?
5 things Medial notch on the spleen Direction of growth Percussion (due to retroperitoneal nature of kidney) Can palpate OVER kidney Balott-able
Abdomen examination
WIPER
IPPA
Think systems -
GI
Hepato-biliary
Gastro-urinary
NB positioning from 45 to FLAT
Inspection
Drugs, drips, devices
Around: lines, catheter (and contents), board, vomit bowl, stoma bags, food and drink?
Patient: jaundiced, unwell, distension, surface markings (scars and bruising), habitus/cachexia, tattoos
Hands - NB to look at both
Clubbing - cyrosis, IBD (Crohn and Ulcerative colitis), NB non-specific (resp. and CVS)
Dupuytren’s - decomp LF, peyronie
Palmar Erythema (thenar or hypothenar) - LF
Capiliary refill - LF (or shock)
Tendon xanthemata - Hyperlipidaemia
Nails
Leukonychia (lines) - Liver (lack of proteins)
Koilonychia (spooning) - iron, folate, B12 def
Muehrcke’s lines - across nail (hypoalbuminaemia)
Blue nails - Wilson’s
Wrist
Pulse
Asterixis - CO2 retention, beta agon, hepato-enceph, uraeminc-enceph
Arms Fistulas IVDU Bruisiing/petechiae - steroid use BP (offer)
Eyes
scleral icterus - jaundice
conjuctival palor - anaemia
corneal arcus and xathalasma - lipoprotein
Kayser-Fleischer rings (green), blood shot - Wilson’s
Mouth
sub-lingual perfusion - central cyanosis
ulcers - celiac
angular stomatatis and glossitis- vitamin deficiencies (thiamine, B12, iron)
general hygiene and candida
telangiectasia - red spider webs, scleroderma or steroid use
peutz jeghers syndrome pigmentation (dark blotches)
Neck
JVP - increased right arterial pressure, left and relax, medial to SCM and stops pulsing on pressure, above 5cm
Lymph nodes (infection and metstasis)
Submental, submandibular, pre and post auricular, occipital, down SCM, Virchows
Back (sit them up)
Sacral oedema, nephrectomy scars
FLAT and expose
Inspect
Gynaecomastia, hair loss
Vessels - NB assess direction of flow: below the umbilicus flowing up = IVC obstructed. Flow radiates from the umbilicus = caput medusae - portal hypertension
Spider nivae - blanch on pressing (if not - Campbell der Morgan)
Scars - NB look round the back for nephrotomy scars
Bloating, obvious masses
Pulsation
Masses
General - Fat, Fluid, Faeces, Foetus
Local - knowledge of underlying (e.g. organomegaly, aneurysm, hernia)
Stoma - arteficial union of conduit and outside
GI pathology - colostomy, iliostomy
Urostomy
Palpation and Percussion
Nine quadrants - soft then deep. NB look at the face whilst palpating
Rebound - pain is worse on letting go, percussion will elicit tenderness (peritonism)
Guarding - involuntary tensing for fear of pain
Murphy’s sign (hand at the costal margin in the right upper abdominal quadrant, ask patient to breathe deeply. If the gallbladder is inflamed, the patient will experience pain and catch their breath) - cholecystisis
Rovsing’s sign (attempt to distend the caecum and appendix by pushing on the left colon in an anti-peristaltic direction) - appendicitis
Liver borders (feel on breath in) - assess size, roughness, regularity and tenderness
Spleen borders - from RIF (should be dull 9-11)
Bladder
Shifting dullness - NB wait 30s and keep hand in same place
Aorta - importantly, is it expansile. Ask to breathe in and out to relax
Auscultation
Bowel noises (2 cm left to umbilicus) - nothing = ileus (adynamic), tinkering (like a penny in a pipe) = obstruction
Bruits (either side a little above the umbilicus) - aorta, renal arteries
Leg
Pitting oedema - 2cm above medial malleolus. Move upwards if positive
To complete Hernial orifices External genitalia Digital rectal exam (uranalysis)
Hepatic encephalopathy
Ammonia builds up and passes to brain
Astrocytes clear it to form glutamine
Excess glutamine cause fluid to shift into cells
Grading:
I - altered mood, sleep disturbances, dyspraxia (5 pointed star)
II - increasing drowsiness, confusion, sluured speech, flap, inappropriate behaviour
III - incoherent, stupor, flap
IV - coma
Management
Prophylactic lactulose and rifaximin
Can also be due to toxins not being bound to albumin
Causes of hepatomegaly
Causes
Malignancy - metastatic or primary (usually irregular shape)
Hepatic congestion - R side heart failure, pulsatile in tricuspid incompetence, hepatic vein thrombosis
Anatomical - Riedel’s lobe
Infection - glandular fever, hepatitis viruses, malaria, schistosomiasis, amoebic abscess, hydatid cyst
Haematological - leukaemia, lymphoma, myeloproliferative disorders, sickle-cell disease, haemolytic anaemias
Others - fatty liver, porphyria, amyloidosis, glycogen storage disorders
Hepatotoxic drugs
Paracetamol - COX inhibition - pyrexia and pain
Methotrexate - inhibition of folic acid reductase (RNA nucleotide formation) - neoplastic disease, psoriasis, rheumatoid
Isoniazid - inhibits the synthesis of mycolic acids, in mycobacterial cell walls - TB
Azathioprine - incorporates into DNA structure and is cytotoxic
Phenothiazines - antipsychotic
Oestrogen - steroid
6-mercaptopurines - inhibits PRPP Amidotransferase in purine sythesis - ALL, Autoimmune hep, UC, Crohn’s
salicylates - COX inhibition - prophylaxis of thromb
tetracyline - block 30S ribosomal subunit in the mRNA translation complex - Abx
Mitomycin - DNa alkylating - cancer
Jaundice
Def: Yellowing of the skin, sclera and mucosae, due to increased plasma bilirubin (>60uM)
Classification - by the site of the problem (pre-hepatic, hepatic, post-hepatic) and the type of bilirubin circulating (conjugated or unconjugated)
Unconjugated - bilirubin is water insoluble and therefore does not enter the urine
Due to:
Overproduction - haemolysis (e.g. malaria/DIC) and ineffective erythropoeisis
Impaired hepatic uptake - drugs (paracetamol, rifampicin), ischaemic hepatitis
Impaired conjugation - Gilbert’s, Crigler-Najjar
Physiological neonatal jaudice
Conjugated - bilirubin is now water soluble Urine -> DARK, Stool -> PALE Hepatocellular dysfunction: Viruses - Heptitis, CMV, EBV Drugs induced - see below Alcohol Sepsis Malignancy GI bleeding Haemochromatosis Autoimmune Leptospirosis Syphilis alpha-anti-1 trypsin Budd-Chiari Wilson's Dubin-Johnson & Rotor RCF Toxins - carbon tetrachloride, fungi
Impaired hepatic excretion (cholestasis):
Primary biliary cholangitis
Primary sclerosing cholangitis
Drug induced - see below
Obstruction (cancer – cholangiocarcinoma or pancreatic cancer; inflammatory – stones/PSC; choledocholithiasis)
Eponymous - Caroli’s, Mirrizi’s
[Drug induced
Haemolysis - antimalarials
Hepatitis - MAOi, Statins, Sodium valproate, Halothanes, Isoniazid/rifampicin/pyrazinamide, Paracetamol
Cholectasis - Flucloxacillin, Fusidic acid, Steroids, Sulfonylureas, Prochlorperazine]
Hepatic (mixed):
Acute liver disease (most common viral, drug induced and ischaemia)
Chronic liver disease (most common: alcohol, NAFLD, hepatitis C)
PHx ?Transfusion ?IVDU ?Piercings/tattoos ?Sexual activity ?Travel abroad ?Fhx ?Alcohol ?Drugs
Examine for Chronic liver disease Hepatic Encephalopathy Lymphadenopathy Hepatomegaly Splenomegaly Ascites Palpable gallbladder
Tests
Urine - bilirubin absent in pre-hepatic, urobilinogen absent in obstructive
Haematology - FBC, clotting, film (e.g. on a slide), reticulocyte count (how fast RBC are made in marrow), Coombs (e.g. in newborn to see if there are anti-RBC Abs due to maternal foetal blood mixing), malarial parasites, Paul Bunnell (EVB)
Chemistry - U&Es, LFT, gamma-GT, total protein, albumin, paracetamol levels
Microbiology
US - to see if bile ducts are dilated
ERCP - if the bile ducts are dilated and LFT not improving
Biopsy
CT/MRI
Liver failure
Def: recognised by the development of coagulopathy (INR>1.5) and encephalopthy
Hyperacute < 7d
Acute 8-21d
Subacute 4-26wks
On a background of cirrhosis - chronic liver failure
Fulminant hepatic failure - massive necrosis of liver cells
Causes:
Infection - viral hepatitis (B, C, CMV), yellow fever, leptospirosis
Drugs - paracetamol OD, halothane, isoniazid
Toxins - amantia phalloides (mushroom), carbon tetrachloride
Vascular - Budd-Chiarim, veno-occlusion
Other - Alcohol, fatty liver, primary biliary cholangitis, primary sclerosing cholangitis, haemochromatosis, autoimmune hep, alpha 1 antitrypsin, Wilson’s, malignancy
Signs: Jaundice Hepatic encephalopy fetor hepaticus (breath smells like pear drops) Asterixis Constructional apraxia
Investigations:
Bloods - FBC (trigger or complication), creatinine (for renal function), LFT, clotting (increase in PT/INR), glucose, paracetamol, hepatitis, ferritin, alpha 1 anti-trypsin, autoAbs
Microbiology - blood culture, urine culture ascites tap (NB neutrophil >250/mm3 indicative of spontaneous bacterial peritonitis)
Radiology - CXR, abdomenal US, Doppler of portal vein
Management: Be aware of sepsis and renal failure Consider NG tube and intubation Urinary and central venous catheters Obs and bloods daily 10% glucose 1L/12h and check levels Treat cause Nutrition control Avoid hepatic metabolised drugs if possible PPI prophylaxis Potentially transplant
Complications:
Cerebral oedema - give 20% mannitol (osmotic diuretic)
Ascites - restrict fluid, low salt diet, weigh daily, diuretic
Bleeding - Vit K 10mg/d for 3d, FFP (fresh frozen plasma) and blood
Hypoglycaemia - 50ml 50% IV glucose
Encephalopathy - tilt head up, correct electrocytes, lactulose 30-50ml/8h, rifaximin
LFTs
NB can be found in 17% of normal population, and just because they are normal doesn’t meant that there is not pathology
AST and ALT - 5-35i.u/L ALP - 30-130i.u/L GGT - Men - 11-50i.u/L, Women - 7-32i.u/L Albumin - 35-50g/L Bilirubin - 3-17uM PR - 12-13s (NB not standardised) INR - 0.8-1.2
Test of hepatocellular injury
Aminotransferases, AST and ALT - enzymes release into blood stream after injury. ALT is more specific to the liver
Alkaline Phosphatases - from liver, bone (in growing children), placenta
Gamma glutamyltransferase, GGT - in liver, pancreas, renal tubules and intestine but not bone
Test of hepatic function
Serum albumin
Serum bilirubin
PT (INR) - indication of extrinsic pathway, for which the liver synthesises factors 1, 2, 5, 8, 10. Blood is citriated, then add excess Ca and tissue factor and time to clot.
Hepatocellular predominant - increase AST and ALT
Cholestasis predominant - increase in ALP and GGT (more than AST and ALT)
Other screens
Suggestive of haemochromatosis
Ferretin
Transferretin - better than the above as it is not raised in inflammation
Suggestive of hepatitis
Viral screen for Hep B and C
AutoAbs
Caeruloplasmin
alpha 1 antitrypsin
Liver transplantation
Donations from DBD or DCD or live, right lobe donors
Indications
Acute Paracetamol induced failure: Arterial pH <7.3, 24h post ingestion or PT >100s + Creatinine >300uM + Grade III or IV enceph
Non- paracetamol induced failure: PT >100s or 3/5 of 1) Drug-induced 2) Age <10 or >40 3) >1wk from first jaundice to enceph 4) PT >50s 5) Bilirubin >300uM
Chronic
Advanced cirrhosis
Hepatocellular cancer (1 nodule <5cm or <5 nodules <3cm)
Contraindications
1) Extrahepatic malignancy
2) Severe cardiorespiratory disease
3) Systemic sepsis
4) Expected non-compliance with drug therapy
5) Ongoing alcohol consumption
Post Op Start enteral feeding and monitor LFTs Immunosuppress: Tacrolimus Azathioprine Prednisolone Prophylaxis against CMV or EBV Usually for the first year use 2 immunosuppressants and then prophylaxis, then scale back to 1 immunosuppressant
Rejection
Hyperacute - ABO mismatch
Acute (5-10d, T cell mediated) - pyrexia and tender hepatomegaly
Chronic (6-9 month)
Other complications
Sepsis
Hepatic artery thrombosis
Disease recurrance
Complications of management
Ciclosporin - gum hypertrophy
Tacrolimus - secondary diabetes
Steroids - cushingoid
SBP
Spontaneous Bacterial Peritonitis
Consider in patients with sudden deterioration from ascites
Commonly:
E.coli
Klebsiella
Strep
Hepatitis A
Type: RNA virus
Transmission: Faecal-oral or shellfish
Demographics: Endemic in Africa and S America. Most common in children.
1/100 result in acute hepatitis - usually in those with bad hygiene
Incubation: 2-6wks
Symptoms:
Initially - Fever, malaise, anorexia, nausea, arthralgia
Then - jaundice, hepatosplenomegaly, adenopathy
Tests: AST and ALT increase 22-40days after exposure then return to normal 5-20wks. IgM after 25d and IgG for life
Management:
Avoid alcohol
IFN alpha if fulminant
Immunisation: inactive, viral protein
Hepatitis B
Type: DNA virus
Transmission: Blood and bodily fluids
Mortality: 1mill/y
Demographics: Endemic in Far East, Africa, Mediterranean. IVDU, men-men sex, sexual promiscuity,, prisoners, workers or other in close contact with someone with it.
Incubation: 1-6months
Symptoms: Similar to the above, but arthralgia and urticaria are commoner.
Tests:
HBsAg - 1-6months after exposure, >6months defines a carrier
HBeAg - 1.5-3months after acute illness, suggestive of high infectivity
NB Abs to HBcAg imply past infection, whereas Abs to only HBsAg imply vaccination
PCR now allows monitoring of therapy quality
Vaccination: Passive of those at risk (although WHO suggest it should be all). Level >1000 Anti-HB is good
Management: Avoid alcohol Immunise contacts If any of 1) chronic liver inflammation (ALT>30) 2) cirrhosis 3) HBV DNA >2000 treat with antivirals - 48wks of PEG IFN alpha 2a Long term tenofovir or entecavir
Complications: Fulminant hepatic failure Cirrhosis HCC Cholangiocarcinoma Cryoglobulinaemia Membranous nephropathy Polyarteritis nodosa
Hepatitis C
Type: RNA flavivirus
Transmission: Blood or sexual contact
Prevalence: >200,000 in UK
Symptoms: 85% mild or asymptomatic but 25% get cirrhosis within 20y and around 4% get HCC/y
Risk factors: Male, older, high load, alcohol, HIV, HBV
Tests: LFTs, anti-HCV Abs, PCR for chronicity, biopsy
Management:
Quit alcohol
Determine genotype (1-6)
Ledipasvir and sofosbuvir
Complications: Glomerulonephritis Cryoglobulinaemia Thyroiditis Autoimmune hep
Hepatitis D
Type: Incomplete RNA (req. HBV)
Prevalence: 5% of HBV have co-infection
Symptoms: Acute liver failure/cirrhosis
Test: Ab only if +ve for HBV
Management: Likely to need a transplant
Hepatitis E and other infective causes
Type: RNA
Demographics: Endemic in Indochina, older men
High pregnancy mortality
Others: EBV, CMV, leptospirosis, malaria, Q fever, syphilis, yellow fever
NASH
Non alcoholic steatoic hepatitis
Linked to obesity
Can be drug induced
• statins
• paracetamol
• TB abx
Chole-
Cholestasis - reduced bile flow
Cholecystectomy - removal of the gall bladder
Cholangitis - inflammation of the bile duct
Cholecystisis - inflammation of the gall bladder
