Abdomen Flashcards
How do you differentitiate splenomegaly from a kidney?
The spleen has no palpable upper border (the kidney does)
The spleen moved inferomedially on inspiration (the kidney doesn’t)
The spleen has a notch (the kidney doesn’t)
There is no resonance to percussion over a splenic mass (there is over the kidney)
The spleen is not ballotatable (the kidney is)
A friction rub can sometimes be heard over the spleen
What is a normal liver span?
Normal liver span is 12cm (11-14cm)
Mildly enlarged 12-15cm
Moderately enlarged 15-20cm
Massively enlarged is >20cm
Spiel for nomral liver findings?
The liver edge was regular, smooth, soft and non-tender and measured [11-14cm]. It was not pulsatile or ptosed.
What is a normal liver span?
11 - 14 cm.
What size is massive hepatomegaly and what are the causes?
A span > 20 cm is massive hepatomegaly.
Malignancy
Hepatoma
Metastases from another primary
Myeloproliferative disorders: myelofibrosis, dysplasia, CML
Hepatic pathologies
Hepatoma
Other
Tricuspid regurgitation (pulsatile hepatomegaly)
What size is moderate hepatomegaly and what are the causes?
A span of 15 - 20 cm is moderate hepatomegaly.
Malignancy
Myeloproliferative: Myelofibrosis / myelodysplasia / CML
Liver metastases
HCC
Primary liver pathologies
NAFLD
Haemachrmatosis
What are the sizes of splenomegaly?
1-2 cm mild splenomegaly
3-7 cm moderate splenomegaly
>7cm marked splenomegaly
What are the sizes and causes of marked splenomegaly?
>7cm = marked splenomegaly
Malignancy
Myelofibrosis, CML, Myelodysplasia
What are the sizes and causes of moderate splenomegaly?
3-7 cm = moderate splenomegaly
Malignancy
Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV
Lymphoma, CLL
Hepatic
Portal HTN (with CLD liver may be small)
What causes hepatosplenomegaly?
Cirrhosis is usually = small liver + splenomegaly
NAFLD, EtOH liver disease, haemachromatosis, HCC causes hepatosplenomegaly
or
infiltrative diseases (lymphoma, amyloid, CTDs)
or
haematological malignancies (myelofibrosis / dysplasia) causes massive hepatosplenomegaly
What are the signs of portal hypertension?
Splenomegaly
Ascites
Prominent paraumbillical veins
History of oesophageal / rectal varicies
What are the peripheral stigmata of EtoH related liver disease?
Dupuytren’s contracture
Parotidomegaly
What are the sizes and causes of mild splenomegaly?
1-2 cm = mild splenomegaly
Malignancy
Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV, ET
Lymphoma, CLL
Hepatic
Portal HTN (with CLD liver may be small)
Other
CTDs (RA)
ITP, Thalassaemia, Sickle Cell
Sarcoid, Amyloid
How do you differentiate splenomegaly from a left renal mass
Spleen
- Moves inferiorly and medially on inspiration
- Not ballotable
- Notch in upper margin (if moderate splenomegaly), and can’t get above
- Dullness in Traube’s space
Renal mass
- Moves inferiorly on inspiration
- Ballotable
- No notch, and can’t get above
- No dullness in Traube’s space
How to present exam findings of liver pathology.
Broad signs of CLD
Cachexia
Clubbing
Leuchonycia
Palmar erythema / Spider naevi (count the number)
Gynaecomastia / loss of body hair
Anaemia (conjunctival pallor and pale palmar creases)
Brusing
Jaundice / scleral icterus
Signs of decompensated liver disease
Jaundice
Ascites / SBP
Hepatic encephalopathy
HCC
HRS
HPS
Or state there is no evidence of decompensation
Signs of portal HTN
Ascites
Splenomegaly
Caput medusae / enlarged paraumbilical veins
In regard to the aetioloigy of the underlyig CLD
EtOH: Dupetryn’s / Parotidomegaly / tremor / Cerebellar syndrome / Peripheral neuropathy
Hep B / C: tatoos, IVDU
PBC: xanthelasma, zanthomata
Haemochromatosis: bronze pigmentation, arthropathy and 2nd and 3rd MCPJ
CCF: tricuspid reugrigitation
Wilson’s: KF rings (only seen on slit lamp!)
Alpha 1 anti-trypsin: signs of COPD
Presenting renal findings on exam:
Non-ballotable kidney and signs of RRT (fistula or transplant)
Ballotable kidney with or without signs of RRT
Aetiology of CKD
Renovascular disease: body habitus, hypertensive
Diabetes if finger pricks / insulin pumps / lipohypertrophy from insulin
Ballotable masses (PCKD)
Vasculitis: vasculitisc skin rash
CTDs: systemic sclerosis
Treatment of CKD
AVF
Tenkhoff catheter
- Functioning or non-functioning*
- Infected or not infected*
Complications of CKD / Adequacy of Renal Replacement Therapy
Asterixis / Altered mental status or encephalopathic
Fluid overload / HTN
Sallow skin complecion / Pruritis / brusing
Pericardial rub
Pale conjunctivae / palmar creases anaemia
Tachypnoea to compensate for metabolic acidosis
Renal Transplant
Transplant tenderness
Complications of immunosupression:
- stigamata of infection
- presence of skin lesion
- cyclosporin: gum hypertrophy,, hirsuitism, tremor
- steroids: cushingoid*
What to examine at the end of PCKD exam?
BP
Neurological exam - cerbeal aneurysms
Cardiac exam - MVP and AR
Respiratory exam - sign of fluid overload
What else to ask for at the end of a renal abdomen exam?
Weight
Urinalysis - haematuria, proteinuria
Cardiac exam - MVP/AR associated with PCKD, pericardial rub
Respiratory exam - sign of fluid overload
Lower limb exam - oedema, or peripheral neuropathy associated with uraemia
What is a normal liver span?
11 - 14 cm.
What size is massive hepatomegaly and what are the causes?
A span > 20 cm is massive hepatomegaly.
Malignancy
Hepatoma
Metastases from another primary
Myeloproliferative disorders: myelofibrosis, dysplasia, CML
Hepatic pathologies
Hepatoma
Other
Tricuspid regurgitation (pulsatile hepatomegaly)
What size is moderate hepatomegaly and what are the causes?
A span of 15 - 20 cm is moderate hepatomegaly.
Malignancy
Myeloproliferative: Myelofibrosis / myelodysplasia / CML
Liver metastases
HCC
Primary liver pathologies
NAFLD
Haemachrmatosis
What are the sizes of splenomegaly?
1-2 cm mild splenomegaly
3-7 cm moderate splenomegaly
>7cm marked splenomegaly
What are the sizes and causes of marked splenomegaly?
>7cm = marked splenomegaly
Malignancy
Myelofibrosis, CML, Myelodysplasia
What are the sizes and causes of moderate splenomegaly?
3-7 cm = moderate splenomegaly
Malignancy
Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV
Lymphoma, CLL
Hepatic
Portal HTN (with CLD liver may be small)
What causes hepatosplenomegaly?
Cirrhosis is usually = small liver + splenomegaly
NAFLD, EtOH liver disease, haemachromatosis, HCC causes hepatosplenomegaly
or
infiltrative diseases (lymphoma, amyloid, CTDs)
or
haematological malignancies (myelofibrosis / dysplasia) causes massive hepatosplenomegaly
What are the signs of portal hypertension?
Splenomegaly
Ascites
Prominent paraumbillical veins
History of oesophageal / rectal varicies
What are the peripheral stigmata of EtoH related liver disease?
Dupuytren’s contracture
Parotidomegaly
What are the sizes and causes of mild splenomegaly?
1-2 cm = mild splenomegaly
Malignancy
Myeloproliferative disorders: myelofibrosis, dysplasia, CML, PRV, ET
Lymphoma, CLL
Hepatic
Portal HTN (with CLD liver may be small)
Other
CTDs (RA)
ITP, Thalassaemia, Sickle Cell
Sarcoid, Amyloid
How do you differentiate splenomegaly from a left renal mass
Spleen
- Moves inferiorly and medially on inspiration
- Not ballotable
- Notch in upper margin (if moderate splenomegaly), and can’t get above
- Dullness in Traube’s space
Renal mass
- Moves inferiorly on inspiration
- Ballotable
- No notch, and can’t get above
- No dullness in Traube’s space
How to present exam findings of liver pathology.
In regard to the aetioloigy of the underlyig CLD
Dupetryn’s / Parotidomegaly
Signs of decompensated liver disease
Ascites / SBP
Hepatic encephalopathy
HCC
HRS
HPS
Or state there is no evidence of decompensation
Signs of portal HTN
Ascites
Splenomegaly
Caput medusae / enlarged paraumbilical veins
Other signs of CLD
Palmar erythema / Spider naevi
Jaundice
How to describe an undifferentiated abdominal mass
Location
Size
Consistency (soft, firm)
Tender, non-tender
Move with respiration?
Pulsatile?
Associated rub or bruit?
Percussion note (resonant or dull)?
What are the relevant positives or negatives to note in the presence of an undifferentiated abdominal mass?
Cachexia
Evidence of anaemia (pallor of the palmar creases, pale conjunctivae)
Presents of lymphadenopathy (especiqally left supraclavicular fossa - Vurchowv’s node)
Relevant positives and negatives for PCKD
Cx of PCKD specifically
Was kidney tender?
Evidence of scars / fistula for current or previous renal replacement therapy
Gross inspection of mental status and neurologucal exam - complications of ruptured aneurysm
Evidence of nodular liver edge / hepatomegaly in keeping with hepatic involvement
No evidence of splenic cysts / splenomegaly
Complications of CKD more broadly
No evidence of anaemia - pallor palmar creases, pale conjunctivae
HT, evidence of fluid overload
Mentating normally, no asterixis / altered conscious state
No sallow skin complexion / pruritis / bruising
What are the causes of a unilateral palpbable kidney?
Simple cysts
Renal carcinoma
PCKD with contralateral nephrectomy
Congeintal abscence of a kidney
Other cystic diseases: Von Hippel Lindau, Tunerous Sclerosis
Relevant positives or negatives in CLD?
Broad signs
- Cachexia
- Hepatic encephalopathy
- Clubbing
- Leuchonycia
- Palmar erythema / Spider naevi (count the number)
- Gynaecomastia / loss of body hair
- Anaemia (conjunctival pallor and pale palmar creases)
- Brusing
- Jaundice / scleral icterus
- Ascites / SBP
Evidence of PHTN?
What features on ascitic fluid is suggestive of portal hypertension as the aetiology?
SAAG > 11
+ total protein < 2.5g/dL
What feature on ascitic fluid is suggestive of SBP?
PMN ≥250 cells/mm3
(if much higher >20,000, think about secondary bacterial peritonitis)
Leucs > 500 cells/mm3
Picture: Slide 10 Portal HTN Lecture
