Abdomen - DPD Flashcards
What are the signs you are looking for in the hands?
Asterixis Bruising Clubbing Dupuytren's Contracture Palmar Erythema Leuconychia Koilonychia
What are the signs you are looking for in the forearms?
AV fistulae
What are the signs you are looking for in the head and neck?
Anaemia
Jaundice
Skin: jaundice, scratch marks (excoriation marks) or spider naevi
Oral Examination:
Pigmentation
Gum hypertrophy
What are the signs you are looking for on the chest?
Gynaecomastia
Hair Loss
Excoriation Marks
Spider Naevi
Causes of hepatomegaly
Cancer (primary or secondary deposits)
Cirrhosis (later on in cirrhosis, the liver will shrink)
Cardiac:
Congestive cardiac failure
Constrictive pericarditis
Infiltration: Fatty infiltration Haemochromatosis Amyloidosis Sarcoidosis Lymphoproliferative disease
Summary of liver disease
Alcohol Autoimmune Drugs Viruses Biliary Disease NOTE: these are the things to think about when you have any patient with jaundice, raised AST/ALT, raised BR
Causes of splenomegaly
Portal hypertension
Haematological:
E.g. haemolytic anaemia, lymphoma, leukaemia
Infection:
E.g. malaria, schistosomiasis, leishmaniasis, TB, infective endocarditis, infectious mononucleosis
Inflammation
DDx of: 75 y/o man Epigastric pain HR: 130bpm BP: 80/50mmHg
Ruptured AAA (pain radiating to back, tachycardiac, low BP)
Pancreatitis
Peptic Ulcer
What does constant abdominal pain usually indicate?
Inflammation
What does colicky abdominal pain usually indicate?
Obstruction
How does acute pancreatitis present? What is the main test to confirm?
Epigastric pain
HIGH amylase
How does chronic pancreatitis present? What is the main test to confirm?
Epigastric pain, weight loss
Loss of exocrine/endocrine function
NORMAL amylase
Faecal elastase (main test)
DDx of right upper quadrant pain
Gallbladder:
Gallstones
Cholecystitis
Cholangitis
Liver:
Hepatitis
Abscess
Above (Lungs)
Basal Pneumonia
Below (Appendix)
Appendicitis
Left (Stomach, Pancreas)
Peptic Ulcer Disease
Pancreatitis
Right (Kidney)
Pyelonephritis
DDx of right iliac fossa pain
GI: APPENDICITIS Mesenteric adenitis Colitis (IBD) Malignancy
Gynaecological:
Ovarian cyst rupture, torsion or bleed
Ectopic pregnancy
DDx of suprapubic pain:
Cystitis
Urinary retention
DDx of left iliac fossa pain:
GI Causes:
DIVERTICULITIS
Colitis (IBD)
Malignancy
Gynaecological:
Ovarian cyst rupture, torsion, bleed
Ectopic pregnancy
DDx of diffuse abdominal pain
Obstruction
Infection:
Peritonitis
Gastroenteritis
Inflammation:
IBD
Ischaemia:
Mesenteric Ischaemia
Medical Causes: DKA Addison's Disease Hypercalcaemia Porphyria Lead poisoning
Which organs does the coeliac artery supply?
Stomach Spleen Liver Gallbladder Duodenum
Which organs does the superior mesenteric artery supply?
Small intestine
Right colon
Which organs does the inferior mesenteric artery supply?
Left colon
65 y/o man AAA repair 2 days ago Diffuse abdominal pain HR: 120bpm RR: 30
What will the blood test likely show?
Any cause of acute abdomen causes HIGH AMYLASE
Unlikely to have a normal amylase because he is tachycardic and tachypnoeic- indicates poor tissue perfusion and therefore some lactic acidosis
55 y/o man Excess ETOH use Cirrhosis Abdominal pain Abdominal distension
O/E: Ascites, liver flap
How many neutrophils are you likely to see in spontaneous bacterial peritonitis?
Ascites neutrophils > 250 cells/mm3
Decompensated features of liver disease
Jaundice
Encephalopathy
Ascites
Causes of abdominal distension
Fluid Flatus Fat Faeces Foetus
Signs of ascites
Shifting dullness
Features of liver disease
Signs of obstruction
Nausea, vomiting Not opened bowel High pitched tinkling bowel sounds ?Previous surgery ?Tender irreducible femoral hernia in the groin
Causes of transudate in ascites
Cirrhosis
Cardiac failure
Nephrotic syndrome
Causes of exudate in ascites
Malignancy
Infection (TB, pyogenic)
Budd-Chiari syndrome
Causes of ascites with albumin gradient <11 g/L
Nephrotic Syndrome Tuberculosis Pancreatitis (acute and chronic) Cancer Peritonitis
Causes of ascites with albumin gradient >11 g/L
CARDIAC FAILURE (acute and chronic)
CIRRHOSIS
Portal Hypertension
Constrictive Pericarditis
(high albumin gradient, likely due to chronic liver disease)
Cause of pale stools
Low stercobilinogen
Pre-hepatic causes of jaundice
Haemolysis, defective conjugation
Hepatic causes of jaundice
Hepatitis
Post-hepatic causes of jaundice
CBD obstruction
Stricture
Cancer of the head of the pancreas
Causes of unconjugated hyperbilirubinaemia
Haemolysis
Gilbert’s syndrome
What is hepatocellular jaundice?
Damage to liver cells, leakage of conjugated bilirubin from hepatocytes
This is soluble and secreted in urine, giving dark urine
Causes of hepatitis
Alcohol
Autoimmune
Drugs
Viruses
Difference in presentation with hepatitis vs obstruction
Both have dark urine
Obstruction also causes pale stools as no bilirubin reaches colon to be converted to stercobilinogen
DDx of: Painless jaundice Wt loss Dark urine Pale stool
Cancer of head of the pancreas
What markers rise in post-hepatic jaundice?
ALP
GGT
Which tumour marker is best associated with pancreatic cancer?
CA19-9
What is Trousseau Sign of Malignancy?
Episodes of vessel inflammation due to a blood clot which are recurrent or appearing in different locations over time
Can be early sign of gastric cancer or pancreatic cancer
Main causes of bloody diarrhoea
Infection
Inflammation
Malignancy
Causes of infection in bloody diarrhoea
Campylobacter Haemorrhagic E. coli Entamoeba histolytica Salmonella Shigella
Which group of people is inflammatory colitis more common in?
Young people with extra-GI manifestations
Which group of people is ischaemic colitis more common in?
Elderly
What are the extra-GI manifestations of inflammatory bowel disease?
Eyes: episcleritis, scleritis, uveitis
Skin: erythema nodosum, pyoderma gangrenosum
What is the lead pipe sign?
Seen on AXR
Feature of inflammatory bowel disease
Loss of haustral markings of colon
How does toxic megacolon appear on an AXR?
Colon diameter >6cm
Management of Acute GI bleed
ABC IV access Fluids Group and Save, cross-match blood OGD (find cause of bleed) Antibiotics (e.g. tazocin, ciprofloxacin) and terlipressin (causes splanchnic vasoconstriction) in addition for variceal bleeds
Management of Acute Abdomen
NBM Fluids Analgesic Anti-emetics Antibiotics Monitor vitals and urine output
Investigations for acute abdomen
FBC- look at WCC (if it is infective)
U&Es- renal function and hydration status
CRP- marker of infection and inflammation
Clotting- to see if patient prone to bleeding in surgery
Erect CXR- look for air under diaphragm
Investigations if patient presents with jaundice
FBC- check for various cause of jaundice
LFTs- important if liver pathology suspected
Abdominal USS- do after a fast, look for gallstones in distended, bile-filled gall bladder. Dilation of ducts shows some kind of obstruction
Investigations if patient presents with dysphagia and wt loss
OGD and biopsy
Investigations if patient presents with PR bleed and wt loss
Colonoscopy
What is Pabrinex?
Injection of water-soluble vitamins
Given to patients with chronic liver disease
Contains thiamine, prevents Wernicke’s encephalopathy
Management plan for patient with ascites
Tap ascites, find WCC (to look for SBP) If infective -> antibiotics Diuretics to remove fluid Dietary sodium restriction Fluid restriction in patients with hyponatraemia Monitor weight daily Therapeutic paracentesis
Management of patient with encephalopathy
Lactulose- osmotic laxative Phosphate enemas Avoid sedation Treat infections Exclude GI bleed- alcoholic patients with chronic liver disease will have low urea, if it rises it could be due to digestion of blood cells
What are the features of an anastamotic leak?
Diffuse abdominal tenderness
Guarding, rigidity
Hypotensive/tachycardic
Features of a pelvic abscess
Pain, fever, sweats, mucus diarrhoea
Presentation and treatment of perianal abscess
Tender, red swelling
Incision and drainage
Presentation and treatment of anal fissures
Rectal pain
Stool coated with blood
Advice regarding diet (fluid, fibre)
GTN cream
Presentation of irritable bowel syndrome
Recurrent abdominal pain, bloating
Improves with defecation
Change in frequency/form of stool (can be diarrhoea or constipation)
No PR bleed, anaemia, wt loss or nocturnal symptoms
Difference in presentation of irritable bowel syndrome and inflammatory bowel disease
IBS does not have nocturnal symptoms, IBD does
How to exclude coeliac disease
Measure tissue transglutaminase
Treatment of IBS
Diet and lifestyle modification
Symptomatic treatment:
Abdominal pain- antispasmodics
Laxatives for constipation
Anti-diarrhoeals
