Abdomen Short Case

Question 1

Distinguishing caput medusae vs. inferior vena caval obstruction

Answer 1

Demonstrate direction of flow of visible vessels below umbilicus.
• Caput medusa: towards legs
• IVC obstruction: towards heart

Question 2

DESCRIPTION FEATURES OF INTRA-ABDOMINAL MASSES

Answer 2

1. State the region involved
2. Tenderness
3. Size (must be measured) and shape: normal liver span <13cm
4. Surface, which may be regular or irregular
5. Edge, with may be regular or irregular
6. Consistency, which may be hard or soft
7. Mobility and movement with inspiration
8. Whether it is pulsatile or not
9. Whether one can get above the mass

Question 3

CAUSES OF HEPATOMEGALY (massive, moderate and mild)

Answer 3

1. Massive
   a. Metastases
   b. Alcoholic liver disease with fatty infiltration
   c. Myeloproliferative disease
   d. Right heart failure
   e. Hepatocellular cancer/secondary metastasis
2. Moderate
   a. Above causes
   b. Haemochromatosis
   c. Haematological disease – chronic leukaemia, lymphoma,
   d. Fatty liver – secondary to diabetes mellitus, obesity, toxins
3. Mild
   a. Above causes
   b. Hepatitis
   c. Biliary obstruction
   d. Cirrhosis
   e. Ischaemia
   f. Infiltration – e.g. amyloid
   g. Granulomatous disorders
   h. Hydatid disease
   i. HIV infection

Question 4

CAUSES OF A FIRM AND IRREGULAR LIVER

Answer 4

• Hepatocellular carcinoma
• Metastatic disease
• Cirrhosis
• Hydatid disease, granuloma (e.g. sarcoid), amyloid, cysts

Question 5

CAUSES OF A TENDER LIVER

Answer 5

• Hepatitis
• Rapid liver enlargement – e.g. right heart failure, Budd-Chiari syndrome (hepatic vein thrombosis)
• Hepatocellular carcinoma
• Hepatic abscess
• Biliary obstruction/cholangitis

Question 6

CAUSES OF A PULSATILE LIVER

Answer 6

• Tricuspid regurgitation
• Hepatocellular cancer
• Vascular abnormalities

Question 7

CAUSES OF HEPATOSPLENOMEGALY

Answer 7

1. Chronic liver disease with portal hypertension
2. Haematological: e.g. myeloproliferative disease, lymphoma, leukaemia, thalassaemia, sickle cell anaemia
3. Infection, e.g. acute viral hepatitis, EBV, CMV
4. Infiltration, e.g. amyloid, sarcoid
5. Connective tissue disease, e.g. systemic lupus erythematosus
6. Acromegaly
7. Thyrotoxicosis

Question 8

CLASSIFICATION OF ASCITES BY THE SERUM ASCITES TO ALBUMIN CONCENTRATION GRADIENT

Answer 8

High gradient (>11g/L)
•	Cirrhosis with portal hypertension
•	Alcoholic hepatitis
•	Budd-Chiari syndrome
•	Fulminant hepatic failure
•	Congestive heart failure, constrictive pericarditis 
•	Myxoedema 
Low gradient (<11g/L)
•	Peritoneal carcinomatosis 
•	Tuberculosis 
•	Pancreatic ascites 
•	Nephrotic syndrome

Question 9

SIGNS OF LIVER DISEASE

Answer 9

• Hands: leukonychia, clubbing, palmar erythema, bruising, asterixis
• Face: jaundice, scratch marks, spider naevi, fetor hepaticus
• Chest: gynaecomastia, loss of body hair, spider naevi, bruising, pectoral muscle wasting
• Abdomen: hepatosplenomegaly, ascites, signs of portal hypertension, testicular atrophy
• Legs: oedema, muscle wasting, bruising

Question 10

SIGNS OF PORTAL HYPERTENSION

Answer 10

• Splenomegaly
• Collateral veins
• Ascites

Question 11

CAUSES OF PORTAL HYPERTENSION

Answer 11

1. Cirrhosis of the liver
2. Other causes
   a. Pre-sinusoidal: portal vein compression, intravascular clotting, umbilical vein phlebitis
   b. Intrahepatic: sarcoid, lymphoma or leukaemic infiltrates, congenital hepatic fibrosis
   c. Post-sinusoidal: hepatic vein outflow obstruction (Budd-Chiari syndrome), veno-occlusive disease, constrictive pericarditis, chronic cardiac failure