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Y6 PACES > Abdominal Examination > Flashcards

Abdominal Examination Flashcards

1
Q

VIVA

Name five causes of abdominal distension

A

5Fs:
Fluid (ascites)
Flatus
Fat (adipose tissue)
Fetus (pregnancy)
Faeces (constipation)

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2
Q

VIVA

What clinical examination features would suggest decompensation of chronic liver disease?

A

Jaundice
Encephalopathy (confusion, asterixis)
Ascites

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3
Q

VIVA

In what circumstances might you be able to palpate a kidney?

A

It is uncommon to palpate a kidney. You may be able to palpate a kidney in some circumstances:
Cysts (e.g. in polycystic kidney disease)
Hydronephrosis
Congenital kidney abnormalities
Renal cell carcinoma

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4
Q

VIVA

What are the causes of hepatosplenomegaly?

A

Chronic liver disease with portal hypertension

Haematological:
o Leukaemia
o Lymphoma
o Myeloproliferative disorders

Infections:
o Acute viral hepatitis
o CMV/EBV
o Malaria
o Visceral leishmaniasis

Infiltration:
o Amyloidosis
o Sarcoidosis

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5
Q

VIVA

What are the complications of stoma formation?

A

Early:
High output stoma >1L/day (→ dehydration, hypokalaemia)
Retraction
Bowel obstruction/ileus
Ischaemia of stoma

Late:
Parastomal hernia
Prolapse
Fistulae
Stenosis
Psychological complications
Skin dermatitis
Malnutrition

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6
Q

VIVA

What are the most common pathologies requiring a renal transplant?

A

A renal transplant is indicated for end stage chronic kidney disease (GFR <15ml/minute), commonest causes include:
Diabetes mellitus
Polycystic kidney disease
Hypertension
Autoimmune glomerulonephritis

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7
Q

VIVA

Name, describe and list the indications for an end colostomy?

A

End colostomy (sigmoid/descending colon): proximal bowel opening brought to surface and distal bowel removed or stapled off/oversewn. Indications:
o Abdominoperineal (AP) resection for low rectal tumours
o Hartmann’s procedure for emergency resection of rectosigmoid lesions where primary anastomosis is unfavourable

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8
Q

Name, describe and list the indications for a loop colostomy?

A

Loop colostomy (transverse/descending colon): two openings made in a loop of intact bowel that is brought to the surface through one incision to form a stoma. The proximal opening drains faeces and the distal opening can drain mucus. It may be initially supported by a plastic rod. It is most commonly performed to divert the faecal stream away from distal bowel because of:
o Impending or actually obstructed large bowel
o Colonic lesions where the patient may not survive extensive surgery
o A distal bowel resection with primary anastomosis (to protect the anastomosis while sutures heal)

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9
Q

Name, describe and list the indications for a loop colostomy?

A

Double barrel colostomy (transverse/descending colon): a segment of bowel removed and both ends brought to the surface separately to form a stoma. The proximal end drains faeces and the distal end (called a ‘mucous fistula’) can drain mucus from the non-functioning bowel. Used infrequently after a segment of colon removed and primary anastomosis is unfavourable

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10
Q

VIVA

How is chronic liver disease managed?

A
  1. Treat/manage cause
    1. General
      o Optimise nutrition
      o Alcohol abstinence
    1. Monitoring
      o Bloods including FBC, LFTs, albumin, coagulation screen, and α-fetoprotein every 6 months (for liver function and hepatocellular carcinoma)
      o USS every 6 months (for hepatocellular carcinoma, hepatic vein thrombus, reversed portal flow)
      o Upper GI endoscopy every 3 years (for varices)
    1. Treat/prevent complications
      o Varices: banding, carvedilol, transjugular intrahepatic portosystemic shunt (for refractory ascites/varices/hepatic pleural effusion)
      o Ascites: spironolactone, low salt diet, fluid restriction
      o Encephalopathy: lactulose, rifaximin
      o Coagulopathy: vitamin K
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11
Q

VIVA

Please list some extra-renal signs of polycystic kidney disease

A

Hepatic Cysts
Ovarian cysts
Pancreatic Cysts
Berry aneurysms
Cardiac valve disease
Colonic diverticula
Aortic root dilatation
Anaemia

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12
Q

VIVA

Which conditions can cause secondary polycythaemia?

A

COPD
Obstructive sleep apnoea
Obesity hypoventilation syndrome
Diuretics
Renal malignancy
Altitude
Cyanotic heart disease

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13
Q

VIVA

A middle-aged female presents to you with jaundice and hepatomegaly, which conditions would you include in your differential diagnosis?

A

Primary biliary cholangitis
Autoimmune hepatitis
Viral hepatitis
Non-alcoholic fatty liver disease
Alcoholic liver disease

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14
Q

VIVA

What are the main ways to prevent graft rejection after renal transplantation?

A

HLA matching
Testing for donor specific antibodies
Immunosuppression (often with MMF, tacrolimus and prednisolone)

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15
Q

Clinical findings of chronic liver disease

A

Clubbing
Leukonychia
Palmar erythema
Dupuytren’s contracture
Jaundice
Spider naevi
Gynaecomastia
Loss of axillary hair
Distended abdominal wall veins/‘caput medusae’ (portal hypertension)
Hepatomegaly (but liver is often small in cirrhosis)
Splenomegaly (portal hypertension)
Ascites

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16
Q

Clincial findings after transplanted kidney

A

Old AV fistula
Rutherford-Morrison scar (usually RIF)
Smooth mass underlying scar (transplanted kidney)

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17
Q

Clinical findings of polycystic kidneys

A

AV fistula (if undergone dialysis)
Hypertension
Pale conjunctiva (anaemia)
Flank scar (if either kidney has been removed)
Bilateral ballotable flank masses
Hepatomegaly (hepatic cysts)

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18
Q

Clinical signs of previous liver transplant

A

Signs of chronic liver disease (but most resolve)
Mercedes Benz modification scar

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19
Q

Clinical findings of combined kidney-pancreas transplant

A

LIF scar (renal graft)
RIF scar (pancreas graft)
Smooth mass underlying LIF scar (transplanted kidney)

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20
Q

Clinical findings of olycythaemia rubra vera

A

Dusky cyanosis
Hypertension
Facial plethora
Splenomegaly

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21
Q

Clinical findings of hereditary spherocytosis

A

Pale conjunctiva
Mild jaundice
Splenomegaly

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22
Q

Clinical findings of primary biliary cholangitis

A

Middle-aged female
Jaundice
Skin hyperpigmentation
Excoriations
Xanthelasma
Hepatomegaly

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23
Q

What is Charcot’s triad?

A

Charcot’s triad represents the clinical features of cholangitis:
Jaundice
Fever
Right upper quadrant abdominal pain

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24
Q

Ultrasound confirms a common bile duct stone. How would you manage the patient?

A

Ensure blood cultures taken
IV antibiotics
IV fluids
ERCP to relieve obstruction (or percutaneous transhepatic biliary drainage if this is unsuccessful)

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25
Q

What are the most common causes of end-stage kidney disease?

A
  1. Diabetes
  2. Hypertension
  3. Glomerulonephritis
  4. Polycystic kidney disease
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26
Q

What symptoms may you expect in end-stage kidney disease?

A

Renal failure is most often asymptomatic but may present with non-specific symptoms such as:
Fatigue
Vomiting and loss of appetitive
Shortness of breath
Muscle cramps
Restless legs
Bone pain
Confusion

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27
Q

What are the main indications for renal replacement therapy in kidney disease?

A

In acute renal failure, AEIOU:
Acidosis
Electrolyte abnormalities (hyperkalaemia, hyponatraemia, hypercalcaemia)
Intoxicants (methanol, lithium, salicylates)
Overload
Uraemia
In chronic kidney disease, renal replacement therapy is generally required when the GFR is <15ml/minute, and there are symptoms or complications of kidney disease

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28
Q

List some complications of chronic kidney disease

A

Renal bone disease due to secondary hyperparathyroidism
Cardiovascular disease
Anaemia due to low EPO production
Arrhythmia related to hyperkalaemia

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29
Q

What options are available to patients with end-stage chronic kidney disease?

A

Dialysis
Haemodialysis: three 4-hourly sessions a week at the hospital, usually via AV fistula
Peritoneal dialysis: carried out at home either 3-5 times a day or 7-10 hours at night, via Tenckhoff catheter

Renal transplant
Live transplant: best outcome overall
Deceased Transplant: can be donation after brain death (DBD) or donation after cardiac death (DCD)
Patients with diabetes, may also be considered for a simultaneous kidney-pancreas transplant

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30
Q

Please list some red flags for anal cancer?

A

A mass at the anal opening
Bleeding from the rectum
Pain or a feeling of fullness in the anal area
Abnormal discharge from the rectum
Bowel incontinence
Change in bowel habit

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31
Q

Can you list some differentials of fresh red PR bleeding?

A

Inflammatory bowel disease
Anal Fissure
Colorectal Cancer
Haemorrhoids
Diverticular disease

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32
Q

How would you expect a cancer of the prostate to feel on digital rectal examination?

A

Hard
Firm
Asymmetrical
Craggy/irregular
Loss of central sulcus

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33
Q

What is Virchow’s node? What is the clinical significance?

A

Virchow’s node is left-sided supraclavicular lymphadenopathy. It is a common place for intra-abdominal malignancies to metastasise to, particularly gastric cancer.

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34
Q

Please list some causes of localised lymphadenopathy

A

Infection of area drained by lymph node (e.g. tonsillitis causing cervical lymphadenopathy)
TB
Lymphoma
Malignancy
Toxoplasmosis

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35
Q

Please list some causes of generalised lymphadenopathy

A
  • Lymphoma
  • Malignancy
  • EBV/CMV
  • HIV
  • Adenovirus
  • Toxoplasmosis
  • Disseminated TB
  • Visceral leishmaniasis
  • Sarcoidosis
  • Still’s disease
  • SLE
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36
Q

What is haemodiafiltration? What is the advantage of it?

A

Haemodiafiltration combines haemodialysis and haemofiltration. It may be used for chronic kidney disease (haemodiafiltration) or acute kidney injury (continuous venovenous haemodiafiltration). It has a theoretical advantage over haemodialysis because it also allows removal of some larger molecules (e.g. β2 microglobulin).

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37
Q

What are the complications of renal replacement therapy?

A

– Common non-severe side effects: headache, itching, muscle cramps
– Disequilibrium syndrome: osmotic changes lead to cerebral oedema
– Hypotension
– Haemolysis (may cause hyperkalaemia)
– Infection
– Problems with fluid balance

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38
Q

What are the commonest reasons for end-stage chronic kidney disease?

A

– Diabetes (secondary glomerular disease)
– Chronic hypertension
– Chronic glomerulonephritis
– Polycystic kidney disease

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39
Q

Why is a fistula needed?

A

The blood volume that needs to be removed and returned during haemodialysis is too great for a normal vein. If a vein and an artery are joined, the pressure of arterial blood entering the vein dilates it and increases the flow rate. After the vein is sufficiently dilated, it can be used for haemodialysis.

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40
Q

How long does it take for an AV fistula becomes patent?

A

It takes 4-6 weeks to sufficiently dilate the vein.

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41
Q

How is an AV fistula used?

A

Once the vein is dilated, two needles are inserted into the vein:
1. Afferent needle: takes blood from the vein to the haemodialysis machine (placed distally)
2. Efferent needle: returns blood from the haemodialysis machine to the vein (place proximally)

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42
Q

What are the complications of an AV fistula?

A

Common complications include: thrombosis, venous stenosis, aneurysm, infection, Steal syndrome (distal ischaemia)

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43
Q

What special instructions should be given to a patient with a new AV fistula?

A

– Do not let anyone take blood from or cannulate the arm on the side of the AV fistula
– Do not let anyone measure blood pressure on the arm on the side of the AV fistula
– Keep the arm clean
– Check the fistula daily for pulse/thrill

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44
Q

What are the advantages of an AV fistula over a central venous catheter?

A
  1. Lower re-circulation rate: afferent and efferent needles can be placed quite far apart up the vein, so only a tiny proportion of the blood returned to the patient (via the efferent needle) it taken back up again (by the afferent needle). Central venous catheter haemodialysis has a higher re-circulation rate because the afferent and efferent tubes are very close to one another.
  2. Lower infection rate
  3. Higher blood flow rate (allowing more efficient dialysis)
  4. Lower incidence of thrombosis
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45
Q

What are the different types of peritoneal dialysis?

A

– Continuous ambulatory peritoneal dialysis: patient replaces peritoneal dialysate manually with fluid bags 3-5 times daily (each exchange takes 30-40 minutes)
– Automated peritoneal dialysis: machine automatically replaces peritoneal dialysate overnight (over 8-10 hours)

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46
Q

What are the contraindications to peritoneal dialysis?

A

– Peritoneal adhesions
– Stoma
– Hernias
– Inflammatory bowel disease

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47
Q

What are the complications of peritoneal dialysis?

A

– Peritonitis
– Infection around catheter site
– Constipation
– Catheter malposition
– Fluid leaks
– Hernias
– Encapsulating peritoneal sclerosis
– Weight gain

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48
Q

What are the advantages of peritoneal dialysis?

A

– Can be done at home
– Dialysis fluid can be delivered to patient’s home
– Easier to travel/go on holiday
– Fewer restrictions on diet and fluid intake

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49
Q

How long does a renal graft last? What affects this time?

A

10-15 years

Affected by:
– ‘Cold time’ (time out of donor/recipient body)
– Type of donor (live/cadaveric)
– Donor age

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50
Q

Which immunosuppressive agents are usually given posttransplant?

A

Triple immunosuppression is usually required:
– Prednisolone
– Calcineurin inhibitor (e.g. ciclosporin, tacrolimus)
– Antimetabolite (e.g. azathioprine, mycophenolate mofetil)

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51
Q

What are the early complications of stoma formation?

A

– High output stoma >1L/day (→ dehydration, hypokalaemia)
– Retraction
– Bowel obstruction/ileus
– Ischaemia of stoma

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52
Q

What are the late complications of stoma formation?

A

– Parastomal hernia
– Prolapse
– Fistulae
– Stenosis
– Psychological complications
– Skin dermatitis
– Malnutrition

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53
Q

What would you expect to happen to the size of the liver and spleen in liver cirrhosis?

A

– The liver is often not palpable in cirrhosis because it shrinks
– Splenomegaly due to portal hypertension is a more common finding

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54
Q

What are the causes of massive splenomegaly?

A

Massive splenomegaly is usually due to: chronic Myeloid leukaemia, Myelofibrosis, Malaria (or less commonly splenic lymphoma or visceral leishmaniasis).

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55
Q

Which other clinical findings may you expect to find in a patient with hepatosplenomegaly due to a haematological cause?

A

– Signs of anaemia (e.g. conjunctival pallor)
– Lymphadenopathy

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56
Q

What are three differential diagnoses of a groin lump?

A

– Inguinal lymph nodes (medial to femoral vein)
– Iliopsoas abscess (lateral to femoral artery)
– Femoral neurofibroma (hard swelling lateral to femoral artery; painful if pressed)
– Saphena varix (dilation of the saphenous vein at junction with the femoral vein)
– Femoral aneurysm (pulsatile)
– Ectopic testes (rare congenital anomaly)
– Hydrocele of spermatic cord (loculated fluid collection along the spermatic cord)

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57
Q

What is is the difference between the midpoint of the inguinal ligament and the mid-inguinal point? What is the significance of each?

A

Midpoint of the inguinal ligament (midpoint between the ASIS and pubic tubercle) = deep inguinal ring position

Mid-inguinal point (midpoint between the ASIS and pubic symphysis) = femoral artery position

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58
Q

Please list some complications of a hernia mesh repair

A

– Pain
– Infection (including chronic mesh infection)
– Recurrence of hernia
– Adhesions
– Bleeding/haematoma
– Bowel obstruction

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59
Q

Please list three causes of chronic liver disease

A

– Alcohol
– Non-alcoholic fatty liver disease
– Viral hepatitides
– Autoimmune (e.g. autoimmune hepatitis, primary biliary cholangitis)
– Metabolic (e.g. haemochromatosis)

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60
Q

How would you investigate a patient with decompensated liver disease?

A

– Bloods: FBC, U&Es, LFTs, CRP, coagulation screen, glucose, blood cultures (if any signs of infection)
– Chest X-ray
– Urine dip and MSU
– Abdominal USS
– Ascitic tap (if ascites present)

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61
Q

How would you manage a cirrhotic patient with an acute upper GI bleed?

A

– A-E assessment
– Fluid resuscitation
– Correct coagulation abnormalities/reverse anticoagulation
– Blood transfusion if Hb<70
– IV terlipressin
– Prophylactic IV antibiotics
– Endoscopy

62
Q

Causes of Dupuytren’s contracture?

A

CLD, diabetes, heavy labour, phenytoin, trauma, familial

63
Q

Where are spider naevi found?

A

In distribution of SVC

Depress to demonstrate central filling

5+ suggests CLD

64
Q

Name the following abdominal scars

A
65
Q

Aetiology of ascites in CLD?

A
66
Q

DDx ascites

A
67
Q

Causes of hepatomegaly (6 subgroups)

A
68
Q

Extra-intestinal manifestations of IBD?

A
69
Q

DDx of gynaecomastia

A
70
Q

Liver edge characteristics? (5)

A
71
Q

Causes of massive splenomegaly

A
72
Q

Features of portal hypertension?

A
73
Q

Name for radio-cephalic fistula?

A

Cimino

74
Q

Why might the skin be yellow in a chronic renal failure patient?

A

Uraemia (∆∆ jaundice)

75
Q

∆∆ LIF mass

A
76
Q

∆∆ Bilateral vs unilateral enlarged kidneys

A
77
Q

∆∆ RIF mass

A
78
Q

Spleen vs left kidney on examination

A
79
Q

Indications for dialysis in chronic renal failure?

A
80
Q

Aspects of renal bone disease

A
81
Q

Complications of haemodialysis? (5)

A
82
Q

Side effects of post-transplant immunosuppressive drug therapy?

A
83
Q

Groin hernias?

A
84
Q

Borders of Hesselbach’s triangle

A
85
Q

Types of surgical hernia repair

A
86
Q

RFs for developing a hernia

A
87
Q

Complications of a hernia?

A
88
Q

Richter’s hernia?

A
89
Q

∆∆ neck lump

A
90
Q

∆∆ goitre

A
91
Q

∆∆ hypothyroidism

A
92
Q

Features of multinodular goitre

A
93
Q

Graves’ disease features

A
94
Q

Causes of thyroid eye signs?

A
95
Q

∆∆hyperthyroidism

A
96
Q

∆∆ parotid swelling

A
97
Q

Hyperthyroidism Rx

A
98
Q

CI to radioiodine

A
99
Q

Complications of thyroidectomy

A
100
Q

Features of stoma types?

A
101
Q

If pt has an end colostomy?

A
102
Q

Ideal site for a stoma?

A
103
Q

Stoma complications?

A
104
Q

Define a hernia

A

The protrusion of whole or part of a viscus through an opening in the wall of its containing cavity into a place where it is not normally found.

105
Q

What are the 6 types of ventral hernias?

A
106
Q

∆∆painless scrotal swelling

A
107
Q

∆∆ painful scrotal swelling

A
108
Q

Indications for a DRE

A
109
Q

Causes of +ve faecal occult blood test

A
110
Q

RFs for colorectal Ca

A
111
Q

Surgery for colorectal Ca

A
112
Q

Abdominal scars - laparotomy vs laparoscopy

A
113
Q

Laparotomy indications

A
114
Q

Paramedian scar

A

not commonly used due to complexity, poor cosmesis and neurovascular disruption

115
Q

Gridiron scar

A

centered over McBurney’s point (2/3 distance between umbilicus and ASIS) for appendicectomy

116
Q

Lanz scar

A

lower and more easily hidden than a gridiron but more likely to involve nerve damage

117
Q

Rutherford-Morrison scar

A

hockey stick incision for renal transplant (or access to colon)

118
Q

Transverse scar

A
  • Paediatric patients
  • Vascular patients (elective/emergency AAA repair)
119
Q

Kocher scar

A

Kocher: subcostal (rooftop if bilateral) for access to the liver / biliary tree / spleen

120
Q

Colostomy vs Ileostomy vs Urostomy

A
121
Q

Loop vs end stoma

A
122
Q

Indications for end colostomy

A

Permanent: distal bowel completely resected = abdominoperineal resection (APR) for cancer

Temporary: distal bowel left inside as stump = Hartman’s for perforation / cancer obstruction

123
Q

Indications for loop colostomy

A

Temporary: defunctions distal bowel to decompress distal obstruction

124
Q

Indications for end ileostomy

A

Permanent: distal bowel completely resected = panproctocolectomy for FAP / IBD

Temporary: distal bowel not completely resected = subtotalcolectomy for FAP / UC

125
Q

Indications for loop ileostomy

A

Temporary: defunctions distal bowel to protect distal anastomosis or rest inflamed bowel in IBD

126
Q

Indications for urostomy

A

Permanent: connects ileal conduit to ureters after radical cystectomy for bladder cancer

127
Q

Complications of stomas

A
128
Q

Colorectal cancer abdominal operations

A
129
Q

Which colorectal cancer operations require a stoma?

A

Colo-colic anastomoses have GOOD blood supply therefore do not need loop ileostomy protection

Colo-rectal anastomoses have POOR blood supply therefore require loop ileostomy protection

130
Q

Abdominoperineal resection of the rectum (APR)

Description, Indication, Scar + Stoma

A
131
Q

Anterior resection

Description, Indication, Scar + Stoma

A
132
Q

Hemicolectomy

Description, Indication, Scar + Stoma

A
133
Q

Subtotal colectomy

Description, Indication, Scar + Stoma

A
134
Q

Panproctocolectomy

Description, Indication, Scar + Stoma

A
135
Q

Hartmann’s procedure

A
136
Q

Causes of splenomegaly

Non-massive vs massive

A
137
Q

Causes of hepatomegaly

A
138
Q

Causes of hepatosplenomegaly

A
139
Q

Renomegaly causes

A
140
Q

Criteria for dialysis

A
141
Q

Stages of CKD

A
142
Q

Haemodialysis vs peritoneal dialysis

A
143
Q

Causes of ESRF?

A

diabetic nephropathy, hypertensive nephropathy, polycystic kidney disease, autoimmune disease e.g. SLE, vasculitis, renovascular disease

144
Q

Types of fistulas

A
145
Q

Examination of an AV fistula

A
146
Q

Fistula complications

A
147
Q

Indications for a kidney transplant

A

ESRF; last approximately 10-15 years (latter if living donor)

148
Q

Procedure description for kidney transplant

A

native kidneys remain in situ; donor kidney implanted in abdomen into iliac fossa via hockev stick incision. and anastomosed onto external iliac vessels

149
Q

Renal transplant immunosuppression

A
150
Q

Complications of renal transplant

A
151
Q

Examine for features of immunosuppression after renal transplant

A

skin cancers, cushingoid features, tremor (tacrolimus), gum hypertrophy (cyclosporin)

Y6 PACES (21 decks)

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