Abdominal examination

Question 1

Multifactorial aetiology of ascites in CLD?

Answer 1

1. Portal hypertension
2. Hypoalbuminaemia
3. Salt and water retention secondary to RAAS activation

Question 2

Ascites classification and causes?

Answer 2

SAAG = serum-ascites albumin gradient

= serum albumin - ascitic albumin

If high (transudate) - >11g/L

If low (exudate) - <11g/L

High SAAG: Cirrhosis (portal hypertension), CLF, Budd-chiari, RHF, constrictive pericarditis

Low SAAG: Malignancy, infection (bacterial - SBP, fungal, TB), pancreatitis, nephrotic)

Question 3

Ascitic fluid tests?

Answer 3

Albumin

LDH (transudate v exudate)

Glucose (normal in SBP)

Amylase (pancreatitis)

pH (<7 suggets bacterial infection)

Trigylcerides

WCC

Gram stain (monomicrobial - SBP)

Cell count, cytology (malignant cells)

Question 4

Ascites Mx

Answer 4

Treat cause

Fluid and Na restriction

Drain for symptomatic relief

Spironolactone, 2nd line - furosemide

If draining >5L - give albumin infusion

if SBP - antibiotics (taz or cefotaxime) and albumin infusion

Question 5

Hepatomegaly causes

Answer 5

2 I’s, 2 B’s, 2 C’s:

Infection - viral hepatitis, EBV, malaria, abscess

Infiltration - sarcoid, amyloid, fatty liver, haemochromatosis

Blood related - lymphoma, leukaemia, myeloproliferative, haemolytic anaemias

Biliary - PBC, PSC

Cancer - HCC (primary), mets

Congestion - RHF, TR, Budd-chiari

Question 6

Hepatosplenomegaly causes?

Answer 6

Viral hepatitis, EBV (IM), Malaria

Sarcoid, amyloid

Leukaemia, lymphoma, MPO, haemolytic anaemias

Question 7

Extra-intestinal manifestations IBD?

Answer 7

Finger clubbing

Mouth ulcers - apthous (crohn’s)

Eyes - episcleritis, conjunctivitis

Skin - erythema nodosum, pyoderma gangernosum

Joints - seronegative spondyloarthropathy

PSC (UC)

Amyloidosis (crohn’s)

Question 8

Gynaecomastia causes?

Answer 8

Physiological (puberty/elderly)

Testicular failure (klinefelter’s, orchitis/trauma, haemodialysis)

Increased oestrogen - CLD, thyrotoxicosis, tumour

Drug induced (DISCO) - digoxin, isoniazid, spironolactone, cimetidine/ketoconozole, Oestrogen

Question 9

Liver edge characteristics

Answer 9

Smooth - venous congestion, fatty infiltration

Knobbly - mets, cysts

pulsatile - TR

Tender - hepatitis, RHF

Bruit - HCC, AV malformation, TIPSS

Question 10

Causes massive splenomegaly (past umbilicus)?

and non-massive?

Answer 10

Malaria

Myelofibrosis

CML

Others (not massive) - IE, RhA - felty’s if low WCC, amyloid, CLL, lymphoma,