Abdominal - GI/renal Flashcards
Go through the Gastrointestinal Short Case
Lying down with a pillow for the head
Liver
- measure span (normal 12.5cm)
Spleen
- percuss over lowest intercostal space, anterior axillary line, at full inspiration
- if dull suspect splenomegaly
- if nothing palpable lie on right side and palpate again
Percussion
- if resonant out to flanks don’t roll them
- if not, percuss til dull, then roll-wait-percuss again
Auscultation
- liver: arterial systolic bruit (HCC; acute alcoholic hepatitis); friction rub (tumour, biopsy, infarction, gonococcal perihepatitis
- spleen: friction rub (infarction); venous hum (portal hypertension, uncommon)
- renal: bruits
If cirrhosis
- 45 degrees: JVP for contrictive pericarditis
- sitting: neck nodes, sacral oedema, spider naevi, pleural effusion
- face: sclera, corneas, xanthelasma (PBC), parotids (ETOH binge), mouth
- arms: bruising, spider naevi
- hands: flap, clubbing, leukonychia, palmar erythema, dupeytren’s, arthropathy
- legs: oedema, bruising, rashes, tendon thickening (if dupuytren’s in hands)
- nervous: peripheral neuropathy, proximal myopathy, wernicke’s (bilat 6th palsy), korsakoff’s
- other: rectal, testicles, temperature, urinalysis, hernias
If haematological
- do haem exam
If pulsatile liver
- do cardio exam, focusing on TR presence/causes
If large kidney
- BP, urine, signs of anaemia/polycythaemia
If malignant suspected
- nodes
- lungs
- breasts
- note: non-haem malignancy causing hepatomegaly rarely causes splenomegaly unless portal vein directly involved
- *Haemochromatosis**
- bronzed skin
- arthropathy (especially 2/3 MCPs)
- testicular atrophy (hypogonadotrophic hypogonadism)
- dilated cardiomyopathy
- glycosuria (diabetes)
Go through the peripheral examination after finding cirrhosis / suspecting chronic liver disease
If cirrhosis
- 45 degrees: JVP for contrictive pericarditis
- sitting: neck nodes, sacral oedema, spider naevi, pleural effusion
- face: sclera, corneas, xanthelasma (PBC), parotids (ETOH binge), mouth
- arms: bruising, spider naevi
- hands: flap, clubbing, leukonychia, palmar erythema, dupeytren’s, arthropathy
- legs: oedema, bruising, rashes, tendon thickening (if dupuytren’s in hands)
- nervous: peripheral neuropathy, proximal myopathy, wernicke’s (bilat 6th palsy), korsakoff’s
- other: rectal, testicles, temperature, urinalysis, hernias
Signs of CLD
- early signs of decomp
- late signs of decom
- alcoholic disease
- portal hypertension
Signs of CLD
- Peripheral signs
- Clubbing
- Palmar erythema
- Leuconekia
- Hormonal signs
- Testicular atrophy/gynaecomastia
- Spider naevi
- Altered hair loss
Early signs of decompensation
- dec production of coag and plts –> bruising/coagulopathy
- dec albumin production –> peripheral oedema and pleural effusion
Late signs of decompensation
- dec clearance of bili –> jaundice
- dec clearance of toxins –> hepatic flap, fetor and encephalopathy
Alcoholic disease
- dupetryns contracture
- parotiditis
Portal HTN
- rectal varices
- caput medusa
- splenomegaly
- ascites
What are the auscultation findings on abdominal examination and their associations?
Auscultation
- liver: arterial systolic bruit (HCC; acute alcoholic hepatitis); friction rub (tumour, biopsy, infarction, gonococcal perihepatitis
- spleen: friction rub (infarction); venous hum (portal hypertension, uncommon)
- renal: bruits
What are the causes of Cirrhosis?
- *Causes**
- Alcohol
- Postviral (hep B/C)
- Non alcoholic steatohepatitis (NASH)
- Drugs (e.g. methyldopa, chlorpromazine, isoniazid, nitrofurantoin, propylthiouracil, methotrexate, amiodarone)
- Autoimmune hepatitis
- Haemochromatosis
- Wilson’s disease
- Primary sclerosing cholangitis (PSC)
- Primary biliary cirrhosis (PBC)
- Secondary biliary cirrhosis
- Alpha1 antitrypsin deficiency
- Cystic Fibrosis
- Budd-Chiari Syndrome
- Cardiac Failure, chronic constrictive pericarditis
- Cryptogenic (idiopathic)
What are the causes of hepatomegaly?
- *Note:**
- causes of massive can cause mod/mild
- causes of mod can cause mild
Massive
- metastases
- alcoholic liver disease with fatty infiltration
- myeloproliferative disease
- RHF
- HCC
Moderate
- haemochromatosis
- CML, lymphoma
- fatty liver: obesity, diabetes, toxins
Mild
- hepatitis
- cirrhosis
- biliary obstruction
- granulomatous disorders
- hydatid disease
- infiltrative: amyloid, sarcoid
- HIV
- ischaemia
What are the causes of hepatosplenomegaly?
CLD with portal hypertension
Haematological
- myeloproliferative
- lymphoma, leukaemia
- pernicious anaemia, sickle cell anaemia
Infection
- acute viral hepatitis
- glandular fever (EBV), CMV
Infiltration
- sarcoid
- amyloid
CTD
- SLE
Acromegaly
Thyrotoxicosis
Note:
- always think of associated PCKD in hepatosplenomegaly
What are the causes of renal masses?
Bilateral
- PCKD
- hydro/pyonephrosis
- hypernephroma (bilat RCC)
- acute renal vein thrombosis
- infiltrative: amyloid, lymphoma, sarcoid
- acromegaly
- rare: very thin with early diabetic nephropathy or nephrotic syndrome
Unilateral
- RCC
- hydro/pyonephrosis
- PCKD
- acute renal vein thrombosis
- normal right kidney or solitary left kidney
What are the clinical findings associated with haemochromatosis?
Haemochromatosis
- bronzed skin
- arthropathy (especially 2/3 MCPs)
- testicular atrophy (hypogonadotrophic hypogonadism)
- dilated cardiomyopathy
- glycosuria (diabetes)
What are the differentiating features of the spleen compared with the kidney?
Spleen
- no palpable upper border
- notched
- moves inferomedially on inspiration
- usually no resonance over a splenic mass
- not ballottable
- may occasionally hear a friction rub
What are the main causes of LIF masses?
- *Gastrointestinal**
- faeces (indentable)
- carcinoma of sigmoid/descending colon
- diverticular disease
- hernias
- *Other**
- ovarian tumour/cyst
- psoas abscess
What are the main causes of RIF masses?
- *Gastrointestinal**
- appendiceal abscess
- caecal carcinoma
- crohn’s
- ilieocaecal tuberculosis
- carcinoid tumour
- amoebiasis
- hernias
- *Other**
- pelvic kidney
- psoas abscess
- ovarian tumour/cyst
What are the main causes of upper abdominal masses?
Lymphadenopathy
Gastrointestinal
- stomach carcinoma
- pancreatic pseudocyst/tumour
- pyloric stenosis
- transverse colon carcinoma
- hernias
Other
- AAA (pulsatile)
What causes a firm, irregular liver?
Cirrhosis
Metastatic disease
Other
- hydatids
- infiltrative: amyloid, sarcoid
- cysts
- lipoidoses
What causes a pulsatile liver?
- TR
- HCC
- Vascular abnormalities
Causes of ascites with interpretation of serum-ascites-albumin gradient
