Abdominal station Flashcards
single palpable kidney causes
PKD
Hydronephrosis
renal cyst
renal carcinoma
hypertrophy pf solitary functioning kidney
signs of PKD
resonant ballotable masses, oedema for renal failure, AV fistula, blood pressure and urine dip for renal failure
PKD associated with
berry aneurysms, hepatic cysts, mitral valve prolapse
PKD facts
Autosomal dominant
1 in 1000
HTN, UTI’s, cyst haemorrhage, haematuria
End stage renal failure at 40-60yo
DDx for bilateral kidney masses
ADPCKD, bilateral renal cysts, bilateral renal cell carcinoma, bilateral hydronephrosis, amyloidosis, tuberous sclerosis
Abdo causes of clubbing
Hepatic cirrhosis
Coeliac disease
Ulcerative colitis
Crohn’s disease
GI lymphoma
What is IBS?
Recurrent abdo pain for 1d/week for 3 months with association with defecation, change in frequency of stool, change in form of stool
IBS treatment
Conservative = advice, FODMAP, CBT
Medical = bulk forming laxatives, analgesia = mebeverine, loperamide for diarrhoea
Coeliac disease…
Villous atrophy, from gliadin + gluten. Associated with other autoimmune conditions
Extra intestinal = dermatitis herpetiformis, anaemia, hyposplenism, osteomalacia, T cell lymphoma
Coeliac disease investigations
Ensure eating gluten for 6w prior to testing
1st line = IgA TTG levels + Serum IgA levels
+ve = endoscopy + duodenal biopsy = increased intraepithelial lymphocytes, villous atropy, crypt hyperplasia
2nd line = IgA EMA
UC treatment acute severe disease
Signs = >6 stools, frank blood, fever, HR >90, anaemia, ESR>90
admit + IV hydrocortisone
If no improvement at 72 hours = IV ciclosporin + biologics then surgical input
UC non-severe treatment
Pancolitis = Topical + oral aminosalicylate if no improvement at 4 weeks = oral corticosteroids
Proctitis, proctosigmoiditis, L sided colitis = topical aminosalicylate if no improvement at 4w = oral corticosteroids
Toxic megacolon
UC or C.diff infection
3-6-9 rule
IV hydrocortisone + infliximab
Renal transplant signs
AV fistula. If no needle marks, no thrill, thrombosed = non-functioning
Glucose monitoring marks on finger
Rutherford Morrison scar, flank scar
Renal failure signs
cachexia, old AV fistula scars, peritoneal catheters, pulmonary and peripheral oedema, pallor
Indications for renal transplant
- Diabetic nephropathy
- Polycystic kidney disease
- Glomerulonephritis
complications of renal transplant
- Rejection
- Cushing syndrome
- Skin malignancy (BCC + SCC)
- Ciclosporin = gym hypertrophy
signs of splenomegaly
Dull mass, moves with respiration and non-ballotable
Beyond midline = massive splenomegaly
Unable to palpate liver edge = tense ascites
causes of splenomegaly
Haematological = CML, myelofibrosis, spherocytosis
Infective = malaria, EBV
Other = portal hypertension, amyloidosis, sarcoidosis
causes of hepatomegaly
Haem = CML
Infective = malaria, EBV
Other = amyloidosis, sarcoidosis
indications for splenectomy
Traumatic rupture, idiopathic thrombocytopaenia, spherocytosis
splenectomy prophylaxis
Pneumococcus, meningococcus, Haem Influenza B, Penicillin V
Signs of decompensated liver disease
Worsening jaundice, ascites, encephalopathy, coagulopathy, hypoglycaemia, varices, splenomegaly
signs of portal HTN
visible veins
splenomegaly
ascites
Signs of chronic stable liver disease
palmar erythema, spider naevi, gynaecomastia, dupytrens contracture, testicular atrophy
liver disease complications
Variceal bleed = terlipressin + banding
Ascites = spironolactone, ascitic drain, TIPS
Encep = lactulose
SBP = broad spec Abx
Hepatorenal syndrome = terlipressin, albumin, TIPS
AST/ALT ratio 2:1
alcohol related
chronic liver disease signs
General = cachexia, jaundice, excoriations, bruising, lack of axillary hair
Hands = dupuytren’s, palmer erythema, clubbing
Face = icteric sclerae, parotid swelling
Abdomen = spider naevi, caput medusae, gynaecomastia, ascites, splenomegaly
Specific signs in chronic liver disease
Parotid swelling = alcohol
Needle marks = hepatitis C
Bronze complexion = haemochromatosis
Obesity + diabetes = NAFLD
Xanthelasma = cholestatic disease
chronic liver disease presentation
“Today I examined this gentleman’s abdominal system. On general inspection he is cachectic, jaundiced and has a distended abdomen. He has digital clubbing and multiple spider naevi. There was no hepatic asterixis present. His abdomen was soft and non tender. Shifting dullness was present. On palpation there was no organomegaly. These signs are consistent with decompensated chronic liver disease with ascites but not encephalopathy. I would like to take a full history and perform blood tests to determine the cause.”
causes of chronic liver disease
Infective = hep B , hep C (serology)
Toxic = alcohol
Metabolic = NAFLD, haemochromatosis, A1AD, wilson’s disease (ferritin, transferrin, caeruloplasmin)
Autoimmune = autoimmune hepatitis, PSC, PBC
complications of cirrhosis
- Portal hypertension - variceal haemorrhages/spontaneous bacterial peritonitis, thrombocytopaenia
- Hepatocellular failure - encephalopathy, HCC, hypoalbuminemia, coagulopathy
IBD signs
young, pallor, ileostomy, oral ulcerations, pyoderma gangrenosum, clubbing, medications e.g. azathioprine or mesalazine
signs of complications of IBD
Scars from Hickman lines for Parenteral nutrition, cushingoid, gum hypertrophy, jaundice, urosdeoxycholic acid, hepatosplenomegaly
identifying stomas
Ileostomy = usually right sided, spouted, looser contents
Colostomy = left sided, flush to skin, thicker contents
Urostomy = urine coloured
IBD presentation
Today I examined this gentleman’s abdominal system. On inspection he was pale and slim. There was no digital clubbing. He had a stoma in his right iliac fossa and a midline laparotomy scar. His abdomen was soft and non tender. There were no hernias or fistulae. These signs would point to a diagnosis of Crohn’s disease with a defunctioning ileostomy, or ulcerative colitis with an end ileostomy, or a panproctolectomy for familial adenosis polyposis. I would like to take a full history and examine him for any perianal disease
Extra-intestinal manifestations of IBD
Eyes = uveitis, episcleritis, scleritis
Skin = pyoderma gangrenosum, erythema nodosum
Other = clubbing, oligoarthritis, anaemia
complications of crohns
strictures, obstruction, fistulae
complications of UC
toxic megacolon, colonic carcinoma, PSC
Indications for stoma in crohns
failure of medical management, obstruction, fistulae
Indications for stoma in UC
failure of medical management, toxic megacolon or malignancy
What stoma for crohns
de-functioning loop ileostomy
what stoma for UC
end ileostomy for a panproctocolectomy or a diversion ilesotomy with a ileal rectal pouch formation
if emergency = hartmanns = colostomy
Erythema nodosum SORE SHINS
Step, IBD, sarcoid, drugs
Normal abdominal exam presentation
Today I performed an abdominal examination of X year old Y.
On general inspection the patient was normal body habitus, was comfortable at rest and did not have any catheters or drains.
On closer inspection of the hands and arms, the patient did not exhibit any stigmata of abdominal disease such as palmar erythema, clubbing or signs of IVDU.
Extremities were warm with normal capillary refill. There was no asterixis. Pulse was regular at Z.
On closer inspection of face and chest, no anaemia, scars or spider nevi were identified.
JVP was non raised and the abdomen did not show any hernias or scars.
Abdomen was soft non tender and with no organomegaly.
Abdominal aortic pulse was present and non-expansile.
Bowel sounds were present and normal, and there were not bruits audible.
In conclusion this was a normal abdominal examination. To complete my examination, I would like to take full history, examine the external genitalia and the hernial orifices.
I would like to take a full set of observations, perform a DRE as well as capillary glucose and urinary dipstick I would like to order bloods, including FBC, U&Es and LFTs for baseline, and order an abdominal CT if indicated.
how do you examine a stoma?
Inspection
1. Location
2. Spouted vs. flush
3. Pink/healthy
4. Bag content
5. Number of lumens
Palpation
1. Para-stomal hernia
Completion
1. Examination of perineum
2. Removal of bag and digital examination of stoma
criteria for AP resection?
Ca <4-5cm from anal verge
what possible procedures cause a midline laparotomy scar?
- AAA repair (emergency or elective)
- Hartmann’s
- Trauma
- Colon Ca removal
- Perforated ulcer (duodenal) repair/resection
- (Conversion from laparoscopic procedure to open)
early complications from stoma formation
- Pain
- Infection
- Haemorrhage
- High output – electrolyte & fluid balance
late complications from stoma formation
Late
* Prolapse
* Skin reactions
* Stenosis/stricture
* Psychological impact
causes of chronic renal disease
Diabetes mellitus 34%
Glomerulonephritis 21%
Hypertension 12%
hemodialysis complications
dialysis washout
bacteremia
bleeding
associated amyloidosis
peritoneal dialysis complications
bacterial peritonitis
failure
DM
hernia
infection
