Clinical signs Flashcards
What is ascites?
A pathological accumulation of fluid in the peritoneal cavity.
What are the four main groups of causes of ascites?
- Fluid imbalance
- Chylous ascites
- Exudative ascites
- Nephrogenic ascites
What are causes of fluid imbalance which can lead to heart failure?
- Cirrhosis
- CCF
- Myoedema
- Budd-Chiari syndrome
What are causes of chylous ascites?
- Obstruction e.g. malignant lymphoma
- Iatrogenic - lymphatics transection
- Retroperitoneal lymph node dissection
What are exudative causes of ascites?
- Exudate-secreting tumours
- Infections - e.g TB
- Inflammatory disease - e.g SLE
What is Cullen’s sign?
Periumbilical ecchymoses.
What is Grey Turner’s sign?
Ecchymoses or purple discolouration of the flanks.
What is the mechanism behind Grey-Turner’s sign?
A hole in the abdominal fascia. A defect in the transversalis fascia allows blood from the posterior pararenal space to move to the abdominal wall musculature and the subcutaneous tissue
What causes cullen’s sign?
Retroperitoneal haemorrhage - The retroperitoneum is connected to the gastro-hepatic ligament, then the falciform ligament, and finally to the round ligament (the obliterated umbilical vein), which tracks to the abdominal wall around the umbilicus. When a haemorrhage (from any cause) occurs, blood is able to move along these ligaments to the abdominal wall to produce ecchymoses
What are other causes of Cullen’s sign, besides acute pancreatitis?
- Retroperitoneal bleeding
- Post surgery
- Anticoagulation
- Rectus sheath haematoma
- Ectopic pregnancy
- Ischaemic bowel
What is erythema ab ignes?
Erythema caused by exposure to heat - in the context of chronic pancreatitis
What is asterixis?
When the patient is asked to hold the arms extended with the hands dorsiflexed, a flapping hand movement that is brief, rhythmless and of low frequency (3–5 Hz) becomes apparent. Asterixis may be bilateral or unilateral.
What conditions can cause asterixis?
- Liver disease – most common
- Chronic obstructive pulmonary disease
- Stroke – rare
What is thought to be the mechanism behind hepatic flap?
Little is known about the mechanism - The net result of the pathology is the failure of the diencephalic motor centres in regulating tone between the agonist and antagonist muscles needed to maintain position and posture
How often may bowel sounds be heard in a heatlhy individual?
5-35 times per minute
What are causes of absent bowel sound?
- Intestinal obstruction
- Paralytic ileus of any cause
- Mesenteric ischaemia
- Pseudo-obsstruction
Why are bowel sounds absent in bowel obstruction?
In a mechanical obstruction due to any cause (hernia, volvulus, adhesion), the intestines are pushing against a fixed object. The normal oscillatory movement of food and water is not happening (as in a blocked pipe), so no sound is produced.
If the obstruction continues, inflammation occurs and, if vascular supply is compromised, normal peristalsis may also stop.
Why can bowel sounds be absent in infection?
Although not entirely explained, there is evidence that the lipopolysaccharides (LPS) present on Gram-negative bacteria initiate an inflammatory response in the intestinal smooth muscle layer, which then reduces smooth muscle contractility, causing an ileus
Why can absent bowel sounds occur in hypokalaemia?
Potassium is needed for normal polarisation and repolarisation of muscle cells. Hypokalaemia causes a hyperpolarisation of muscle cells, reducing excitability of the neurons and therefore smooth muscle activity, leading to ileus.
Why can bowel sounds be absent in a post-operative situation?
Post-operative ileus
Hypothesised to be a combination of manipulation of the small intestine and bacterial overgrowth, which both contribute to inflammation of the bowel which leads to ileus
What is borborygmus?
Frequent, loud, gurgling or ‘rushing’ bowel sounds that sometimes may be clearly heard even without a stethoscope.
What are causes of borborygmus?
- Bowel obstruction
- IBD
- Food hypersensitivity
- Gastroenteritis
- Normality
- GI haemorrhage
Why does borborygmus occur in intestinal obstruction?
When obstruction is present, the bowel increases peristalsis in an attempt to overcome the blockage.
What are tinkling bowel sounds?
High-pitched ‘tinkling’ sound heard on auscultation of the abdomen that is often described as like pouring water into an empty glass.
When do tinkling bowel sounds occur?
Bowel obstruction
What is the following?
Caput medusae - Dilated veins of the abdominal wall, named after the snakes that made up the hair of the goddess Medusa in Greek mythology.
Whaat causes the following?
Any condition causing portal hypertension, e.g.:
- Cirrhosis of the liver
- Severe heart failure
- Inferior vena cava obstruction
- Budd–Chiari malformation
What is the mechanism behind caput medusa?
Portal hypertension causes backflow from the portal vein to the para-umbilical veins. The increased pressure and blood volume distend the veins.
How would you determine if caput medusae are being caused by IVC obstruction or portal hypertension?
Occlusion of the vein - Measure the flow of the vein below the umbilicus and use the following criteria:
- Severe portal hypertension - flow goes away from the umbilicus towards the feet.
- IVC obstruction - flow moves towards the head
Abdominal veins distend as they take blood back to the heart, bypassing the blocked IVC.
What is coffee ground vomit/haematemisis?
The vomiting of red blood or a coffee-ground-like substance. Haematemesis refers to the coughing up or vomiting of frank red blood.
What are causes of coffee ground vomit/haematemesis?
Upper GI bleed
- Peptic ulcer disease
- Gastritis
- Oesophagitis
- Oesophageal varices
- Mallory–Weiss tear
- Vascular
- Tumour
- Vasculitis
Why is coffee gorund vomit the colour and consistency that it is?
Coffee ground vomits owe their distinctive appearance to blood that has been oxidised by gastric acid, similar to malaena.
What does coffee ground vomit indicate?
It indicates that the blood and/or bleeding has been present for some time, and potentially is higher up in the gastrointestinal tract (i.e. the duodenum or stomach).
Why can haematemesis occur in peptic ulcer disease?
Inflammation and erosion of the normal mucosal surface into an underlying artery causes bleeding. Blood irritates the gut and is vomited back up.
What is the following?
Erythema nosodum - A skin disorder of acute onset with eruption of red, tender nodules and plaques, predominantly over the lower extremities, especially the extensor surfaces. It is a form of panniculitis
What are causes of the following?
- Inflammatory bowel disease
- Infections – streptococcal, tuberculosis, URTIs, yersiniosis
- Sarcoidosis
- Rheumatological disorders
- Drug reactions – usually sulfonamides and the oral contraceptive pill
- Malignancies
- Pregnancy
What is the mechanism behind erythema nodosum?
In theory, immune complexes form after exposure to an antigen and are deposited in venules around areas of subcutaneous fat and connective tissue. The subsequent inflammation causes the lesions.
Why the lesions appear so frequently on the shins has not been explained - suggested that a combination of a relatively meagre arterial supply combined with gravitational effects on venous system gravitational favour deposition in that area
What is voluntary guarding?
May be voluntary or involuntary in nature.
Voluntary guarding is the conscious contraction of the abdominal musculature, usually in response to fear of pain or anxiety.
What are causes of involuntary guarding?
Any cause of peritonism:
- Inflammation of any visceral organ
- Abdominal infection
- Bleeding
What is the following?
Gynaecomastia - A benign proliferation of glandular tissue in the male breast, clinically presenting as a firm disc of tissue underlying the nipple, which is at least 2 cm in diameter. Gynaecomastia usually develops bilaterally.
Gynaecomastia must be differentiated from adipomastia/lipomastia (pseudogynaecomastia), which refers to fat deposition without glandular proliferation (i.e. adipose tissue rather than true breast tissue).
What are causes of gynaecomastia?
- Physiological
- Drugs
- Radioiotherapy
- Hepatic cirrhosis
- Hypogonadism of any cause
- Hyperthyroidism
- Re-feeding syndrome
- Testicular tumours
- Renal failure/dialysis dependence
- Congenital abnormalities
What drugs can cause gynaecomastia?
- Cimetidine
- Digitalis
- Spironolactone
- Methyldopa
- Captopril
- Calcium channel blockers
- Chemotherapeutic agents
What are the general mechanisms behind gynaecomastia development?
- High levels of circulating oestrogen
- Increases in the oestrogen : testosterone ratio
- Androgen insensitivity
What are causes of haematuria?
- Kidney stones
- Malignancy
- Trauma to the urinary tract (e.g. infection or instrumentation)
- Glomerulonephritis – nephritis syndrome
- IgA nephropathy
- Goodpasture’s syndrome
- Vasculitis
- Interstitial nephritis
- Polycystic kidneys
- Papillary infarction
What is hepatic encephalopathy?
Refers to an array of symptoms resulting from acute or chronic liver failure:
- Forgetfulness
- Decreased cognitive function
- Confusion
- Altered sleep–wake cycle
- Irritability
- Asterixis
- Decreased level of consciousness
- Can have coma
When can hepatic encephalopathy be caused by?
Acute or chronic renal failure
What mechanisms are thought to contribute tot he development of hepatic encephalopathy?
- Portal hypertension
- Inability to metabolise ammonia
- Increased manganese
- Increased GABA
- Increased benzodiazapine like substance
What is hepatic foetor?
A sweet/musty odour emanating from the breath
When does hepatic foetor occur?
Hepatic failure
What is the mechanism behind hepatic failure?
Due to the failing liver’s inability to metabolise bacterially degraded methionine and mercaptan dimethyl sulfide, these substances pass through the lungs and are exhaled, producing a distinctive smell. Trimethylamine has also been implicated as a cause of the odour