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amir sam dpd 2018 > DPD 3 - Abdo pain > Flashcards

DPD 3 - Abdo pain Flashcards

1
Q

What are the signs of chronic liver disease seen in the hands? (A - J)

A 
Asterixis (liver flap) - hepatic encephalopathy
Bruising
Clubbing
Dupuytren's contracture
Erythema (Palmar) - redness
Fetor
Gynaecomastia
Hair loss
Jaundice
Leuconychia - hypoalbuminaemia  (decreased liver function)
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2
Q

What are the signs suggestive of abdominal disease seen on the arms, hands + neck?

A

AV fistulae - current or previous renal replacement therapy
Anaemia
Jaundice
Skin: excoriation marks or spider naevi
Oral examination: pigmentation, gum hypertrophy (on ciclosporine after renal transplant)
Lymphadenopathy

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3
Q

What are the signs suggestive of abdominal disease seen on the chest?

A

Gynaecomastia = benign proliferation of glandular tissue in a man
Hair loss
Excoriation marks
Spider naevi

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4
Q

What are the signs suggestive of abdominal disease seen on the abdomen?

A

Abdominal distension
Caput medusae = distended superficial abdominal veins; direction of flow in the veins below the umbilicus is towards the legs

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5
Q

Which surgical scar suggests biliary surgery?

A

Right subcostal (Kocher’s incision)

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6
Q

Which surgical scar suggests liver transplant surgery?

A

Mercedes-Benz incision

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7
Q

Which surgical scar suggests a GI or major abdominal surgery?

A

Midline laparotomy incision

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8
Q

Which surgical scar suggests an appendicectomy?

A

McBurney’s (Gridiron) incision

Lanz for cosmetic purposes (along the bikini line)

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9
Q

Which surgical scar suggests a renal transplant surgery?

A

J-shaped/’hockey stick’ incision

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10
Q

Which surgical scar suggests a gynaecological surgery?

A

Pfannenstiel incision/low transverse

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11
Q

Which surgical scar suggests a hernia repair/vascular access surgery?

A

Inguinal incision

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12
Q

Which surgical scar suggests a nephrectomy?

A

Loin incision

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13
Q

What are the causes of hepatomegaly? (3 C’s + infiltration)

A
  1. Cancer - primary or secondary deposits
  2. Cirrhosis (early, usually alcoholic - in late cirrhosis, the liver shrivels so actually becomes smaller)
  3. Cardiac - CCF, constrictive pericarditis
  4. Infiltration of the liver - infection, inflammation, malignancy e.g. fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis
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14
Q

What are the causes of splenomegaly? (2 H’s, 2 I’s)

A
  1. Portal Hypertension - signs of chronic liver disease
  2. Haematological - lymphoma, haemolytic anaemia, leukaemia
  3. Infection - TB, infectious mononucleosis, malaria, schistomiasis
  4. Inflammation - sarcoidosis
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15
Q

A 75 y/o man presents w/ epigastric pain + back pain. HR: 130 bpm. BP: 80/50 mmHg. What is the most likely diagnosis?

  1. Peptic ulcer
  2. Pancreatitis
  3. Gastritis
  4. GORD
  5. Ruptured aortic aneurysm
A

Ruptured aortic aneurysm due to the hypotension + back pain

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16
Q

What are the 2 types of abdominal pain?

A 
Constant = inflammation
Colicky = obstruction
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17
Q

What are the DDx for diffuse abdominal pain? (x 5)

A
  1. Obstruction - pt may present w/ N+V and tinkling bowel sounds due to faecal impaction
  2. Infection: peritonitis, gastroenteritis
  3. Inflammation: IBD
  4. Ischaemia: mesenteric ischaemia (post-prandial pain)
  5. Medical: DKA (check glucose, bicarb, VBG - Tx: fluids, insulin, potassium); Addison’s (fall in cortisol); Hypercalcaemia; porphyria (acute abdo pain + muscle weakness); lead poisoning
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18
Q

What are the DDx for epigastric pain? (x 5 broad categories)

A
  1. Stomach: peptic ulcer (NSAID overuse –> inhibits COX1 –> decreases gastrin –> decreases GI barrier properties); GORD; Gastritis; malignancy
  2. Pancreas: acute/chronic pancreatitis
  3. Heart: MI
  4. Aorta: ruptured aortic aneurysm
  5. Liver/gallbladder: cholecystitis, hepatitis
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19
Q

What is the definitive Ix for acute and chronic pancreatitis?

A

Acute: serum amylase will be increased
Chronic: faecal elastase will be decreased; serum amylase may be normal

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20
Q

What is the presentation of acute pancreatitis?

A

Pain, increased serum amylase + alcohol Hx

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21
Q

What is the presentation of chronic pancreatitis?

A

Pain, weight loss
Loss of exocrine function - steatorrhoea (pale stool that is difficult to flush)
Loss of endocrine function - diabetes
Normal amylase
Decreased feacal elastase - stool sample for Ix

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22
Q

What are the DDx for RUQ pain? (x 6 broad categories)

A
  1. Gallbladder: cholecystitis, cholangitis (infection of bile duct - jaundice, fever, rigor), gallstones
  2. Liver: Hepatitis, abscess
  3. Lungs: basal pneumonia
  4. Appendix: appendicitis (esp. in pregnant women), retrocaecal appendix (going up and backwards + is inflamed)
  5. Stomach, pancreas: peptic/duodenal ulcer, pancreatitis
  6. Kidney: pyelonephritis (pain when tapping on renal angle)
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23
Q

What are the DDx for RIF pain? (x 2 broad categories)

A
  1. GI: appendicitis, mesenteric adenitis, colitis (IBD), IBS, malignancy
  2. Gynaecological: ovarian cyst rupture, twist, bleed; salpingitis (= inflammation of Fallopian tubes); ectopic pregnancy
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24
Q

What are the DDx for suprapubic pain? (x 3)

A
  1. Cystitis
  2. Urinary retention
  3. UTI
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25
Q

What are the DDx for LIF pain? (x 2 broad categories)

A
  1. GI: Diverticulitis (note how this is only more likely on LHS not RHS); colitis (IBD, ischaemic colitis); malignancy; faecal impaction
  2. Gynaecological: ovarian cyst rupture, twist, bleed; ectopic pregnancy
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26
Q

Blockage of which artery causes ischaemia in the stomach/spleen/liver/gallbladder/duodenum?

A

Coeliac artery

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27
Q

Blockage of which artery causes bowel ischaemia in the small intestine + right colon?

A

Superior mesenteric artery

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28
Q

A pt comes in w/ severe abdominal pain + signs of shock. Abdo exam is normal. What is the most likely Dx? (dNTK)

A

Acute mesenteric ischaemia: this is classic triad of severe abdo pain, normal abdo exam + shock. Caused by obstruction of superior mesenteric artery

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29
Q

A pt comes in w/ poorly localised, colicky, post-prandial abdo pain; PR bleeding + weight loss. On abdo X-ray, a gassless abdomen is seen w/ thickening of bowel wall. What is the most likely diagnosis? (dNTK)

A

Chronic mesenteric ischaemia

Causes: low flow state e.g. HF, atherosclerotic disease. Obstruction of superior mesenteric artery

30
Q

A 65 y/o man w/ an AAA repair 2 days ago presents w/ diffuse abdominal pain. HR: 120 bpm and RR: 30. What are his blood tests likely to show?

  1. Normal lactate
  2. High amylase
  3. High bicarbonate
  4. High sodium
  5. High calcium
A

High amylase - this is a feature of ANY cause of acute abdo pain (not just pancreatitis)
Lactate will likely be high due to acidosis (high lactate indicates poor perfusion + ischaemia)
Bicarbonate likely to be low due to acidosis
Sodium won’t usually be high, only observed in DI

31
Q

A 55 y/o presents w/ confusion, abdo pain + abdo distension. SHx: Excess EtOH use. PMHx: cirrhosis. O/E: Ascites, liver flap. What is the most likely diagnosis?

A

Decompensated liver disease = classic triad of jaundice, encephalopathy + ascites

32
Q

Which of the following is consistent w/ spontaneous bacterial peritonitis?

  1. Ascites neut > 25 cell/mm^3
  2. Ascites neut > 50 cell/mm^3
  3. Ascites neut > 100 cell/mm^3
  4. Ascites neut > 250 cell/mm^3
  5. Ascites neut > 500 cell/mm^3
A

Ascites neut > 250 cell/mm^3

33
Q

What are the causes of abdominal distension (5 F’s)?

A

Fluid (ascites) - shifting dullness, features of liver disease (A to J)
Flatus (due to obstruction) - N&V, bowels not opening, high-pitched tinkling sounds, adhesions, tender irreducible femoral hernia in groin
Fat
Faeces
Foetus

34
Q

What is the name and causes of ascites w/ low protein level?

A

Transudate

Causes: cirrhosis, cardiac failure, nephrotic syndrome i.e. The failures

35
Q

What is the name and causes of ascites w/ high protein level?

A

Exudate

Causes: infection (TB, pyogenic), malignancy, Budd-Chiari syndrome

36
Q

A serum-ascites albumin gradient result has come out as < 11g/L, what does this indicate + what could the causes be?

A

Serum ascites albumin gradient = serum albumin - ascitic albumin. If it is < 11 g/L this suggests that the ascitic albumin is high therefore it is exudative. Causes are: TB, pancreatitis, cancer + peritonitis
N.B. Nephrotic syndrome is an important exception to this because it also has a low SAAG because of the hypoalbuminaemia so there is low serum albumin. (IMPORTANT TO REMEMBER)

37
Q

A serum-ascites albumin gradient result has come out as > 11g/L, what does this indicate + what could the causes be?

A

> 11 g/L suggests that the serum albumin is high and suggests the ascitic fluid is transudative. Causes include: chronic liver disease, portal HTN, constrictive pericarditis, cardiac failure (acute, chronic), cirrohsis (decreased albumin production)

38
Q

A 50y/o man presents w/ jaundice, RUQ pain, dark urine + pale stool. What is the cause of his pale stool?

  1. Low bilirubin
  2. High unconjugated Br
  3. High conjugated Br
  4. Low stercobilinogen
  5. Low urobilinogen
A

Low stercobilinogen - this is because in an obstruction there is less Br in bile so less stercobilinogen hence pale stools (Br is conjugated in liver and secreted in bile)
Dark urine due to conjugated Br - found in hepatic or post-hepatic cause

39
Q

What can the causes of jaundice be classified into?

A

Pre-hepatic
Hepatic
Post-hepatic

40
Q

What is the pathophysiology of pre-hepatic jaundice + give examples of causes?

A

Haemolysis - Haem broken down to form bilirubin in the spleen
Gilbert’s syndrome - defective conjugation in the liver due to lack of glucoronidation so Br not being conjugated at all

41
Q

What is the pathophysiology of hepatic jaundice + give examples of causes?

A 
Hepatitis - alcohol, autoimmune, drugs, viruses
Conjugated BR (which is water soluble) leaks out of hepatocytes and into the blood which causes dark urine. 
LFTs: raised ALT/AST
42
Q

What is the pathophysiology of post-hepatic jaundice + give examples of causes?

A

Common bile duct (CBD) obstruction from gallstone, stricture, pancreatic cancer (head) causing dark urine + pale stools
Obstruction causes decrease in BR in bile which causes decrease in stercobilinogen hence pale stools
LFTs: raised ALT/AST, ALP (obstruction) and GGT (obstruction)

43
Q

A 50 y/o man presents w/ painless jaundice, weight loss, dark urine + pale stools. O/E: Trousseau’s sign of malignancy. Which is most likely to be elevated in his blood test?

  1. ALP, CA 19 9
  2. AST, CA 125
  3. ALP, alfa-fetoprotein
  4. ALT, alfa-fetoprotein
  5. ALP, CEA
A

ALP, CA 19 9
This is most likely to be cancer of head of pancreas given the Hx and examination findings. In post-hepatic jaundice there is a raised ALP + GGT
CA 19 9 is tumour marker for pancreatic cancer
CA 125 = ovarian cancer
CEA = colorectal cancer
alfa-fetoprotein (aFP) = liver cancer, testicular (non-seminoma) cancer

44
Q

What is Trousseau’s sign of malignancy?

A

Migratory thrombophlebitis; paraneoplastic feature of pancreatic cancer. Not to be confused with Trousseau’s sign of hypocalcaemia (= spasm of hand/arm when BP cuff inflated and occludes brachial artery)

45
Q

What is bloody diarrhoea due to?

A

Loss of epithelial integrity

46
Q

What are the 5 most common causative organisms of infective colitis causing bloody diarrhoea?

A 
CHESS
Campylobacter
Haemorrhagic E coli
Entamoeba histolytica
Salmonella
Shigella
47
Q

What are the DDx of bloody diarrhoea? (x 5)

A
  1. Infective colitis (CHESS organisms)
  2. Inflammatory colitis (IBD) - young, extra-GI manifestations: episcleritis, scleritis, uveitis + erythema nodosum, pyoderma gangrenosum)
  3. Ischaemic colitis - elderly
  4. Diverticulitis
  5. Malignancy
48
Q

What does thumbprinting on an AXR indicate?

A

Mucosal oedema - inflammation in the bowel wall e.g. IBD

49
Q

What does a featureless colon on an AXR indicate?

A

Leadpipe - feature of IBD

50
Q

How does a toxic megacolon present on AXR + clinically?

A 
Dilatation of large bowel (> 6 cm)
Systemically unwell (tachycardia, hypotensive, fever)
51
Q

A 80 y/o patient presents w/ diarrhoea and confusion. AXR shows a fluffy, homogenous image. What is the most likely Dx?

A

Faecal impaction/loading

Overflow diarrhoea is not what it seems!

52
Q

What is the Tx of an acute GI bleed?

A
  1. ABCDE
  2. IV access: fluids, G&S, X-match
  3. OGD - find underlying cause
53
Q

What is the Tx of a variceal bleed?

A
  1. Antibiotics e.g. broad-spectrum Tazocin to treat any bacterial translocation
  2. Terlipressin - causes splanchnic vasoconstriction
54
Q

What are the Ix of acute abdo?

A
  1. Bloods: FBC (WBC); U&Es (renal function, dehydration); LFTs (pancreatitis, cholangitis, cholecystitis); CRP (marker of infection + inflammation); clotting (measured pre-operative) G&S; X-match
  2. Erect CXR or CT: look for pneumoperitoneum (= air under the diaphragm)
55
Q

What is the management of an acute abdomen?

A

Think 3 A’s!

  1. NBM + NG tube
  2. Fluids
  3. Analgesic
  4. Anti-emetics e.g. ondansetron
  5. Antibiotics - over anaerobes e.g. cef + metronidazole
  6. Monitor vitals + Urine output
56
Q

A patient presents w/ jaundice. What are the Ix?

A
  1. Bloods: FBC - Hb?; LFTs: BR, ALP& AST if post-hepatic; CRP
  2. Abdo USS: gallstones better visualised after a fast due to distended, bile-filled gallbladder. Look for duct dilatation
57
Q

A patient presents w/ dysphagia + weight loss. What are the Ix?

A
  1. OGD

2. Biopsy

58
Q

A pt presents w/ PR bleed + weight loss. What are the Ix?

A

Colonoscopy

59
Q

What is the management of ascites?

A
  1. Ascites tap: measure WCC to check for SBP - if present, Abx
  2. Diuretics (spironolactone and/or furosemide) - add furosemide if peripheral oedema. Spironolactone needed because cirrhosis causes vasodilation which causes secondary hyperaldosteronism
  3. Dietary Na+ restriction if hyponatraemic
  4. Monitor weight daily
  5. Therapeutic paracentesis (removing ascites) but must replace IV human albumin
60
Q

What is the management of encephalopathy?

A
  1. Lactulose - osmotic laxative so decreases gut transit time i.e. bacteria don’t have enough time to make toxic metabolites
  2. Phosphate enemas - saline laxative so increases fluid in small intestine
  3. Avoid sedation e.g. benzodiazepines
  4. Treat underlying cause of decompensation of chronic liver disease i.e. jaundice, encephalopathy, ascites
61
Q

What urea levels would an alcoholic with chronic liver disease have and what is a significant value of it?

A

They may have a low urea of 1. If they have urea of 7, this may not be abnormal for people w/o CLD but for patients w/ CLD this is significant because the urea is increased due to protein meal e.g. digesting GI bleed

62
Q

A pt had surgery 2 days ago but the site wound is now erythematous and has discharge. What is the most likely post-operative care complication seen here?

A

Wound infection

63
Q

A pt had surgery 1 week ago but is now presenting w/ diffuse abdo tenderness, guarding and rigidity. HR: 110 bpm. BP: 90/60. What is the most likely post-operative care complication seen here?

A

Diffuse ado tenderness due to peritonitis, guarding + rigidity. hypotensive/tachycardia all lead to anastomotic leak

64
Q

A pt recently had an appendectomy but is now presenting w/ pain, fever, sweats + mucus diarhoea. What is the most likely post-operative care complication seen here?

A

Pelvic abscess

65
Q

A pt presents w/ a tender, red swelling near the anus. What is the most likely Dx and what is the Tx?

A

Perianal abscess

Tx: incision, drainage

66
Q

A pt presents w/ rectal pain that is worse on defecation. The stool is coated w/ blood but isn’t mixed in. The diet is described to be heavily read-meal based. What is the most likely diagnosis? What is the Tx?

A

Anal fissure

Tx: GTN cream (analgesia) and lifestyle advice

67
Q

A pt presents w/ recurrent abdominal pain and sense of bloating. This improves w/ defecation. There is no PR bleed, anaemia or weight loss. What is the most likely Dx?

A

Irritable bowel syndrome
This is a diagnosis of exclusion - no nocturnal symptoms seen in IBD + exclude coeliac disease (measure anti-tTG). There may be a change in frequency/form of stool i.e. may be diarrhoea-predominant IBS or constipation-predominant IBS

68
Q

What is the Tx for IBS?

A

Diet + lifestyle modification

Symptomatic treatment: abdo pain - antispasmodics; constipation - laxatives; diarrhoea - antidiarrhoeal e.g. loperamide

69
Q

A 26 y/o woman has intermittent loose stool for the last 3 months on a bg of IBS. She is otherwise well, no abdo pain, no vomiting, no wght loss. Abdo SNT, bowel sounds normal. Temp: 37.1, HR: 64 bpm; BP 114/76mmHg, RR 14 breaths/min + O2 sats 100% on air. What is the most appropriate medication to prescribe?

  1. Cyclizine 50mg PO
  2. Hyoscine Butylbromide 20mg PO
  3. Lactulose 15ml PO
  4. Loperamide 2mg PO
  5. Metoclopramide 10mg PO
A

Loperamide

70
Q

A 54 y/o man has epigastric pain for 2 months. The pain started after he sustained a sporting injury, for which he took ibuprofen. His physical examination is normal. His temperature is 37.3 degrees, HR 78 bpm, BP 136/76 and RR 14 bpm. O2 sats 100% on air. Upper GI endoscopy: small gastric ulcer w/ a smooth rounded edge, appears benign, H. pylori test negative. What is the most appropriate medication to prescribe?

  1. Amoxicillin
  2. Cyclizine
  3. Diclofenac
  4. Metronidazole
  5. Omeprazole
A

Omeprazole

amir sam dpd 2018 (8 decks)

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