DrE: Abdomen Flashcards
1
Q
What are the stages of clubbing?
A
- Congestion
- Loss of angulation
- Increased AP diameter
- Drumsticking
2
Q
What are the causes of clubbing?
A
- Gastrointestinal:
- Cirrhosis - PBC
- Inflammatory bowel disease - crohns
- Malabsorption - coeliac disease
- GI lmphoma
- Respiratory
- Chronic suppurative - CF, abscess, bronchiectasis, empyema
- Intestitial disease - ideopathic fibrosis
- Non-small cell Ca - bronchial carcinoma
- Mesothelioma
- Sarcoidosis
- Cardiovascular:
- Infective endocarditis
- Cyanotic congenital heart disease
- Atrial myxoma
- ToF
- Other:
- Graves - autoimmune hyperthyroidism - thyroiid acropachy
- Familial - pseudoclubbing
- Unilateral:
- Axillary artery aneurysm
3
Q
What is dyspagia?
A
Difficulty swallowing
4
Q
What are the causes of dysphagia?
A
- Congenital: oesophageal atresia
- Acquired:
- Luminal
- Food bolus
- Foreign body
- Oesophageal web
- Plummer Vinson syndrome (assoc Fe def)
- Intramural:
- Achalasia - increased risk of Ca
- Carcinoma
- GORD
- Oeophagitis
- Oesophageal dysmotility
- Scleroderma
- Stricture e.g. radiation
- Extramural:
- Hilar lymphadenopathy
- Pharyngeal pouch
- Retrosternal goitre
- Lung Carcinoma
- Neurological:
- Stroke
- Myasthenia gravis
- Motor Neuron Disease
- Other
- Stomatitis
- Glossitis
- Tonsillitis
- Pharyngitis
- Luminal
5
Q
What is odynophagia?
A
Pain on swallowing
6
Q
A
Barium swallow
1) Apple core - oesophageal Ca
2) Achalasia - bird’s beak
3) Oesophageal web
7
Q
What are the causes of Odynophagia?
A
- Trauma: pharyngeal trauma, radiation, oesophageal burn, mallory-weiss syndrome, ruptured oesophagua
- Foreign body: oropharengeal/pharyngeal
- Infection: pharyngitis, tonsillitis, osphagitis (HSV, candida), abscess
- GORD: oesophagitis, ulceration
- Neoplasia: pharyngeal, laryngeal, oesophageal carcinoma
- Motility: achalasia, oesophageal dysmotility syndromes
- Neurological: stroke, myasthenia gravis, MND
- Other: plummer Vinson, pharyngeal pouch, sleroderma
8
Q
Causes of osophageal mass?
A
- Skn and soft tissue:
- cyst
- lipoma
- sarcoma
- GI:
- Epigastric herna
- Gastric carcinoma
- Pancreatic carcinoma
- Pancreatic pseudocyst
- Vascular:
- AAA
- Lymphadenopathy
9
Q
What are the causes of hepatomegaly?
A
- Physiological:
- Riedel’s lobe
- hyperexpanded chest
- Infective
- Viral: hepatitis, EBV, CMV
- Bacterial: TB, abscess
- Protozoal: malaria, schistosomiasis (protozoa)
- Malignant:
- Primary/secondary
- Lymphoma
- Leukaemia
- Alcohol:
- Fatty liver/crrhosis
- Metabolc:
- Amyloid
- Hereditary haemochormatosis
- Wilson’s disease
- Congestive
- Right heart failure
- Tricuspid regurgitation (pulsatile liver)
- Budd chiari syndrome
10
Q
What are the most common causes of hepatomegally in the UK?
A
- Malignancy:
- primary/secondary, haemotological (CML)
- Alcohol related:
- Fatty liver disease, alcoholic hepatitis
- Infective:
- Viral - Hep ABC, EBC
- Bacterial - liver abscess
- Parasitic - malaria
11
Q
What is Budd Chari Syndrome?
A
hepatic vein obstruction e.g. thrombosis/carcinoma
Upper abdo pain, jaundice, hepatomegally, ascitis
LFTs deranged
Progress to encephalopathy
12
Q
What are the causes of cirrhosis?
A
- Congenital:
- HHC
- Wilsons
- Alpha 1 antitripsin deficiency
- Autoimmune
- Autoimmune hepatitis
- Biliary:
- Primary Biliary Cirrhosis (PBC)
- Primary Sclerosis Cholangitis
- Cardiac
- CCF
- Drugs:
- ETOH
- Infectve:
- Hep B and C
- Schistosomiasis
- Other:
- Sarcoid
13
Q
What is portal hypertension?
A
Portal vein pressure >10mmHg
14
Q
What are the causes of portal hypertension?
A
- Pre-hepatic:
- Portal vein thrombosis
- Splenic vein thrombosis
- Splenic arterio-venous fistula
- Hepatic
- Cirrhosis
- Sarcoid
- Schistosomiasis
- Post hepatic:
- Budd-Chiari syndrome
- Constrictive pericarditis
- Right heart failure
15
Q
What are caput medusae?
A
Distended, engorged perumbilcal veins
due to severe portal hypertension
with porto-systemic shunting of bloods through the umbilical veins
16
Q
What are the causes of distended umblical veins?
A
- Physiological
- Portal hypertension leading to porto-systemic shunting - blood flow central to distal
- IVC obstruction - blood flow inferior - to- superior
17
Q
What is ascitis?
A
Fluid in the peritoneal cavity
18
Q
What are the causes of ascitis?
A
- Transudate (Protein <30g/L)
- Cirrhosis
- nephrotic syndrome
- CCF
- Pericarditis
- Exudate
- Inflammation e.g. pancreatitis
- Infection e.g. TB
- Malignancy e.g. primary/secondary
19
Q
How would you investigate ascitis?
A
- Blood tests
- FBC, U&E, LFT, CRP, Coagulation, (group and save?)
- Diagnostic paracentesis:
- microbiology: MC&S
- Cytology: malignant cells
- Biochemistry: Protein, glucose, amylase
- Serum ascites albumin gradient
- difference <1.1 = exudate, >1.1 = transudate
- USS
- Intra-abdominal organs, extent of ascites, (guide drainage)
- Doppler
- portal vein flow, budd-chiari syndrome, portal vein thrombosis
- Abdo CT
- details inta abdo organism
20
Q
What are the treatment opertions for ascites?
A
- Conservative:
- Salt restriction
- Water restriction - if hyponatraemic
- Weight monitoring - weight loss of no more than 0.5Kg/day (if ascites alone), 1Kg/day if peripheral oedema
- Medical:
- Rx cause
- Diuretics: spironolactone
- Surgical:
- Paracentesis - diagnostic/therapeutic
- TIPS - Transjugular intrahepatic portosystemic shunt (pt with advanced cirrhosis and recurrent ascites)
- LeVeen Peritoneovenous shunt - drains ascites directly into venous circulation connecting peritoneal cavity to SVC/IJV via 1 way valve (prevents backflow)
- Complication: fluid overload, shunt blockage, bacterial colonisation
- Liver transplant: end stage liver disease
21
Q
What are the causes of gall bladder enlargement?
A
- Jaundice
- Pancreas carcinoma (head)
- Cholangiocarcinoma
- Non-jaundice:
- Mucocoele
- Empyema
- Gall bladder carcinoma
- Acute cholecystitis
Gallstones -> chronic inflammation -> firbous thickening (non-distended)
22
Q
What are the functions of the spleen?
A
- Reticuloendothelial system
- filters and removes FBC, WCC, platelets
- Storage:
- Holds c.35% platelets
- Immunological:
- Destruction of encapsulated organisms via phagocytosis e.g. Haemophilus influenzae, streptococcus pneumoniae, neisseria meningitidis
- Synthesis:
- antibodies & opsonins
23
Q
What are the causes of splenomegaly?
A
- Haemolytic anaemia:
- Sickle cell
- Thalassaemia
- Elliptocytosis
- Spherocytosis
- Neoplastic:
- Leukaemia - chronic myeloid (MASSIVE)
- Myelofibrosis (MASSIVE)
- Non-hodgkin’s lymphoma
- Tumour - primary/secondary
- Infective
- Bacterial - Abscess, TB, Endocarditis
- Viral - HIV, EBV, hepatitis
- Protozoa - malaria (MASSIVE), schisto
- Parasite - hydatid cyst
- Inflammatory:
- Rheumatoid arthritis (Felty’s syndrome -RA, splenomegally, neutropenia)
- Sarcoid
- Splenic vein hypertension :
- Cirrhosis
- Budd-Chiari syndrome
- Portal vein thrombosis
- Other:
- Amyloid
- CCF
24
Q
What is hypersplenism?
A
Retrospective diagnosis
- Splenomegaly
- Cytopenia
- normal/hyperplastic bone marrow
- Response to splenectomy
25
What are the causes of a kidney mass?
* Congenital:
* Simple solitary cyst
* Polycystic kidney disease (PCLD)
* Horseshoe kidney
* Hypertrophic single kidney
* Neoplastic:
* RCC
* Adenoma
* Wilm's tumour
* Secondary metastasis
* Infective:
* Abscess
* Hydatid cyst
* TB
* Inflammatory:
* Sarcoid
* Vascular:
* Infarct
* Renal vein thrombosis
* Other
* amyloid
* Hydronephrosis
26
What is PCKD?
characterised by the presence of bilateral renal cysts
Important cause of renal failure
May be classified as infantile or adult
27
What is the difference between infantile and adult PCKD?
* Infantile:
* Genetic: AR
* Yrs : @birth/infancy, USS in utero diagnosis
* PC: Renal mass, poor renal function
* Assoc: hepatic fibrosis -\> portal hypertension -\> splenomegaly
* Prognosis: to childrhood only without transplant
* Adult:
* Genetic: AF
* Yrs: commonly adulthood
* PC: 5th decade, declining renal function. Mass/loin pain/haematuria/hypertension
* Assoc: 40% berry aneurysms -\> SAH
* Prognosis: ESRF @ 50-70yo, good survival with dialysis
28
Clinical features of chronic renal failure?
* CV: HF, HTN, pericarditis (uraemia), PVD
* Dermatological: yellow skin, pruritis
* Endocrine: amenorrhoea, imptence, infertility
* Fluid: JVP rise, Peripheral oedema, pulmonary oedema
* GI: anorexia, diarrhoea, N&V
* Haematological: anaemia, ecchymosis, epistaxis
* Neurological: confusion, coma, fits, peripheral neuropathy
* Resp: halitosis & pleural effusion
* Surgical: fistula, nephrectomy scar
29
What is IDB?
idiopathic inflammatory disease with genetic prdisposition & probable autoimmune component against the GI tract
Comprised of ulcerative colitis (UC) and Crohn's disease (CD)
Both more prevalent in Ashkenazi jews, followed by white caucasian populations
Peak c.20-30yrs
Crohns = more prevalent in smokers
US = more prevalent in non-smokers
30
What are the initial presenting features in IBD?
similar = e.g. diarrhoea, mucus PR but UC more severe
CD = growth retardation in children, anaemia, occult blood loss, low grade fever, weight loss
UC = acute PC abdo pain, diarrhoea, frank blood loss PR
CD = entire tract, UC = colon
31
What features are characteristic of an acute exacerbation of UC?
* Abdo pain & distension - may indicate perforated toxic megacolon
* Bloody stool
* Diarrhoea (\>10 episodes in 24hrs)
* Faecal urgency
* Pallor
* Pyrexia
* Tachycardia
32
What investigations would assist in the diagnosis of IBD?
* Bloods - FBC, U&E, CRP
* Imaging - AXR, braium enema, small bowel follow through
* Procedure - colonoscopy
* Histology - biopsy at colonoscopy
33
whats the difference seen between CD & US on barium enema?
* Chron's:
* string sign (terminal ileum strictures)
* Cobblestone/skip lesions
* Rose thorn ulcers
* UC:
* Lead piping (scarred, rigid colon)
* Loss of haustration
* Toxic megacolon
34
What are the pathological differences between CD & UC?
* Macroscopic
* Crohns:
* pseudopolyps
* fistula
* strictures
* thickened wall
* UC:
* pseudopolyps
* Microscopic
* crohns:
* granuloma
* inflammation - patchy and transmural
* UC:
* crypt abscess
* inflammation - continuous & mucosal
35
Complications of IBD?
* Crohn's
* infection
* FTT
* GI fistula
* Subacute GI obstruction
* UC:
* infection
* Toxic megacolon
* Primary sclerosing colangitis (PSC)
* PSC present in 6-7% of pt with UC
* UC present in 60-70% of pt with PSC
* Colorectal carcinoma
36
What are the extra-intestinal associations of IBD?
* Mouth ulcers - CD only
* Perianal skin tags - CD only
* Ankylosing spondylitis
* Athritis
* Iritis
* Erythema Nodosum
* Pyoderma gangrenosum
37
What are the treatment options for CD?
* Conservative:
* diet modification
* psycological
* support groups
* Medical:
* systemic steroids
* immunosuppressants e.g. azathioprine
* anti-TNF alpha e.g. infliximab
* Surgical:
* drainage of perianal sepsis
* seton fistulotomy
* stricturoplasty
* segmental resection
* defunctioning loop ileostomy
38
What are the treatment options for UC?
* Conservative:
* psychological
* support groups
* Medical:
* topical steroids e.g. predfoam enemas
* systemic steroids
* 5-Aminosalicylic Acid e.g. mesalazine
* Surgical:
* proctocolectomy and end ileostomy
* ileo-anal pouch formation
39
Is surgery for IBD curative?
UC may be cured by surgery as the disease is limited to the colon
as CD affects the entire GIT relapses can occur even after surgical intervention
c.70% of CD and 30% of UC pt require surgery at some time
40
What are the indications for surgery in IBD?
* Medical treatment complications - pt who experience severe side effects from medical treatment
* Medical treatment failure - IBD resistant to medical treatment
* disease process complications:
* acute - abscess, fistula, toxic megacolon
* chronic - strictures, colonic dysplasia (-\> carcinoma)
41
What are the causes of an iliac fossa mass?
* skin and soft tissue:
* cyst, lypoma, sarcoma
* GIT:
* RIF: caecal carcinoma, IBD, appendix
* LIF: diverticulitis, faeces
* Vascular:
* iliac aneurysm, lymphadenopathy
* Gynaecological:
* benign ovarian Tx, malignant ovarian Tx, fibroids
* Testicular:
* incomplete descent, ectopic testis
* Urological:
* transplant kidney
42
What is a sinus?
Blind ending tract extending from an epithelial defect.
Normal e.g cardial, Pathological e.g. pilonidal sinus
43
What is a fistula?
abnormal communication between 2 epithelial surfaces
44
Give an example of a fistula
* Acquired:
* Trauma e.g. ear piercing
* Infective e.g. TB/Perianal
* Inflammatory e.g. CD
* Neoplastic
* iatrogenic
* trauma - e.g. bowel refection
* cimino brescia fistula - arteriovenous fistula for HD
* congenital
* parkes weber syndrome
* tracheo-oesophageal fistula
45
What is the cryptoglandular sepsis theory?
anorectal abscess is a disrete soft tissue infection around the anus
highly variable severity & depth
cavity of the abscess may discharge in a manner associated with formation of a fistulous tract
cryptoglandular sepsis theory attributes a particular level of an anal fistula development from a particular level of anorectal abscess
* Perianal abscess = subcutaneous/submucosal fistula
* intersphincteric = intersphincteric
* ischiorectal = high anal (involves both anal sphincters), low anal (involves internal anal sphincter only)
* supralevator = pelvirectal (above anal ring)
46
How would you manage a patient with a perianal abscess?
* Full history e.g. history of IBD, previous abscesses or immunosuppression e.g. diabetes, steroids, immunosuppresants, HIV
* Clinical examination - incl PR
* Proctoscopy/sigmoidoscopy - seek internal fistula opening if present
* Surgery: GA incision & drainage, sending puss for MC&S, once deroofed, irrigate, deloculate, wash and pack abscess to assist healing by secondary intention. DO NOT EXPLORE FOR A FISTULA ACUTELY
* Clinical follow up - if MC&S confirms presence of intestinal bacteria suspect a fistula and arrange further investigation e.g. MRI or treatment as necessary
47
Surgical options for anal fistula?
depends on level and severity of fistula
* lay open - subcutaneous, submucous, low anal
* steon - high anal, intersphincteric
* fistulotomy & flap - complicated fistulae
48
what is goodsall's rule?
describes the predictable course of an anal fistula, governed by its external opening
Patient in lithotomy position, imaginary line 3-9 o;clock
fistulae with openings above the line form a radial tract directly to the same position internally
fistulae with external openings below the line run a horseshowing course to midline internal openings
49
Common abdominal scars:
* R thoracoabdomina - R pleura and peritoneum exposure
* Mercedes - upper GI
* Rooftop - upper GI
* Kocher's - cholecystectomy
* R loin - nephrectomy
* R paramedian - R hemicolectomy
* Laparotomy - AAA, bowel
* Gridion/Lanz - appendicectomy
* Pfannenstiel - caesarean section
* L inguinal - inguinal hernia
* L femoral - L femoral embolectomy
50
