Gastrointestinal Flashcards
Acanthosis nigricans
Describe
Ddx
Brown velvety elevation of epidermis
Usually in axilla or neck
GI carcinoma, lymphoma
Endocrinopathies (acromegaly, DM…)
Slate grey or brown bronze pigmentation on face, predominantly at UV exposed areas
Likely condition
Associated GI symptoms
Haemochromatosis
Hepatomegaly
Signs of chronic liver disease
Signs specific for obstructive jaundice
→ Greenish jaundice (bile regurgitation)
→ Xanthelasma (↓Ch excretion)
→ Xanthomas (↓Ch excretion)
→ Scratch marks (pruritus due to retention of bile acid content)
Cause of xanthelesma
Hypercholesterolemia
May occur in cholestasis, esp primary biliary cirrhosis
Common cause of black eye syndrome after proctosigmidoscopy
Periorbital purpura due to amyloidosis
Amyloid factor binds to factor 10 causing coagulopathy
How to palpate for parotid glands?
Causes of unilateral parotid gland enlargement?
Palpate for enlargement:
→ Ask pt to clench teeth to tighten masseter
→ Normal = impalpable
→ Enlarged = palpable behind masseter and in front of ear
Unilateral:
- Mixed parotid tumour
(occ. bilateral) - Tumour infiltration
- Duct blockage
Causes of bilateral parotid gland enlargement
Bilateral:
- Mumps (may be unil.)
- Sarcoidosis (painless)
- Lymphoma (painless)
- Mikulicz syndrome (painless)
- Alcoholism (fatty infiltration)
- Malnutrition
- Severe dehydration
List 5 abnormal fetor and their underlying causes
□ Poor oral hygiene
□ Fetor hepaticus: sweet smell
→ Indicates severe hepatocellular disease (late sign)
□ Ketosis: sickly sweet smell
→ Indicates diabetic ketoacidosis
□ Uraemic fetor: fishy ammonia smell → Indicates uraemia
□ Putrid smell:
→ Due to anaerobic chest infection with large amounts of sputum
□ Alcohol and cigarette smokin
Cause of lingua nigra and geographic tongue
Lingua nigra: bismuth compound or benign keratin accumulation
Geographic tongue: benign or vitamin b12 deficiency
Causes of leukoplakia
Leukoplakia: white-coloured thickening of mucosa of tongue and mouth → A premalignant condition → Causes: ‘5S’ - Sore teeth (poor dental hygiene) - Smoking - Spirits - Sepsis - Syphilis
Causes of glossitis
Glossitis: smooth tongue surface ± erythema
→ May present with shallow ulceration in later stages
→ Indicates nutritional deficiencies, eg. Fe, B9, B12
- Alcoholics (common)
- Carcinoid syndrome
- Elderly people
Causes of macroglossia
Macroglossia: enlargement of the tongue
→ Congenital conditions, eg. Down syndrome
→ Endocrine diseases, eg. acromegaly
→ Tumour infiltration, eg. haemangioma, lymphangioma
→ Amyloidosis infiltration
Cause of cracks at corners of mouth
Angular stomatitis: cracks at corners of mouth
→ Indicates nutritional deficiencies incl. B6, B9, B12, iron
Spider angioma
Sites
How to exam
Causes
□ Site: SVC drainage areas, i.e. arms, neck, chest
→ Can be found in oral and nasal mucous membrane
→ Rarely found below nipples
□ Central arteriole from which radiate numerous small vessels
□ Confirmed by pressing on central arteriole
→ Should result in blanching of whole lesion
→ Release → rapid refilling from centre to legs
□ Possible causes:
→ Normal variation
→ Cirrhosis (esp if ≥3 or new spider naevus formation)
→ Pregnancy (2nd to 5th month)
→ Hepatitis (may occur transiently in viral hepatitis)
→ Rheumatoid arthritis
→ Scleroderma
Mimics of spider angioma
Common mimics: → Cherry angioma (Campbell de Morgan spots): - Elevated red circular lesions - Occurs on abdomen or anterior chest - Do not blanch upon pressure - Very common in elderly and benign
→ Venous stars (spider veins):
- Usually located on the leg, but can occur elsewhere near major veins
- Not obliterated by pressure
- Cause: chronic venous insufficiency
Causes of gynaecomastia
How to confirm in exam
Confirmed by feeling under nipple for genuine breast tissues (cf fat)
□ D/dx:
→ Healthy adolescence
→ Chronic liver disease5, esp alcoholic cirrhosis and chronic autoimmune hepatitis
→ Alcoholism
→ Chronic starvation (↓gonadotropin and testosterone production)
→ Oestrogen-secreting testicular tumours
→ Drugs, eg. spironolactone, digoxin, cimetidine
GI causes of lymphadenopathy
Cervical lymphadenopathy: palpate L supraclavicular node ± other cervical nodes
□ D/dx: infections (esp TB), malignancies
□ Troisier’s sign: large Lt supraclavicular (Virchow’s) node + CA stomach
GI cause of generalised scratch marks
Scratch marks may indicate obstructive jaundice
□ Mechanism: retention of bile acids → pruritus
□ Significance: generalized pruritus a common presenting feature of
primary biliary cholangitis before other signs are apparent
GI causes of ecchymoses and petechiae
□ Ecchymoses: large bruises >1cm
→ Indicates clotting factor abnormalities
- Hepatocellular damage → ↓clotting factor synthesis
- Obstructive jaundice → ↓bile acid for vitamin K absorption
□ Petechiae: small bruises <3mm7 → Indicates thrombocytopenia - Chronic alcoholism → BM depression → thrombocytopenia - Portal hypertension → hypersplenism - Severe liver diseases (esp acute hepatic necrosis) → DIC
Signs at axilla that may indicate CA stomach
□ Inspect for acanthosis nigricans
→ paraneoplastic manifestation of CA stomach
□ Palpate for lymphadenopathy
→ for Irish nodes of CA stomach
GI causes of clubbing
□ Cirrhosis (up to 1/3) (AV shunting in lungs of unknown cause → cyanosis) □ Inflammatory bowel disease (long-standing nutritional depletion) □ Coeliac disease (long-standing nutritional depletion)
Causes of palmar erythema
Site: thenar/hypothenar eminence sparing the centre □ Mechanism: attributed to ↑oestrogen level (?) □ D/dx: → Chronic liver diseases → Pregnancy → Rheumatoid arthritis → Thyrotoxicosis → Polycythaemia → Chronic febrile illness → Chronic leukaemia
Causes of dupuytren’s contracture
visible, palpable thickening and contraction of palmar fascia causing permanent flexion contracture
□ Site: first affects 4th and 5th tendons of fingers
→ Can involve any fingers and toes
→ Often bilateral
□ Mechanism: unknown, palmar fascia found to contain ↑xanthine
□ Causes:
→ Normal, esp in manual workers
→ Cirrhosis, esp alcohol-related
→ DM
→ Systemic fibrosclerosing syndromes (IgG4 disease)
□ D/dx: G3/4 trigger finger
Hepatic flap
How to examine
Causes
Ask pt to stretch out arms in front, separate fingers and extend wrists for 15s
□ Push on pt’s finger to keep them extended and observe for any flapping tremor
D/dx: indicates inability to maintain posture
→ Hepatic encephalopathy
→ Cardiac, respiratory and renal failure
→ HypoGly, hypoK, hypoMg, barbiturate poisoning
Other causes of tremors:
□ Wilson’s disease
□ Alcoholism (fine-resting tremor)
□ Other causes, eg. Parkinson’s, essential tremor
Hand signs of chronic liver disease and causes
Hand signs:
□ Clubbing → ↑AV shunting
□ Leukonychia → hypoalbuminaemia
□ Palmar erythema → ↑oestrogen
□ Dupuytren’s contracture → xanthine deposits
□ Flapping tremor (asterixis) → hepatic encephalopathy
Leg signs of chronic liver disease
Leg signs: □ Ankle oedema → hypoalbuminaemia □ Ankle pigmentation ± leg ulcers → Associated with hypersplenism → Can regress after splenectomy
Abdominal signs of chronic liver disease
Abdominal signs: □ Hepatomegaly □ Splenomegaly → portal hypertension □ Ascites → portal hypertension □ Caput medusa → portal hypertension
Causes of distended abdomen
Distended due to → Fat: gross obesity → Fluid: ascites → Foetus: pregnancy → Flatus: gaseous distension due to bowel obstruction → Faeces
Cause of exerted umbilicus
Bulging/everted indicates ↑intra-abdominal pressure
→ Ascites: bulging flanks8 with umbilicus everted or resembling horizontal slit
→ Pelvic mass: umbilicus pointing upwards
Name of scar for liver transplant, gallbladder surgery, nephrectomy, appendectomy, kidney transplant, C-section
Mercedes Benz scar for liver transplant
Kosher scar for gallbladder and biliary tract surgeries
Nephrectomy scar for nephrectomy
Lanz incision for appecdectomy
Hockey stick incision for kidney transplant
Pfannenstiel incision for C-section
Causes of striae
Striae: whitish/pinkish linear marks with wrinkled appearance
→ Indicates acute abdominal distension
- Whitish in eg. pregnancy, ascites, recent weight gain
- Purplish in Cushing’s syndrome
→ Mechanism: acute stretching results in rupture of skin elastic fibres
Signs for hemoperitoneum
□ Cullen’s sign: faintly blue discolouration near the umbilicus
→ Indicates extensive haemoperitoneum
→ Commonly occur in acute pancreatitis
□ Grey-Turner’s sign: faintly blue discolouration at flanks
→ Indicates retroperitoneal haemorrhage
→ Commonly occur in acute pancreatitis
Types of dilated veins at abdomen and underlying causes
□ Determine direction of flow at inferior abdomen using two fingers
→ Downward → portal hypertension
→ Upward → IVC obstruction
□ Caput medusa: engorged paraumbilical veins → Indicates portal hypertension → Blood flow: portal blood → ligamentumteres → umbilicus → other superficial veins
□ Dilated thoracoepigastric veins:
→ Indicates IVC obstruction
→ Blood flow: supf epigastric v.
→ thoracoepigastric v. → lateral thoracic v.
Structures that intersect the transpyloric plane
Transpyloric plane (L1-2):
□ Plane joining tip of 9th costal cartilage
□ Left: renal hilum (above), pylorus
□ Midline: L1-2, origin of SMA, conus medullaris
□ Right: neck of pancreas, D1, fundus of gallbladder, renal
hilum (below)
List peritoneal signs
□ Guarding: involuntary contraction of abdominal muscles upon palpation
→ Always associated with tenderness
→ +ve → suggestive of peritonitis
□ Rebound tenderness:
→ Slowly press on the area of tenderness
→ Warn the patient that you are going to let go
→ Let go quickly and watch pt’s facial expression
→ +ve → strongly suggestive of peritonitis
□ Rigidity:
→ Involuntary contraction of entire abdominal wall against palpation
→ Indicates generalized peritonitis
Causes of Hepatomegaly
Chronic parenchymal diseases:
Alcoholic liver disease, hepatic steatosis, viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis
Malignancy: primary HCC or secondary metastatic
Haematological: lymphoma, leukaemia, myelofibrosis, polycythaemia
Others: Amyloidosis, sarcoidosis
How to describe palpable liver
→ Edge: sharp vs rounded
→ Surface: regular, well-defined, smooth (normal) vs nodular12 (HCC or polycystic liver)
→ Consistency: soft (normal) vs firm (cirrhotic) vs hard (HCC or metastasis)
→ Tenderness
→ Bruit: only if suspect
- Compression of aorta due to large liver13
- Vascular tumour, eg. HCC or hemangioma
(bruit heard over entire liver)
- Alcoholic hepatitis (bruit heard over entire liver)
Normal borders of liver
Surface anatomy:
□ Upper border: Rt 5th ICS (full expiration)
□ Lower border: Rt costal margin at MCL (full inspiration)
Normal location of spleen
Describe gardners line
□ Normal: 9th to 11th rib, posterior to MAL
□ Enlarged along Gardner’s line (Rt iliac fossa → umbilicus
→ tip of 10th costal cartilage → Rt anterior axillary fold)
How to palpate for spleen
Use tip of finger and palpate along Gardner’s line up to costal margin
□ If splenomegaly is suspected but spleen not palpable
→ Turn pt to Rt lateral position
→ Hook the spleen with left hand at lower rib cage
- Apply firm pressure medial and downward
- Aim: limit lower rib cage expansion
→ Dipping (ballottement) in case of ascites
Describe castell method for spleen percussion
Percussion by Castell method: percuss at Castell’s spot (lowest Lt
ICS along AAL) with pt in full inspiration and expiration
→ Note becomes dull during inspiration if splenomegaly
Ddx splenomegaly
□ Massive: CML, MF
□ Moderate: portal hypertension, haematological malignancy
□ Minimal: haemolytic anaemia (thal intermedia), autoimmune cytopenia (ITP, AIHA)
Normal kidney position
Surface anatomy:
□ Position: T12-L3, 7cm from midline
□ Hilum at transpyloric lane (L1-2)
□ Rt kidney 2-3cm lower than left
How to palpate and ballot kidneys
□ Bimanually to trap the lower pole on inspiration
→ Lt hand at renal angle15
→ Rt hand at subcostal area
□ If palpable, attempt balloting16
→ Lt hand ‘throw’ → press sharply at renal angle
→ Rt hand ‘feel’ at subcostal area
□ Palpable kidney → a swelling with rounded lower pole and medial dent (hilum)
Difference between spleen and kidney
□ Spleen is anterior to kidney
→ Bimanual (kidney)
vs anterior palpation (spleen)
→ Subcostal gap present for kidney
(kidneys enlarge anteriorly vs spleen enlarges along Gardner’s line)
→ Resonant17 (kidney) vs dull on percussion (spleen)
□ Spleen is notched medially when enlarged >10cm
□ BOTH moves with respiration
Causes of unilateral palpable kidney
Unilateral palpable kidney:
- Normal – Rt kidney, compensatory hypertrophy of single kidney
- Vascular – acute renal vein thrombosis
- Infection – pyelonephritis, renal abscess, pyonephrosis
- Neoplasm – RCC
- Congenital – polycystic kidney (with asymmetrical enlargement)
- Hydronephrosis
Causes of bilateral palpable kidney
Bilateral palpable kidney:
- Unilateral causes occurring bilaterally
- Endocrine – diabetic nephropathy (common), acromegaly
- Infiltrative – amyloid, lymphoma
Interpret:
Parotid swelling
Hepatomegaly: firm, tender +/- bruit
Splenomegaly
Ascites
Dx?
Alcoholic liver disease
Ddx of Cirrhosis with enlarged liver
Alcoholism Primary biliary cirrhosis Autoimmune hepatitis Cardiac cirrhosis Hepatocellular carcinoma Wilson's disease
Investigations for enlarged liver with suspected cirrhosis
LFT Copper and ceruloplasmin Anti-mitochondrial antibody Anti-nuclear antibody AFP
Ultrasound
Most common cause of ascites AND splenomegaly
Post- HepB or HepC infection viral cirrhosis
GI disease with erythema nodosum
IBD: ulcerative collitis or Crohn’s disease
Also have pyoderma gangrenosum
