Gen Med 3 Abdo Flashcards
What are the headings you talk about in your presentation of a patient?
• General inspection (patient & bedside) • Hands (& arms) • Head & neck • Inspection of the chest • Abdomen (inspection, palpation, percussion & auscultation)
General inspection what might you see?
Jaundice? Pallor?
What is the ABCDE (L) of the hand?
• Asterixis (liver flap) • Bruising • Clubbing • Dupuytren’s contracture • Erythema (palmar) • Leuconychia
What might you see on the arms in CKD?
• AV fistulae • Current or previous renal replacement therapy
What might you see in the Head and Neck?
• Anaemia • Jaundice • Skin: jaundice, excoriation marks or spider naevi? • Oral examination: – Pigmentation – Gum hypertrophy (? On ciclosporine after renal transplant)
What might you see on the chest?
• Gynaecomastia • Hair loss • Excoriation marks • Spider naevi (fill centrally out)
What might you see on inspection of the abdo?
• Abdominal distension? • Caput Medusae? – distended superficial abdominal veins – direction of flow in the veins below the umbilicus is towards the legs. • Scars?
What scars might you see in the abdo?
- Right subcostal (Kocher’s) incision (biliary surgery) 2. Mercedes-Benz incision (liver transplant) 3. Midline laparotomy incision (GI or any major abdominal surgery) 4. McBurney’s (Gridiron) incision (appendicectomy) 5. J-shaped/ ‘hockey stick’ incision (renal transplant) 6. Low transverse (Pfannenstiel) incision (gynaecological procedures) 7. Inguinal incision (hernia repair, vascular access) 8. Loin incision (nephrectomy)
What are the causes of hepatomegaly?
3 C’s • Cancer (primary or secondary deposits) • Cirrhosis (early, usually alcoholic) • Cardiac: – Congestive cardiac failure – Constrictive pericarditis • Infiltration – Fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis, lymphoproliferative diseases
What do you always forget to examine but which gives you thinking time?
Lymphadenopathy
What causes liver disease?
• Alcohol • Autoimmune • Drugs • Viral • Biliary disease
What are the causes of splenomegaly?
• H (portal Hypertension) • H (Haematological) • Infection • Inflammation
• Abdominal pain • Abdominal distension • Change of bowel habit • GI bleed • Jaundice • Ascites Differentials for symptoms in isolation?
• Peptic ulcer • Pancreatitis • Pancreatic cancer • Cholecystitis • Hepatitis • Chronic liver disease • Appendicitis • Diverticulitis • Ruptured aortic aneurysm • IBD • Coeliac
• 75 year old man • Epigastric pain • Back pain • PR: 130 bpm • BP: 80/50 mm Hg Most likely diagnosis?
Ruptured AAA
What do you need to know about abdo pain?
Nature: constant (infl.), colicky (obstruction) Location: Epigastric, RUQ, RIF, Suprapubic, LIF, General, Medical
Differentials for epigastric pain
• Stomach: – Peptic ulcer (?NSAID use) – GORD (better with antacids) – Gastritis (retrosternal, ETOH) – Malignancy • Pancreas: • Acute Pancreatitis – (?Gallstones, high amylase) • Above (heart) – MI • Below (Aorta) – ruptured aortic aneurysm • Right: (liver/gall bladder) – Cholecystitis – Hepatitis
What would you have in acute pancreatitis?
• Pain • High amylase
What would you see in chronic pancreatitis?
• Pain, wt loss • Loss of exocrine function • Loss of endocrine function • Normal amylase • Faecal elastase (high)
What are the differentials for RUQ pain?
• Gall bladder: – Cholecystitis – Cholangitis – Gallstones • Liver: • Hepatitis • Abscess • Above (lungs) – Basal pneumonia • Below (appendix) – Appendicitis • Left (Stomach, pancreas) – Peptic ulcer, Pancreatitis • Right: (kidney) – pyelonephritis
Differentials RIF pain
• GI – Appendicitis – Mesenteric adenitis – Colitis (IBD) – Malignancy • Gynaecological – Ovarian cyst rupture, twist, bleed – Ectopic pregnancy
Differentials Suprapubic pain
• Cystitis • Urinary retention
Any acute abdominal problem might have a high…
Amylase
What is the level of of neutrophils from an ascites tap in SBP?
>250 cells/ mm3
LIF pain differentials?
Colitis Colonic malignancy Diverticulitis Gynae- testicular/ ovarian torsion, Ovarian Cysts (rupture, twist, bleed), ectopic pregnancies
Causes of diffuse abdominal pain
Peritonitis/ gastroenteritis Obstruction IBD IBS Mesenteric ischaemia DKA, Addisons, Hypercalcaemia, porphyria, lead poisoning
What is the structure of the abdominal arteries?
AORTA > Coeliac trunk >> Stomach, spleen, liver, gallbladder, duodenum >>>Pancreaticoduodenal arcade >Superior Mesenteric Artery >> Small intestine, right colon >>>Arch of riolan, marginal artery of drummond >Inferior Mesenteric Artery >> Left colon >>>Ileomesenteric arcade >Iliac artery >> Rectum
65 yr old man, triple A repair 2 days ago Diffus abdo pain 120 bpm RR30 What are his blood tests likely to show?
High amylase due to acute abdomen
What can abdominal distension be?
Fat Flatus Foetus Fluid Faeces Foreign bodies (tumours)
What is fluid (ascites) a sign of?
Liver disease Found via shifting dullness
What is flatus (diffuse tympanism) associated with?
obstruction
Also: N/V Not opening bowels High pitched tinkling BS Previous surgery (adhesions) Tender irreducible femoral hernia in groin
What are the causes of transudate (ascites)?
Transudate = low protein
Cirrhosis
Cardiac failure
Nephrotic syndrome
What are the causes of exudate (high protein)?
Malignancy
Infection
Budd-Chiari (hepatic vein thrombosis)
Portal vein thrombosis
Jaundice is due to…
…Low stercobilinogen (due to BR not being conjugated and put in bile acids)
What are the classes of jaundice?
Pre hepatic (haemolytic anaemia and defective conjugation /Gilberts/) Hepatic (hepatitis) Post hepatic (CBD obstruction)
What are the causes of hepatitis?
Alcohol
Autoimmune
Drugs
Viruses
50 M painless jaundice, weight loss, dark urine, pale stool and erythema What type of jaundice is this and what is likely to be raised in his bloods?
Obstructive jaundice caused by pancreatic tumour Will have a raised ALP and CA19-9(cancer) (and Alk phosphatase for cancer)
What is raised in obstructive jaundice?
ALP
What is raised in hepatic jaundice?
ALT
What is Ca 125 elevated in?
Gynaecological malignancies (women)
What is AST raised in?
Hepatocyte damage
What are the causes of blood diarrhoea?
Infective colitis (Campylo bacter, haemorrhagic E.Coli, Entamoeba histolytica, salmonella, shigella) Inflammatory colitis/ IBD (young with extra GI manifestations) Ischaemic colitis (elderly) Diverticulitis/ malignancy
What do you see in inflammatory conditions?
Thumbprinting (inflammation)
When do you see lead pipe colon?
Ulcerative colitis
What does AXR show in obstruction?
Bowel dilation
What is the management of an acute GI bleed?
ABC IV access- fluids Group and save/ Cross match OGD Variceal bleed- Abx/ terlipressin
How do you manage an acute abdomen?
Inx: - FBC/ U&E/ LFT/ CRP/ Clotting/ G&S/ X-mathc - Erect CXR - CT
Tx:
- NBM
- FLuids
- analgesia
- Anti emetics
- Antibiotics
- Monitor vitals and UO
How do you assess a patient with GI disease?
Jaundice- FBC/ LFT/ CRP, Abdo USS (after a fast) Dysphagia, wt loss- OGD/ biopsy PR bleed, wt loss- Colonoscopy
What is the management for a patient with ascites?
Diuretics (Spirinolactone / furosemide) Dietary sodium restriction Fluid restriction Monitor wt daily Therapeutic paracentesis (IV human albumin)
How do you use albumin in ascites to figure out the causative condition?
Serum albumin minus ascites albumin >11 g/L - cirrhosis, cardiac failure <11 g/L TB, cancer (nephrotic syndrome
How do you treat encephalopathy?
- Lactulose - Phosphate enemas - Avoid sedation - Treat infections - Exclude GI bleed
What are the forms of perianal disease and treatment?
Peri anal abscess (incision and drainage) Anal fissure- rectal pain, stool coated with blood, (advice re diet- fluids/ fibre GTN cream)
What is the presentation and treatment of IBS?
Presentation - Recurrent abdo pain, bloating - improves with defacation - Change in frequency/ form of stool - No PR bleed, anaemia, wt loss or nocturnal symptoms except coeliac Treatment - Diet and lifestyle modifications - Symptomatic treatment- antispasmodics, laxatives, anti diarrhoeals
What can you give for post op care?
