Gen Med 3 Abdo

Question 1

What are the headings you talk about in your presentation of a patient?

Answer 1

• General inspection (patient & bedside) • Hands (& arms) • Head & neck • Inspection of the chest • Abdomen (inspection, palpation, percussion & auscultation)

Question 2

General inspection what might you see?

Answer 2

Jaundice? Pallor?

Question 3

What is the ABCDE (L) of the hand?

Answer 3

• Asterixis (liver flap) • Bruising • Clubbing • Dupuytren’s contracture • Erythema (palmar) • Leuconychia

Question 4

What might you see on the arms in CKD?

Answer 4

• AV fistulae • Current or previous renal replacement therapy

Question 5

What might you see in the Head and Neck?

Answer 5

• Anaemia • Jaundice • Skin: jaundice, excoriation marks or spider naevi? • Oral examination: – Pigmentation – Gum hypertrophy (? On ciclosporine after renal transplant)

Question 6

What might you see on the chest?

Answer 6

• Gynaecomastia • Hair loss • Excoriation marks • Spider naevi (fill centrally out)

Question 7

What might you see on inspection of the abdo?

Answer 7

• Abdominal distension? • Caput Medusae? – distended superficial abdominal veins – direction of flow in the veins below the umbilicus is towards the legs. • Scars?

Question 8

What scars might you see in the abdo?

Answer 8

1. 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)

Question 9

What are the causes of hepatomegaly?

Answer 9

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

Question 10

What do you always forget to examine but which gives you thinking time?

Answer 10

Lymphadenopathy

Question 11

What causes liver disease?

Answer 11

• Alcohol • Autoimmune • Drugs • Viral • Biliary disease

Question 12

What are the causes of splenomegaly?

Answer 12

• H (portal Hypertension) • H (Haematological) • Infection • Inflammation

Question 13

• Abdominal pain • Abdominal distension • Change of bowel habit • GI bleed • Jaundice • Ascites Differentials for symptoms in isolation?

Answer 13

• Peptic ulcer • Pancreatitis • Pancreatic cancer • Cholecystitis • Hepatitis • Chronic liver disease • Appendicitis • Diverticulitis • Ruptured aortic aneurysm • IBD • Coeliac

Question 14

• 75 year old man • Epigastric pain • Back pain • PR: 130 bpm • BP: 80/50 mm Hg Most likely diagnosis?

Answer 14

Ruptured AAA

Question 15

What do you need to know about abdo pain?

Answer 15

Nature: constant (infl.), colicky (obstruction) Location: Epigastric, RUQ, RIF, Suprapubic, LIF, General, Medical

Question 16

Differentials for epigastric pain

Answer 16

• 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

Question 17

What would you have in acute pancreatitis?

Answer 17

• Pain • High amylase

Question 18

What would you see in chronic pancreatitis?

Answer 18

• Pain, wt loss • Loss of exocrine function • Loss of endocrine function • Normal amylase • Faecal elastase (high)

Question 19

What are the differentials for RUQ pain?

Answer 19

• Gall bladder: – Cholecystitis – Cholangitis – Gallstones • Liver: • Hepatitis • Abscess • Above (lungs) – Basal pneumonia • Below (appendix) – Appendicitis • Left (Stomach, pancreas) – Peptic ulcer, Pancreatitis • Right: (kidney) – pyelonephritis

Question 20

Differentials RIF pain

Answer 20

• GI – Appendicitis – Mesenteric adenitis – Colitis (IBD) – Malignancy • Gynaecological – Ovarian cyst rupture, twist, bleed – Ectopic pregnancy

Question 21

Differentials Suprapubic pain

Answer 21

• Cystitis • Urinary retention

Question 22

Any acute abdominal problem might have a high…

Answer 22

Amylase

Question 23

What is the level of of neutrophils from an ascites tap in SBP?

Answer 23

>250 cells/ mm3

Question 24

LIF pain differentials?

Answer 24

Colitis Colonic malignancy Diverticulitis Gynae- testicular/ ovarian torsion, Ovarian Cysts (rupture, twist, bleed), ectopic pregnancies

Question 25

Causes of diffuse abdominal pain

Answer 25

Peritonitis/ gastroenteritis Obstruction IBD IBS Mesenteric ischaemia DKA, Addisons, Hypercalcaemia, porphyria, lead poisoning

Question 26

What is the structure of the abdominal arteries?

Answer 26

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

Question 27

65 yr old man, triple A repair 2 days ago Diffus abdo pain 120 bpm RR30 What are his blood tests likely to show?

Answer 27

High amylase due to acute abdomen

Question 28

What can abdominal distension be?

Answer 28

Fat Flatus Foetus Fluid Faeces Foreign bodies (tumours)

Question 29

What is fluid (ascites) a sign of?

Answer 29

Liver disease Found via shifting dullness

Question 30

What is flatus (diffuse tympanism) associated with?

Answer 30

obstruction Also: N/V Not opening bowels High pitched tinkling BS Previous surgery (adhesions) Tender irreducible femoral hernia in groin

Question 31

What are the causes of transudate (ascites)?

Answer 31

Transudate = low protein Cirrhosis Cardiac failure Nephrotic syndrome

Question 32

What are the causes of exudate (high protein)?

Answer 32

Malignancy Infection Budd-Chiari (hepatic vein thrombosis) Portal vein thrombosis

Question 33

Jaundice is due to...

Answer 33

...Low stercobilinogen (due to BR not being conjugated and put in bile acids)

Question 34

What are the classes of jaundice?

Answer 34

Pre hepatic (haemolytic anaemia and defective conjugation /Gilberts/) Hepatic (hepatitis) Post hepatic (CBD obstruction)

Question 35

What are the causes of hepatitis?

Answer 35

Alcohol Autoimmune Drugs Viruses

Question 36

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?

Answer 36

Obstructive jaundice caused by pancreatic tumour Will have a raised ALP and CA19-9(cancer) (and Alk phosphatase for cancer)

Question 37

What is raised in obstructive jaundice?

Answer 37

ALP

Question 38

What is raised in hepatic jaundice?

Answer 38

ALT

Question 39

What is Ca 125 elevated in?

Answer 39

Gynaecological malignancies (women)

Question 40

What is AST raised in?

Answer 40

Hepatocyte damage

Question 41

What are the causes of blood diarrhoea?

Answer 41

Infective colitis (Campylo bacter, haemorrhagic E.Coli, Entamoeba histolytica, salmonella, shigella) Inflammatory colitis/ IBD (young with extra GI manifestations) Ischaemic colitis (elderly) Diverticulitis/ malignancy

Question 42

What do you see in inflammatory conditions?

Answer 42

Thumbprinting (inflammation)

Question 43

When do you see lead pipe colon?

Answer 43

Ulcerative colitis

Question 44

What does AXR show in obstruction?

Answer 44

Bowel dilation

Question 45

What is the management of an acute GI bleed?

Answer 45

ABC IV access- fluids Group and save/ Cross match OGD Variceal bleed- Abx/ terlipressin

Question 46

How do you manage an acute abdomen?

Answer 46

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

Question 47

How do you assess a patient with GI disease?

Answer 47

Jaundice- FBC/ LFT/ CRP, Abdo USS (after a fast) Dysphagia, wt loss- OGD/ biopsy PR bleed, wt loss- Colonoscopy

Question 48

What is the management for a patient with ascites?

Answer 48

Diuretics (Spirinolactone / furosemide) Dietary sodium restriction Fluid restriction Monitor wt daily Therapeutic paracentesis (IV human albumin)

Question 49

How do you use albumin in ascites to figure out the causative condition?

Answer 49

Serum albumin minus ascites albumin \>11 g/L - cirrhosis, cardiac failure \<11 g/L TB, cancer (nephrotic syndrome

Question 50

How do you treat encephalopathy?

Answer 50

- Lactulose - Phosphate enemas - Avoid sedation - Treat infections - Exclude GI bleed

Question 51

What are the forms of perianal disease and treatment?

Answer 51

Peri anal abscess (incision and drainage) Anal fissure- rectal pain, stool coated with blood, (advice re diet- fluids/ fibre GTN cream)

Question 52

What is the presentation and treatment of IBS?

Answer 52

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

Question 53

What can you give for post op care?

Answer 53