General Internal Mushkies Flashcards
What are the causes of hepatomegaly?
3Cs, 2Is, 2Bs
- Cancer = primary or secondary
- Cirrhosis = early, usually alcoholic
- Cardiac = CCF, congestive pericarditis
- Infiltration = fatty, haemochromatosis, amyloidosis, sarcoidosis
- Infection = Viral, Malaria, Abscess
- Blood = leukaemia, lymphoma, myeloproliferative, haemolytic
- Biliary = PBC, PSC
What is are the signs of hepatic failure?
Asterixis Bruising Clubbing Dupuytren's contracture Erythema (palmar) Foetor Gynaecomastia Hair loss Icterus Jaundice
How can you classify the causes of liver disease?
- Alcohol
- Autoimmune
- Drugs
- Viral
- Biliary Disease
- Metabolic
- Malignancy
- Vascular
What are the causes of splenomegaly?
2Hs, 2Is
- Haematological = lymphoma, leukaemia, myelofibrosis, haemolytic anaemia
- Portal HTN
- Infection = EBV, IE, malaria
- Inflammation = amyloidosis/sarcoidosis
What are the causes of epigastric pain?
- Stomach (peptic ulcer, GORD, gastritis, malignancy)
- Pancreas (acute pancreatitis)
- Right = Hepatitis/cholesystitis
- Above = MI
- Below = AAA
What is a faecal marker that is a sign of chronic pancreatitis?
Low faecal elastase
What are the features of chronic pancreatitis?
- Pain
- Weight loss
- Loss of exocrine function –> steatorrhoea
- Loss of endocrine function –> diabetes
- Normal amylase
- Low faecal elastase
What are the causes of RUQ pain?
- Gallbladder = colic, cholecystitis, cholangitis
- Liver = hepatitis, abscess
- Above = basal pneumonia
- Below = appendicitis
- Left = stomach/pancreas
- Right = pyelonephritis
What are the causes of RIF pain?
- GI = appendicitis, mesenteric adenitis, colitis (IBD), malignancy, Meckel’s diverticulum
- Gynaecological = ovarian cyst rupture/torsion/bleed, ectopic pregnancy
What are the causes of suprapubic pain?
Cystitis or UTI
What are the causes of LIF pain?
- GI = diverticulitis, colitis (IBD), malignancy
2. Gynaecological = ovarian cyst rupture/torsion/bleed, ectopic pregnancy
What are the causes of diffuse abdominal pain?
- Obstruction
- Infection = peritonitis, gastroenteritis
- Inflammation = IBD
- Ischaemia = mesenteric ischaemia
- Medical = DKA, Addison’s, hypercalcaemia, Porphyria, Lead poisoning
How does mesenteric ischaemia present?
Pain after eating
How does porphyria present?
Abdominal pain
Vomiting
Weak handshake
Red/purple urine
At what levels do the Coeliac artery, SMA and IMA come off the abdominal aorta?
Coeliac = T12 SMA = L1 IMA = L3
What does the coeliac trunk supply? (x5)
Stomach, spleen, liver, gallbladder, duodenum
What does the SMA supply?
Small Intestine + Right Colon
What does the IMA supply?
Left colon
What connects the Coeliac trunk to the SMA?
Pancreaticoduodenal arcade
What connects the SMA to the IMA?
The Arc of Riolan and the Marginal Artery of Drummond
What are the branches of the coeliac artery?
- Left gastric artery
- Common hepatic artery
- Splenic artery
What are the branches of the SMA?
- Inferior pancreaticoduodenal artery
- Intestinal branches (jejunal, ileal)
- Ileocolic artery
- Right colic artery
- Middle colic artery
What are the branches of the IMA?
- Left colic artery
- Sigmoid branches
- Superior rectal artery
What are the signs of decompensated liver disease?
JEA
Jaundice
Encephalopathy
Ascites
What ascites neutrophil level is characteristic of spontaneous bacterial peritonitis?
≥250 cells/mm³
What are the causes of abdominal distension? (x5)
Fat, fluid, faeces, flatus, foetus
What kind of bowel sounds are heard in obstruction?
High pitched, tinkling
What are the ways you can classify ascites?
- Low vs. high albumin gradient
2. Transudate vs. exudate
What is meant by a low albumin gradient and what are some causes?
Serum - ascites albumin gradient <11g/L
- TB
- Nephrotic Syndrome
- Cancer
- Peritonitis
- Pancreatitis
What is meant by a high albumin gradient and what are some causes?
Serum - ascites albumin gradient >11g/L
- Portal HTN
- Cirrhosis
- Cardiac failure (acute + chronic)
- Constrictive pericarditis
What are the transudate causes of ascites?
Cirrhosis, Cardiac failure, Nephrotic Syndrome
What are the exudate causes of ascites?
- Malignancy (abdo, pelvis, peritoneal mesothelioma)
- Infection (TB, pyogenic)
- Budd-Chiari syndrome (hepatic vein thrombosis)
- Portal vein thrombosis
How can you classify the causes of jaundice?
Pre-hepatic, hepatic, post-hepatic
What are the pre-hepatic causes of jaundice?
Haemolysis or defective conjugation (Gilbert’s syndrome) –> high unconjugated bilirubin
What causes Gilbert’s syndrome?
Mutation in the UGT1A1 gene that leads to decreased activity of uridine diphosphate glucuronosyltransferase, with subsequent reduction in glucorinidation
What is the path of bilirubin synthesis, conjugation, and excretion in the body?
RBC → Spleen → RBC breakdown → unconjugated bilirubin → liver (UDPGT) → conjugated bilirubin (water soluble) → bile → bowel → urobilinogen → stercobilinogen (brown)
What are the hepatic causes of jaundice?
Hepatitis = alcohol, autoimmune, drugs, viruses
Why do you get dark urine with hepatic jaundice?
Hepatocellular damage causes conjugated bilirubin to leak out → dark urine
What are the post-hepatic causes of jaundice?
1/3rd gallstones, 1/3rd pancreas, 1/3rd other
What are the ‘other’ causes of post-hepatic jaundice?
- Lymph nodes at Porta Hepatis = TB, Ca
- Inflammatory = PBC, PSC
- Drugs = OCP, sulfonylureas, flucloxacillin
- Neoplastic = Cholangiocarcinoma
- Mirizzi’s syndrome
What are the features of post-hepatic jaundice?
High conjugated bilirubin, pale stool (low stercobilinogen), dark urine (leaking conjugated bilirubin)
What is the tumour marker for pancreatic cancer?
Ca 19-9
What is Trousseau’s sign of malignancy?
Migratory thrombophlebitis most commonly due to adenocarcinomas of the lung and pancreas, and gliomas
What are the causes of bloody diarrhoea?
Infective colitis = CHESS Inflammatory colitis = IBD Ischaemic colitis Diverticulitis Malignancy
What does thumb-printing on an AXR mean?
Inflammation in the wall of the bowel e.g. IBD
What does a lead-pipe on AXR mean?
IBD
What is the AXR cut-off for a toxic megacolon?
> 6cm
What is the management of a variceal bleed?
- ABCDE + Fluids, G&S + X match blood
- OGD to find underlying cause
- Abx (Tazocin, ciprofloxacin)
- Terlipressin (causes splanchnic vasoconstriction, dont give to a peptic ulcer pt)
What is the management of ascites?
- Diuretics (spironolactone +/- furosemide)
- Ascitic tap (to rule out SBP)
- Dietary Na restriction + fluid restriction in pts w/ hyponatraemia
- Monitor weight daily + therapeutic paracentesis (w/ 20% human albumin)
What is the management of hepatic encephalopathy?
- Lactulose + phosphate enemas
2. Avoid sedation, treat infections, exclude a GI bleed
What are 3 common post-operative surgical complications?
- Wound infection
- Anastomotic leak
- Mucus diarrhoea
