interactive cases iii Flashcards
What signs do you look for in the hands for an abdo exam?
A sterixis (liver flap) B ruising C lubbing D upuytren's contracture E rythema (palmar) ... L euconychia
What is caput medusae indicative of?
Portal hypertension
Possible ddx of hepatomegaly
C ancer - primary/secondary C irrhosis - early on, usually alcoholic C ardiac - congestive heart failure - constrictive pericarditis Infiltration - fatty, haemochromatsis, amylodosis, sarcoidosis, hypoproliferative diseases
Main causes of liver disease
Alcohol Autoimmune Drugs Viral Biliary disease
Possible ddx of splenomegaly
H - portae hypertension
H - haematological
I - infection
I - inflammation
What do you need to distinguish regarding abdo pain?
Nature - constant (inflammation) or colicky (obstruction) Location - 9 regions - general pain - medical cause?
Possible ddx of epigastric pain
Stomach - peptic ulcer (NSAID use) - GORD (better with antiacids) - gastritis (retrosternal, ETOH) - malignancy Pancreas - acute pancreatitis (gallstones, high amylase) Heart (above) - MI Aorta (below) - ruptured aortic anuerysm Liver/gallbladder (right) - cholecystitis - hepatitis
Differentiate between acute and chronic pancreatitis
Acute - high amylase - pain Chronic - pain w/ wt loss - normal amylase - loss of endocrine and exocrine function (malabsorption hence wt loss) - faecal elastase decreased
Possible ddx of RUQ pain
Gallbladder - cholecystitis - cholangitis - gallstones Liver - hepatitis - abscess Lungs (above) - basal pneumonia Appendix (below) - appendicitis Stomach, pancreas (left) - peptic ulcer, pancreatitis Kidney (right) - pyelonephritis
Possible ddx of RIF pain
GI - appendicitis - mesenteric adenitis - colitis (IBD) - malignancy Gynaecological - ovarian cyst rupture/twist/bleed - ectopic pregnancy
Possible ddx of suprapubic pain
Cystitis
Urinary retention
Possible ddx of LIF Pain
GI - diverticulitis - colitis (IBD) - malignancy Gynaecological - ovarian cyst rupture/twist/bleed - ectopic pregnancy
Possible ddx of diffuse/generalised pain
Obstruction Infection (peritonitis, gastroenteritis) Inflammation (IBD) Ischaemia (mesenteric ischaemia) Medical causes
What are medical causes of abdo pain?
DKA Addison's Hypercalcaemia Porphyria Lead poisoning
Name the arteries of the GI blood supply
Coeliac
Superior mesenteric artery
Inferior mesenteric artery
Iliac
What does the coeliac artery supply?
Stomach, spleen, liver, gallbladder, duodenum
What does the SMA supply?
Small intestine, right colon
What does the IMA supply?
Left colon
What does the iliac artery supply?
Rectum
What reading would you expect from amylase when pt has abdo pain?
High amylase
What does an ascites neutrophil count greater/equal to 250 cells/mm3 indicate?
Evidence of spontaenous bacterial peritonitis
What causes abdo distention?
Fluid (ascites) Flatus (obstruction) Fat Faeces Foetus Foreign body (mass)
Features of ascites
Shifting dullness
Signs of liver disease
Features of obstruction
Nausea + vomiting Not opened bowels High pitched, tinkling bowel sounds ?previous surgeries (adhesions) ?tender, irreducible femoral hernia in groin
Possible causes of transudate ascites
(transudate = albumin levels not high)
Cirrhosis
Cardiac failure
Nephrotic syndrome
Possible causes of exudate ascites
(exudate = albumin levels high) Malignancy - abdo, pelvic, peritoneal mesothelioma Infection - TB, pyogenic Budd-Chiari syndrome (hepatic vein thrombosis) Portal vein thrombosis
What causes pale stool?
Low stercobilinogen
Pre-hepatic causes of jaundice
Haemolysis
Defective conjugation
Gilbert’s syndrome (decreased glucuonidation)
=> unconjugated bilirubin present
Hepatic causes of jaundice
Hepatitis
- alcohol, autoimmune, drugs, viral
=> conjugated bilirubin present
Post-hepatic causes of jaundice
CBD obstruction
- gallstones in CBD
- stricture
- Ca of head of pancreas
=> conjugated bilirubin present
Which types of jaundice may also have dark urine and/or pale stool?
Hepatic => dark urine
Post-hepatic => dark urine and pale stool
Which proteins are high in pancreatic cancer?
ALP and alpha-fetoprotein
Possible ddx of bloody diarrhoea
Infective colitis
Inflammatory colitis (young, extra-GI manifestations)
Ischaemic colitis (elderly, high lactate)
Diverticulitis, malignancy
Which bacteria commonly cause infective colitis?
C ampylobacter H aemorrhagic E Coli E ntamoeba histolytica S almonella S higella
What would you see in an abdo X-ray for the following conditions:
a) inflammation,
b) toxic megacolon,
c) overflow, spurios diarrhoea?
a) thickening of bowel wall, thumb print
b) dilated loops of large bowel
c) faecal loading
How would you manage an acute GI bleed?
ABCDE IV access Fluids G&S, X-match blood OGD
Which drugs are used to treat variceal bleeds?
Antibiotics (evidence of reduced mortality)
Terlipressin (splanchnic vasoconstrictor)
Which ix would you take for an acute abdo presentation?
Bloods: FBC, U&E, LFTs, CRP, clotting, G&S, X-match
Erect CXR
CT
What mx would you do for an acute abdo presentation?
NBM Fluids Analgesic Anti-emetics Antibiotics Monitor fluids and urine output
What specific ix would you do for the following PCs:
a) jaundice
b) dysphagia, wt loss
c) PR bleed, wt loss?
a) Bloods (FBC, LFTs, CRP) and abdo USS (after fast as gallstones better visualised)
b) OGD + biopsy
c) Colonoscopy
How is ascites managed?
Diuretics (spironolactone and/or furosemide)
Dietary Na+ restriction
Fluid restriction in pt w/hyponatraemia
Monitor wt daily
Therapeutic paracentesis (with IV human albumin)
What is SAAG?
Serum albumin ascites gradient:
serum albumin - ascites albumin
What are ddx when SAAG > 11g/L?
Cirrhosis
Cardiac failure
Budd-Chiari syndrome
What are ddx when SAAG < 11g/L?
TB
Cancer
Nephrotic syndrome
What causes SAAG to increase?
Portal hypertension -> increase in hydrostatic pressure -> more fluid leaves circulatory system -> enter peritoneal space causing ascites -> albumin too large molecule to pass membrane -> serum albumin concentrated
tl;dr more water in peritoneal space, more albumin in vasculature
How do you manage encephalopathy?
Lactulose Phosphate enemas Avoid sedation Treat infections Exclude GI bleeds
What are complications of post-op care?
Wound infection - erythematous - discharge Anastomotic leak - diffuse abdo tenderness - guarding, rigidity - hypotensive/tachycardic Pelvic abcess - pain, fever, sweats, mucus diarrhoea
Compare two perianal diseases pc and mx
Perianal abcess - tender, red swelling - incision + drainage Anal fissure - rectal pain (defecation) - stool coated w/blood - GTN cream - advice re diet (fluids, fibre)
What is a typical hx of IBS?
Recurrent abdo pain, bloating Improves w/defecation Change in freq./form of stool No PR bleed, anaemia, wt loss or nocturnal sx Exclude coeliac
How is IBS managed?
Diet + lifestyle modification Symptomatic rx - abdo pain: anti-spasmodics - laxatives for constipation - anti-diarrhoeals
