Lecture 2 - Abdo Flashcards
What does it mean when a patient has a Right subcostal scar?
Possible history of biliary surgery.
What does it mean when a patient has a Mercedes-Benz Scar?
Possible history of Liver Transplant.
What does it mean when a patient has a midline laparotomy incision?
Possible history of GI/Any major Abdo surgery.
What does it mean when a patient has a McBurney’s Scar?
Possible history of appendicectomy.
What does it mean when a patient has a J shaped/hockey stick incision?
Possible history of Renal Transplant.
What does it mean when a patient has a ‘Low Transverse’ Scar?
Possible history of gynaecological surgery.
What does it mean when a patient has an Inguinal Scar?
Possible history of hernia repair/vascular access.
What does it mean when a patient has a Loin scar?
Possible history of nephrectomy.
What are the main causes of Hepatomegaly?
Cancer (Primary or Secondary)
Cirrhosis (early, usually alcoholic)
Cardiac:
- Congestive Heart failure
- Constrictive Pericarditis
Could also be Infiltrative, due to: fatty infiltration, haemochromatosis, amyloidosos, sarcoidosis or lymphoproliferative disease.
What are the main causes of Liver Disease and abnormal LFTs?
Alcohol
Autoimmue
Drugs
Viruses
Biliary
What are the causes of Splenomegaly?
Portal Hypertension
Haematological
Infection
Inflammation
What would be the most likely diagnosis if a 75yo M presents with:
Epigastric pain that radiates to the back
Tachycardia
Hypotension
?
Ruptured Aortic Aneurysm
How can Abdominal pain be classified?
Nature:
- Constant (Inflammation)
- Colicky (Obstruction)
Location
Name a medical cause of acute abdominal pain.
Addisonian Crisis
DKA
What would be your Ddx if a patient presents with epigastric pain?
Stomach:
- Peptic Ulcer (?NSAIDs)
- Gord (Response to antacids)
- Gastritis (retrosternal, ?ETOH use)
- Malignancy
Pancreas
-Acute Pancreatitis (?Gallstones, high amylase)
Hepatobilliary
- Cholecystitis
- Hepatitis
Other
- AAA
- MI
How does Acute Pancreatitis present?
Epigastric pain
High Amylase
How does Chronic Pancreatitis present?
Pain
Weight Loss
Loss of exocrine (malabsorption) & endocrine function (diabetes)
Normal Amylase, High Faecal Elastase
What would your Ddx be if a patient presents with RUQ pain?
Gall Bladder:
- Cholecystitis
- Cholangitis
- Gallstones
Liver:
- Hepatitis
- Abscess
Other:
- Basal Pneumonia
- Appendicitis
- Peptic Ulcer
- Pancreatitis
- Pyelonephritis
What would be your Ddx if a patient presented with RIF pain?
GI:
- Appendicitis
- Mesenteric Adenitis
- Colitis (IBD)
- Malignancy
Gynae:
- Ovarian Cyst
- Ectopic pregnancy
What would be your Ddx if a patient presented with acute suprapubic pain?
Cystitis
Urinary retention
What would be your Ddx if a patient presented with LIF pain?
GI:
- Diverticulitis
- Colitis
- Malignancy
Gynae:
- Ovarian Cyst
- Ectopic Pregnancy
What would be your Ddx if a patient presented with diffuse abdominal pain?
Obstruction
Infection: Peritonitis, Gastroenteritis
Inflammation: IBD
Ischaemia: Mesenteric Ischaemia
Medical:
- DKA
- Addison’s
- Hypercalcaemia
- Porphyria
- Lead Poisoning
Which artery supplies the Left Colon?
Inferior Mesenteric Artery
Which artery supplies the small intestine and right colon?
Superior Mesenteric Artery
Which artery supplies the Stomach, Spleen, Liver and Gallbladder?
Coeliac Artery
What blood abnormality is likely to be present in a patient presenting with acute, diffuse abdominal pain post-surgery?
High Amylase is likely to be present in all patients who present with abdominal pain.
The level will be distinctively higher in those presenting with Acute Pancreatitis.
How is Spontaneous Bacterial Peritonitis defined?
Ascites Neutrophiles >250 cells/mm3
How would you classify the causes of Abdominal Distension?
Fluid: Ascites (presents with shifting dullness and commonly features of liver disease.)
Flatus: Due to obstruction
Also: Fat, Faeces, Fetus, Fucking huge tumour
How does Bowel Obstruction present?
- Distension
- Nausea, vomiting
- Lack of bowel movements
- High-pitched ‘tinkling’ Bowel Sounds.
- ?Hx of abdo surgery (adhesions)
- ?Tender irreducible femoral hernia in the groin
What are the main causes of Ascites?
Cirrhosis
Cardiac Failure
Nephrotic Syndrome
Malignancy
Infection (eg. TB, pyogenic)
Budd-Chiari Syndrome (Hepatic Vein Thrombosis), portal vein thrombosis.
What makes faeces brown?
Stercobilinogen
How is jaundice classified?
Pre-hepatic:
- Haemolysis
- Defective Conjugation (Gilbert’s)
Hepatic:
-Hepatitis
Post-Hepatic:
-CBD Obstruction
Which enzyme is defective in Gilbert’s Syndrome?
Glucuronyltransferase
Which symptoms are typically present in a patient with Pre-hepatic Jaundice?
Just yellowing of the skin.
Which symptoms will a patient with hepatic jaundice typically present with?
Yellowing of the skin
Dark Urine (leakage of conjugated bilirubin from hepatocytes)
Which symptoms will a patient with post-hepatic jaundice typically present with?
Yellow skin
Dark urine
Pale stools
What can cause post-hepatic jaundice?
Gallstones
CBD Stricture
Carcinoma in the head of the pancreas
Which blood tests are likely to be elevated in a patient presenting with:
Painless Jaundice
Weight Loss
Dark Urine
Pale Stools
?
ALP
CA19-9
What are the main causes of Bloody Diarrhoea?
Infective Colitis
Inflammatory Colitis (Patients will be younger and present with extra-GI manifestations)
Ischaemic Colitis (Typically Elderly)
Diverticulitis
Malignancy
Which organisms most commonly cause Infective Colitis?
CHESS
Campylobacter
Haemorrhagic E.Coli
Entamoeba histolytica
Salmonella
Shigella
How would you investigate a patient with bloody diarrhoea?
Stool Test, for infective causes
Colonoscopy, for inflammatory causes
CT & AXR, for ischaemia.
Lactate & CK, for ischaemia.
What does this AXR show?
Thickening of the bowel wall, most likely due to inflammatory causes.
What does this AXR show?
‘Lead Pipe Colon’
Featureless colon typical of chronic UC
What is shown in this AXR?
Megacolon (Toxic, if the patient is acutely unwell)
What does this AXR show in a patient who presents with diarrhoea?
Faecal Overload.
The Diarrhoea is Overflow Diarrhoea, which requires laxatives to treat.
How would you manage an Acute GI Bleed (non-variceal)?
ABC
IV Access
Fluids - 0.9% NaCl
G&S X-match blood
OGD
How would you manage an Acute Variceal Bleed?
Same as normal Acute GI Bleed
+ Antibiotics
+Terlipressin
Which investigations would you order for a patient presenting with an Acute Abdomen?
FBC, U&Es, LFTs, CRP, Clotting Profile, G&S, X-Match
Erect CXR
CT
What would be the first line management for a patient being investigated for an Acute Abdomen?
Nil-by-Mouth
Fluids
Analgesic
Anti-emetics
Antibiotics
Monitor vitals & urine output
How would you investigate a jaundiced patient?
Bloods: FBC, LFTs, CRP
Abdominal USS (after fasting)
How would you investigate a patient presenting with Dysphagia & Weight Loss?
OGD & Biopsy
How would you investigate a patient presenting with PR bleed & Weight Loss?
Colonoscopy
What would be your next investigation in a patient with deranged LFTs?
Abdominal Ultrasound
How would you manage a patient with Ascites?
Diuretics (Spironolactone +- furosemide)
Dietary Na restriction
Fluid restriction in patients with hyponatraemia
Daily weight monitoring
Therapeutic Paracentesis (with IV human albumin)
How should you classify Ascites?
Serum Ascites Albumin Gradient (SAAG)
Serum Albumin - Ascites Albumin
>11g/L = Cirrhosis, Cardiac Failure
<11g/L = TB, Cancer, Nephrotic Syndrome
How would you manage a patient with Hepatic Encepalopathy?
Lactulose (Increased Bowel movements helps flush toxins out, compensating for Liver Failure)
Phosphate Enemas
Avoid Sedation (eg. benzodiazepines)
Treat infections
Exclude GI bleeds (Bleeding provides toxin-producing bacteria with a plentiful supply of proteins to feast on)
How would you identify an infected wound post-op?
The wound would be:
- Erythematous
- Would be secreting discharge
How would you identify an Anastomotic Leak post-op?
Diffuse Abdominal Tenderness
Guarding, rigidity of the abdomen
?Hypotensive & Tachycardic.
How would you identify a Pelvic Abscess post-op (commonly post-appendicectomy)?
Pain
Fever
Sweats
Mucous
Diarrhoea
How would you identify and treat a Perianal Abscess?
Tender red swelling around the back passage.
Treat with incision & drainage.
How would you identify an Anal Fissure?
Patient presents with rectal pain on defaecation.
The stool would be coated in blood.
How would you manage a patient with an Anal Fissure?
Give lifestyle advice RE. Diet (Adequate fluid intake, high fibre)
GTN cream
How would you identify a case of IBS?
Diagnosis of exclusion.
Bloating tends to improve with defecation.
No Red Flag symptoms:
-No PR Bleed, Anaemia, Weight loss, or Nocturnal Symptoms
-Must exclude Coeliac
How would you treat a patient with IBS?
Diet & lifestyle Advice
Symptomatic treatment:
Abdominal Pain - Antispasmodics
Constipation - Laxatives
Diarrhoea - Anti-Diarrhoeals
