Medical Abdomen Flashcards
Chronic liver disease
On examination
Inspect: general, hands, face, trunk, ankles
Abdo: inspect/palpate
sig negatives!
Peripheral Inspection
-
General
- Jaundice
- Ascites
- Cachexia
- Tattoos and track marks
- Pigmentation
-
Hands
- Clubbing (esp. in PBC)
- Leukonychia
- Terry’s nails (white proximally, red distally)
- Palmer erythema
- Dupuytren’s contracture
-
Face
- Pallor: ACD
- Xanthelasma: PBC
- Keiser-Fleischer rings
- Parotid enlargement (esp. c¯ EtOH)
-
Trunk
- Spider naevi
- Gynaecomastia
- Loss of 2O sexual hair
-
Ankles
- Peripheral oedema
Abdomen
-
Inspection
- Distension ± Para- / umbilical hernia
- Dilated veins
- Drain scars
-
Palpation
- ± hepatomegaly
- ± splenomegaly
- Shifting dullness
Significant Negatives
- Evidence of decompensation
- Jaundice
- Encephalopathy: asterixis, confusion
- Foetor hepaticus: ammonia and ketones
- Hypoalbuminaemia: oedema and ascites
- Coagulopathy: bruising
- Evidence of SBP: esp. if ascites
- Cause: xanthelasma, pigmentation, KF rings, tattoos
Definition of Chronic liver disease
Progressive destruction of the liver parenchyma over a period greater than 6 months leading to fibrosis and cirrhosis
CLD
Differentials
(common/rare)
- Common
- EtOH
- Viral
- NASH
- Rarer
- Genetic: HH
- AI: AH
- Drugs: methotrexate
History Qs in CLD case
(cases)
- EtOH
- Sexual Hx, IVDU, transfusions
- FH
- Other AI disease: e.g. DM, thyroid
- DH
Investigations in CLD case
Initial work up
(and 2 ‘other’)
Initial Workup
- Urine: dip ± MC+S (? UTI)
- Bloods: FBC, U+E, LFTs, INR, glucose
- LIVER SCREEN!
- Ascitic tap: chemistry, cytology, MC+S, SAAG
- PMN >250mm3 indicates SBP
- US + PV duplex
- Liver size and texture
- Focal lesions
- Ascites
- Portal vein flow
- Other:
- liver biopsy
- MRCP: PSC
CLD
Liver screen
(7-think ‘cause’)
- EtOH: MCV, GGT, AST:ALT >2
- Viral: Hep B and C serology
- NASH: lipids
- AutoAbs: SMA, AMA, pANCA, ANA
- Ig: ↑IgG – AIH, ↑IgM – PBC
- Genetic: caeruloplasmin, Ferritin, α1-AT
- Ca: AFP, Ca 19-9
Treatment of CLD
General/specific (to cause)
General
- MDT: GP, hepatologist, dietician, palliative care, family
- EtOH abstinence
- Good nutrition
- Cholestyramine for pruritus
- Screening: liver screen
- HCC: US + AFP
- Varices: OGD (propranolol+banding, acute UGI bleed: terlipressin)
Specific
- HCV: protease (-) + ribavarin
- PBC: ursodeoxycholic acid
- Wilson’s: penicillamine
- HH: venesection, desferrioxamine
Complications of CLD
(7)
- Varices: β-B, banding
- Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
- Coagulopathy: Vit K, FFP, platelets
- Encephalopathy: avoid sedatives, lactulose, rifaximin
-
Sepsis / SBP: tazocin or cefotaxime
- Avoid gent: nephrotoxicity
- Hypoglycaemia: dextrose
- Hepatorenal syndrome: IV albumin + terlipressin
Causes of CLD
(common-3/other-5)
Common
- Chronic EtOH
- Chronic HCV (and HBV)
- NAFLD / NASH
Other
- Congenital: HH, Wilson’s, α1ATD, CF
- AI: AH, PBC, PSC
- Drugs: Methotrexate, amiodarone, isoniazid
- Neoplasm: HCC, mets
- Vasc: Budd-Chiari, RHF, constrict. pericarditis
4 important complications of CLD
- Liver failure / decompensation
- SBP
- Portal HTN: SAVE (splenomegaly/ascites/varices/encephalopathy)
- HCC
Child-Pugh Grading of cirrhosis
Evaluates prognosis in Cirrhosis
Graded A-C using severity of 5 factors
- Albumin
- Bilirubin
- Clotting
- Distension: ascites
- Encephalopathy
A.5-6 = [0] 1 yr Mortality
B.7-9 = [20] 1 yr Mortality
C.10-15 = [50] 1 yr Mortality
CLD Decompensation precipitants
(HEPATICS)
- Haemorrhage: e.g. varices
- Electrolytes: ↓K, ↓Na
- Poisons: diuretics, sedatives, anaesthetics
- Alcohol
- Tumour: HCC
- Infection: SBP, pneumonia, UTI, HDV
- Constipation (commonest cause)
- Sugar (glucose) ↓: e.g. low calorie diet
General Management of CLD decompensation
(5)
- HDU or ITU
- Rx any precipitant
- Good nutrition: e.g. via NGT c¯ high carbs
- Thiamine supplements
- Prophylactic PPIs vs. stress ulcers
Important monitoring in CLD decompensation
(3)
- Fluids: urinary and central venous catheters
- Bloods: daily FBC, U+E, LFT, INR
- Glucose: 1-4hrly + 10% dextrose IV 1L/12h
Management of (6) Complications of decompensated CLD
- Ascites: daily wt, fluid and Na restrict, diuretics, tap
- Coagulopathy: Vit K, FFP, platelets
- Encephalopathy: avoid sedatives, lactulose, rifaximin
- Sepsis / SBP: tazocin or cefotaxime
- Hypoglycaemia: dextrose
- Hepatorenal syndrome: IV albumin + terlipressin
PAthophysiology of encephalopathy (CLD)
↓ hepatic metabolic function -> Diversion of toxins from liver directly into systemic system. -> Ammonia accumulates and pass to brain where
astrocytes clear it causing glutamate → glutamine -> ↑ glutamine → osmotic imbalance → cerebral oedema
Presentation of encephalopathy
(5)
- Asterixis, Ataxia
- Confusion
- Dysarthria
- Constructional apraxia
- Seizures
Single key invesigation in encephalopathy (CLD)
Plasma NH4 (raised!)
Teatement of encephalopathy
- Nurse in well lit, calm environment
- Correct any precipitants
- Avoid sedatives
- Lactulose
- ↓ nitrogen-forming bowel bacteria
- 2-4 soft stools/d
- Rifaximin PO: kill intestinal microflora
Hepatorenal syndrome
pathophysiology
(and classification)
Renal failure in pts. c¯ advanced CLF
Pathophysiology: “Underfill theory”
Cirrhosis → splanchnic arterial vasodilatation → effective
circulatory volume → RAS activation → renal arterial
vasoconstriction. Persistent underfilling of renal circulation → failure
- *Type 1:** rapidly progressive deterioration (survival <2wks)
- *Type 2**: steady deterioration (survival ~6mo)
Treatment of hepatorenal syndrome
- IV albumin + terlipressin
- Haemodialysis as supportive Rx
- Liver Tx is Rx of choice
SBP
Presenation
Pt. c¯ ascites and peritonitic abdomen
Complicated by hepatorenal syn. in 30%
SBP: Common organisms
Common organisms: E. coli, Klebsiella, Streps
SBP: 1 key investigation
ascites PMN >250mm3 + MC+S
SBP management
taxocin
or
cefuroxime
until sensitivities known
prophylaxis: high recurrence therefore long term cipro given
Poor prognosis in CLD (4 factors)
Worsening encephalopathy
↑ age
↓ albumin
↑ INR
Ascites
examination
inspection: cause
abdo
completion
sig negatives
-
Peripheral inspection: Cause
- Signs of CLD
- CCF: ↑ JVP, bibasal creps, peripheral oedema
- Nephrotic: periorbital oedema
- Budd Chiari: abdo pain, hepatomegaly, jaundice
-
Abdomen
- Shifting dullness
- Portal HTN: splenomegaly
-
Completion
- CVS and Resp for CCF
- Urine dip: proteinuria in nephrotic syndrome
-
Significant Negatives
- CLD
- Acute liver failure / decompensation
- Cause: ↑ JVP, periorbital oedema
Causes of ascites
3: common
‘SAAG’
Commonest
- Cirrhosis
- CCF
- Carcinomatosis
Serum Ascites Albumin Gradient (SAAG) = Se albumin – Ascites Albumin
SAAG ≥1.1g/dL = Portal HTN (97% accuracy) (transudate)
- Cirrhosis in 80%
SAAG <1.1g/dL (exudate)
- Neoplasia: e.g. peritoneal mets or ovarian Ca
- Inflammation: pancreatitis
- Nephrotic syndrome
- Infection: TB peritonitis
Portal HTN Causes
pre/hep/post
Portal pressure >10mmHg (norm 5-10): 80% cirrhosis in UK
Pre-hepatic
- Portal vein thrombosis
- PV, ET (polycythemia vera (PV), essential thrombocythemia (ET))
- PNH
- Nephrotic syndrome
Hepatic
- Cirrhosis
Post-hepatic
- Cardiac: RHF, TR, constrictive pericarditis
- Budd-Chiari (hepatic vein thrombosis)
History Qs in ascites
- SBP: fever, abdo pain
- Cause
- Liver disease
- Cardiac failure, MI
Key investigations in ascites
Bedside/bloods/special/imaging
Bedside
- Urine: dip ± MC+S
- Exclude nephrotic syn.
- ? UTI
Bloods
- FBC
- U+E
- LFTs: esp. albumin
- INR
- Glucose
- Liver screen
Ascitic tap
- Chemistry
- Cytology: malignancy, PMN (>250/mm3 = SBP)
- Bacteriology: MC+S, Ziehl-Neelson Stain
- SAAG
US + PV duplex
- Liver size and texture
- Focal lesions
- Ascites
- Portal vein flow
Treatment of ascites
(general/diurectic/therapeutic paracentesis)
General
- EtOH abstinence
- Daily wts: aim for ≤0.5kg/d reduction
- Fluid restrict: <1.5L/d
- Low Na diet: 40-100mmol/d
Diuretics
- Spironolactone
- Add frusemide if response poor
Therapeutic Paracentesis
- Temporary insertion of pig-tail drain or Bonnano catheter
- Indications
- Respiratory compromise
- Pain / discomfort
- Renal impairment
- Risks
- Severe hypovolaemia: replenish albumin
- SBP
Treatment of refractory ascites
TIPSS
Transplant
Treatment/prophylaxis of SBP
- *Rx**: Tazocin or cefotaxime until sensitivities known
- *Prophylaxis**: high recurrence -> cipro long-term
Medical jaundice
- examination (cause)*
- Abdo*
- completetion*
- sig negatives*
Cause
- CLD
- Pancreatic Ca: cachexia, Virchow’s node
- Haemolysis: pallor
Abdomen
- Excoriations and pruritus
- Splenomegaly
- Hepatomegaly
- Palpable gallbladder: Ca head of pancreas
Completion
- Urine dip: look for BR, urobilinogen and Hb
Significant Negatives
- Acute liver failure / decompensation
- CLD
- Organomegaly
Differential for medical jaundic
(CLD/splenomeg/hepatomeg/none)
- CLD: EtOH, viral, NAFLD
-
Splenomegaly
- Haemolysis
- CLD ( → portal HTN)
- Viral hepatitis: e.g. EBV
-
Hepatomegaly
- Hepatitis
- CLD
-
No CLD or organomegaly
- Biliary obstruction
- Haemolysis
- Drugs: fluclox, OCP
- Gilberts
Liver transplant
Examination: peripheal general/immunosupp
abdo
sig negatives
Peripheral Inspection
-
General
- Evidence of CLD
- Pigmentation: HH
- Tattoos and needle marks: Hep B/C
-
Immunosuppressant Stigmata
- Cushingoid
- Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM
- Gingival hypertrophy: ciclosporin
Abdomen
- Mercedes-Benz scar
Significant Negatives
- Evidence of CLD or cause for Tx
- Evidence of immunosuppression
- Absence of features of liver failure = working Tx
Differential for Mercedes Benz Scar
-
Hepatobiliary surgery
- Liver transplant
- Segmental resection
- Whipples’: pancreaticoduodenectomy
History for liver transplant patient
causes/Tx/current/DHx
-
Cause
- EtOH
- Sexual Hx, IVDU, transfusions
- FH
- Other AI disease: e.g. DM, thyroid
- DH
-
Transplant
- adaveric or live segmental
- Any complications
-
Current health
- Acute rejection: fever, graft pain
- Immunosuppression
- Infection: e.g. CMV pneumonitis
- Skin Ca
- DH
Investigations for liver tranplant
bloods/other
Bloods
- FBC: infection
- U+E: ciclosporin can → renal impairment
- LFTs: assess graft function
- Clotting
- Fasting glucose: tacrolimus and steroids → DM
- Drug levels: ciclosporin, tacrolimus
Other
- Liver biopsy: if rejection suspected
Top causes for liver tranplatnt (3)
- Cirrhosis
- Acute liver failure
- Hep A, B
- Paracetamol overdose
- Malignancy
Success of liver transplant
80% 1 year survival
70% 5 year survival
Liver transplant immunosuppression regime
Tacrolimus/ciclosporin
azathioprine
prednisolone (+/- withrawal @3mo)
Hepatomegaly
- Examination:*
- peripheral: causes*
- abdo*
- completion*
- sig negatives*
- *Peripheral Inspection**
- Cause*
- CLD
- EtOH: palmar erythema, Dupuytren’s
- HH: skin discolouration
- Ca: cachexia
- CCF: ↑ JVP, bibasal creps, ascites, peripheral oedema
- Haematological: pallor, bruising, purpura, LNs
Abdomen
- Hepatomegaly
- Define fingerbreadths below costal margin at which liver edge palpable.
- Moves inferiorly on inspiration
- Can’t get above it
- Dull PN
- Features to note
- Edge: smooth, craggy, nodular
- Tenderness
- Pulsatile
- Percuss above and below to confirm enlargement
- Auscultate for liver bruit
- HCC
- Define fingerbreadths below costal margin at which liver edge palpable.
- Other
- Splenomegaly
- Inguinal nodes
- Ascites
Completion
- CVS and Resp: CCF
Significant Negatives
- Splenomegaly
- Acute liver failure / decompensation
- Cause: CLD, ↑JVP, pallor, bruising, LNs
Hepatomegalu
common causes (3)
Other causes (MACHO)
Common Causes
- Hepatitis: EtOH, viral, NAFLD
- CLD
- Congestion 2O to cardiac failure
Other Causes: MACHO
- Malignancy: 2O
- Anatomical: Riedel’s lobe, hyperexpanded chest
- Congestion: TR, Budd Chiari
- Haem: leukaemia, lymphoma, myeloproliferative, SCD
- Other: sarcoidosis, amyloidosis, Gaucher’s, ADPKD
Key history Qs
Hepatomegaly (3)
- Hepatitis / CLD: EtOH, viral exposure, FH
- Cardiac: dyspnoea, PND, previous MI, rheumatic fever
- Haem: tiredness, bruising, infections, bone pain
Hepatomegaly investigations
bedide/bloods/imaging/histology
Urine dip
- BR, urobilinogen
- Proteinuria: amyloid
Bloods
- FBC
- ↓Hb: malignancy, chronic disease
- Lymphocytosis: hepatitis viruses, EBV (atypical)
- U+E: CCF → renal impairment
- LFT
- Clotting
- Liver screen
Imaging
- Abdo US + PV and hepatic duplex
- Liver size and texture
- Focal lesions
- Ascites
- Portal vein flow
- Hepatic veins: thrombosis
- CT: e.g. for tumour
- MRI: good quality images of liver parenchyma
Liver Biopsy
- Check clotting first
- Nodular Pattern
- Micronodular: EtOH, HH, Wilson’s
- Macronodular: viral
- Iron: Pearl’s stain
- Copper: Rhodamine stain
- α1ATD: PAS stain (α1AT globules accumulate in liver)
- Amyloid: apple-green birefringence c¯ Congo Red
- Granulomata: PBC
Causes of hepatomegaly
(6)
- EtOH: abstinence + support
- Viral: supportive or anti-viral therapy
- HH: venesection ± desferrioxamine
- Wilson’s: penicillamine
- CCF: ACEi, β-B and diuretics
- Haematological: monitoring or chemo
Splenomegaly
Examination
Peripheral: cause
abdo:inspect/palpate
completion
sig negatives
Peripheral Inspection: Cause
- Haematological: pallor, bruising, purpura, LNs, cachexia
- Cervical, axilla, inguinal
- Portal HTN: CLD signs
- IE: splinter’s, clubbing
- Felty’s Syndrome: rheumatoid hands
- *Abdomen**
- Inspection*:Asymmetry
- Palpation*
- Splenomegaly
- Can’t get above it
- Moves inferiorly toward RIF on respiration
- Notch
- Dull PN
- Not ballotable
- Size: big or small?
- Hepatomegaly?
- Inguinal nodes?
Completion
- Cardio and Resp exam: IE and sarcoid
- Urine dip: haematuria (IE), proteinuria (amyloid)
Significant Negatives
- Hepatomegaly
- Haem: pallor, bruising, LNs
- CLD
- IE: splinters, clubbing
- RA hands: Felty’s Syndrome
(isolated) Big spleen: limitted differential (4 categorieS)
- Myeloproliferative: CML, MF
- Lymphoproliferative: CLL, lymphoma
- Infiltrative: amyloidosis, Gaucher’s
- Developing world: malaria, visceral leishmaniasis
Small spleen (common/other)
Common
- Haem: myelo- / lympho-prolif disorders, haemolysis
- Portal HTN: mostly 2O to cirrhosis
- Infection: EBV
Other
- Infection: herpes viruses, hepatitis virus, IE, malaria
- Inflammation: RA, SLE, Sjogren’s
- Rare: sarcoidosis, amyloidosis, Gaucher’s, CVID
Hepatosplenomegaly:
same differentials as isolated splenomegaly (except inflammatory)
causes of MASSIVE splenomegaly
Causes of Massive Splenomegaly: >20cm
- CML
- Myelofibrosis
- Malaria
- LeishManiasis
- Gaucher’s (AR, glucocerebrosidase deficiency)
History Qs in splenomegaly (4)
- Haem: tiredness, bruising, infections, bone pain
- CLD: EtOH, viral exposure, FH
- Infections: fever, sore throat, jaundice, foreign travel
- Inflammation: arthritis
Haematological Ix in splenomegaly
splenomegaly= haematological + infective + liver Ix
-
FBC
- CML: ↑↑↑WBC – PMN, basophils, myelocytes
- MF: pancytopenia
- CLL: lymphocytosis
- Haemolysis: ↓ Hb, ↑MCV, ↑RDW
-
Film
- MF: leukoerythroblastic c¯ teardrop poikiolcytes
- CLL: smear cells
- Haemolysis: spherocytes, reticulocytosis
-
Other Bloods
- DAT
- U+E and urate: ↑ malignancy → uropathy
-
Imaging
- Abdo US
- CT chest and abdomen
- PET scan
-
Histology / Cytology
- LN biopsy
- BM aspirate or trephine biopsy (MF)
-
Genetic Analysis
- CML: Ph Chr, t(9:22)
- MF: Jak2+ in 50%
Infective Ix in splenomegaly
splenomegaly= haematological + infective + liver Ix
-
Urine Dip
- Haematuria: IE
-
Bloods
- FBC: lymphocytosis (may be atypical in EBV)
- U+E: renal impairment in IE
- Thick and thin films
-
Imaging
- Abdo US
- Echo: IE
Liver Ix in splenomegaly
splenomegaly= haematological + infective + liver Ix
-
Bloods
- FBC
- LFT
- Clotting
- Liver screen
-
Imaging
- Abdo US + PV duplex
Myloproliferative Disorders
CML
- symptoms*
- genetics*
CML
Clonal proliferation of myeloid cells
15% of leukaemia
Symptoms
- Hypermetabolism: wt. loss, fever, night sweats, lethargy
- Massive HSM → abdo discomfort
- Bruising / bleeding (platelet dysfunction)
- Gout
- Hyperviscosity
Philadelphia Chromosome
- Reciprocal translocation: t(9;22)
-
Formation of BCR-ABL fusion gene
- Constitutive tyrosine kinase activity
- Present in >80% of CML
- Discovered by Nowell and Hungerford in 1960
CML
Investigations
- ↑↑WBC
- PMN and basophils
- Myelocytes
- ± ↓Hb and ↓plat (accelerated or blast phase)
- ↑urate
- BM cytogenetic analysis: Ph+ve
CML
management
-
Imatinib: tyrosine kinase inhibitor
- → >90% haematological response
- 80% 5ys
- Allogeneic SCT
- Indicated if blast crisis or TK-refractory
Primary myelofibrosis
symptoms (/presentation)
Clonal proliferation of megakaryocytes → ↑ PDGF →Myelofibrosis
Extramedullary haematopoiesis: liver and spleen
Symptoms
- Elderly
- Massive HSM
- Hypermetabolism: wt. loss, fever, night sweats
- BM failure: anaemia, infections, bleeding
Investigations of myelofibrosis
- Film: leukoerythroblastic c¯ teardrop poikilocytes
- Cytopenias
- BM: dry tap (need trephine biopsy)
- 50% JAK2+ve
Treatment of primary myelofibrosis
- Supportive: blood products
- Splenectomy
- Allogeneic BMT may be curative in younger pts.
Prognosis of myelofibrosis
5 yr median survival
Anatomy of the spleen
Intraperitoneal structure lying in the LUQ
Measures 1x3x5 inches
Weighs ~7oz
Lies anterior to ribs 9-11