PACES - Abdo Flashcards
Hypoalbuminaemia
Chronic liver disease
Koilonychia
Iron deficiency
Palmar Erythema
Chronic Liver Disease
Pregnancy
Hypertension
AV fistula
Indication of dialysis
Kayser Fleischer Rings
Wilson’s Disease
Angular Cheilitis
Severe IDA
Atrophic Glossitis
IDA
What is Troisier’s Sign
Node in left supraclavicular fossa (Virchow’s Node)
Gastric Cancer
Breast Cancer
Any other Abdominal Cancer
Spider Naevus
Fill from centre, caused by chronic liver disease (if more than 5)
Ileostomy
Spouted, typically RIF
Colostomy
Flush with skin, typically LIF
Caput Medusae
Cirrhosis
What can cause ascites?
Cirrhosis
Cancer
Heart Failure
Rarely Tb
How is jaundice classified?
Pre-Hepatic (Haemolysis, SCA, Spherocytosis, G6PD def, Malaria, Drug reactions, transfusion reactions)
Hepatic - Conjugated (Viral, Malignancy, Cirrhosis, Drugs) Unconjugated (Gilbert’s, Crigler-Najar)
Post-Hepatic (Gallstones, Biliary tree compression eg pancreatic cancer, PBC, PSC
Which 3 blood tests examine synthetic liver function?
Clotting (PT)
Platelets
Albumin
List some extra-intestinal features of crohn’s
Enteric Arthritis
Uveitis
Erythema Nodosum
Pyoderma Gangrenosum
Clubbing
How is Crohn’s managed?
A-E if acute
Bloods - FBC, CRP, ESR etc
Cultures - Blood and Stool
Small bowel follow through (Barium enema)
CT/MRI
Colonoscopy with Biopsy
Aid with nutritional and occupational support
How is Crohn’s managed?
Supportive management = fluids, analgesia, thromboprophylaxis
Steroids, Anti-TNFS, Aminosalicylates
Surgery
What are the main complications of IBD?
Toxic Megacolon
Strictures and obstruction
Cancer
Nutritional Deficiencies
What are the most common cause of hepatomegaly in the UK?
Alcohol
Cancer (mets then HCC)
Congestive Cardiac Failure
List a few differentials for hepatomegaly
Infection 0 Hepatitis, malaria, EBV, CMV, abscess
Cirrhosis, NAFLD,
Tumours
Amyloidosis, Sarcoidosis
Drugs
metabolic - haemochromatosis, wilson’s, porphyrias
Biliary, PBC, PSC, Onstruction
Congestive - CCF
budd- chiari
How would you differentiate between a kidney and splenomegaly on examination?
Spleen has a medial notch, kidney doesn’t
You can’t get above the spleen (ribs overly it)
The spleen moves towards RIF with inspiration, the kidney moves posterior only (if at all)
The spleen is not ballotable like the kidney
What can cause massive splenomegaly?
Myelofibrosis
CML
Malaria
VIsceral liesmaniasis
What can cause moderate splenomegaly?
Other myeloproliferative diseases (note CML and myelofibrosis can cause massive splenomegaly)
Portal hypertension
Thalassaemia
Glycogen storage disorders
What can cause mild splenomegaly?
Polycythaemia
Haemolytic anaemias
Infection
Infiltration
Connnective tissue diseases
What are the haematological causes of hepatosplenomegaly?
Leukaemias (AML, CML, ALL, CLL)
Lymphomas
Myelofibrosis
Myeloproliferative disease
Essential thrombocytopenia, polycythaemia, primary myelofibrosis, CML
Haemolytic anaemias
Hb disorders: Thalassaemia, sickle cell disease (eventually leads to splenic atrophy)
Red cell structure: Spherocytosis/elliptocytosis
Enzyme: G6PD deficiency, pyruvate kinase deficiency
What are the most common causes of cirrhosis in the UK?
Alcohol
Viral
NAFLD
Autoimmune (PBC, PSC, AIH)
Genetic (WIlson’s, HH)
Drugs (Isoniazid, Methotrexate, Amiodarone)
Vascular (Budd-Chiari)
Idiopathic
What are the complications of cirrhosis?
Liver Failure
Ascites
Portal Hypertension
Jaundice
HCC
How do you manage Cirrhosis?
Slow disease (Antiretrovirals, immunosuppression)
Prevent damage (Stop drinking, vaccinate against Hep B/C)
Screen for complications (USS and AFP, 6 monthly)
ABx
Liver transplant
Why do people get oedema in liver disease?
Low albumin due to poor synthetic function
Stimulated RAAS = fluid retention
What are the signs of a patient having undergone renal replacement therapy?
AV Fistula
Scars from catheter sites
Which drugs are used in suppressing the immune response following renal transplant?
Ciclosporin
Steroids
Which clues might indicate the aetiology behind the disease leading to a patient’s need for a renal transplant?
Unilateral/bilateral palpable kidneys (PKD)
What are the indications for renal transplant?
All with end stage renal failure (GFR <15)
Those with stage 4 CKD and progressive disease
What are the key contraindications for renal transplant?
Untreated malignancy
Untreated HIV
Any condition with life expectancy of <2 years
malignant melanoma
What might cause the need for a kidney transplant?
HTN
DM
Glomerulonephritis
PKD
Which symptoms might indicate a failing graft?
Tenderness, fever, fluid retention, abdo pain, oliguria
Which investigations must be carried out prior to renal transplant?
Renal screen
Routine Bloods
Viral Serologies
G&S Cross Match
ECG
Echo
PFTs
CXR (immunosuppressants can reactivate TB)
How are patients with kidney grafts routinely managed?
Reviewed at specialist centre
Regular Bloods
BP/CVS risk monitored
Assessment for graft function, drug side effects (check gums for gum hypertrophy if on ciclosporin)
Annual Flu Vaccine
Dip urine
Incision and indication?
Kocher Incision
Biliary Surgery
Hepatic Surgery (needs wider incision if transplant)
Upper Midline Laparotomy
Nissen’s Fundoplication
Upper GI Surgery
Realistically any major abdo surgery, especially emergency repairs of AAA, hartmann’s procedure etc
Number 3, couldnt find a real pic sorry
Transverse Upper Abdominal Incision
Repair of congenital diaphragmatic hernia
Splenic Surgery
Ramstedt’s Pyloromyotomy
Pyloric Stenosis mx
Gridiron scar at mcburney’s point
Mcburney’s Point = Junction of distal third and proximal two thirds of the line between the umbilicus and the ASIS
Umbilical Scar
Hernia repair
Gastrochisis Repair
Exomphalos
Laparoscopic port scars
Drian Sites
Inguinal hernia in man with midline laparotomy scar
Markings for hockey stick incision (likely renal transplant)
Scars indicating previous laparoscopy
Pfannenstiel Scar
C-Section
Gynae surgery
Rooftop scar
Hepatobiliary Surgery (Liver transplant, whipple’s procedure, liver resection)
Gastric Surgery
Nephrectomy
RCC
PKD
What are the main complications of abdominal surgery?
Immediate - Anaesthetics (oropharyngeal trauma, malignant hyperthermia), Surgical trauma to local structures (AVN), Haemorrhage
Early - VTE, atelectasis, urinary retention
Late - Scarring, Neuropathy, Graft failure
Infected midline laparotomy
Which operations form an ileostomy?
End Ileostomy - Panproctocolectomy (Permanent), Total Colectomy - UC, FAP
Loop Ilesotomy - Anterior resection for colon cancer/Crohn’s
Which operations form a colostomy?
End Colostomy - AP resection, Hartmann’s (Diverticulitis, Colon Cancer)
Loop Colostomy - Inoperable bowel cancer which is obstructing
How do you present a stoma?
Where?
Spouted?
How many lumens?
Bag contents?
Signs of complications?
Associated scars?
I would like to assess more closely for complications, digitate the hernia and assess the perineum.
Differentials for hernia
What are the complications of stomas?
Immediate - anaesthetic risks, haemorrhage, perforation
Early - Ischaemia, high output, retraction
Late - Hernia, prolapse, dermatitis
How would you carry out an abdominal exam?
Inspect from edge
Inspect Hands, Pulse, Clubbing, Asterixis, Look specifically for AV fistula
Inspect Face, eyes, mouth
Inspect abdomen - look for scars and stoma
Palpate soft and deep
Offer murphy’s sign in patient with suspected biliary pathology
Palpate for liver and spleen
Palpate AAA
Percuss for liver and spleen
Percuss for Bladder
Percuss for Ascites (Shifting dullness)
Listen for bowel sounds
Listen for Aortic/Renal Bruits
Offer to assess for hernias and genitals
Conclude.
How would you present a normal abdominal exam?
I performed an abdominal exam on X
From the edge of the bed the patient looked well at rest lying at 45 degrees, and there were no paraphernalia of abdominal disease around the bed.
On inspection of the hands, CAP refill was normal, pulse was 60 and regular and there were no signs of abdominal pathology, including no AV fistulae.
Inspection of the face displayed no signs of abdominal pathology.
On inspection of the abdomen, no scars or stomas were noted.
No signs of hepatosplenomegaly were noted on palpation and percussion. There was no shifting dullness.
No pulsatile mass indicative of a AAA was identified.
Bowel sounds were present and normal.
To conclude etc.
Extra parts to offer at end of abdo exam
For completeness, I would like to take a comprehensive history and perform examinations of the Cardiovascular and respiratory systems.
Which investigations are commonly offered in Abdo stations?
Bedside: Urine dipstick
Labs: Full liver screen including LFTs, FBC, Clotting and GGT
Autoantibody screen including ANA, Anti-mitochondrial, Anti-smooth muscle
U&Es, Urine dip
Imaging: MRCP, USS, AXR
Other: Biopsy, Ascitic tap, MRCP/ERCP,
Mercedes Benz Scar
Liver Transplant
Whipple’s Procedure
What is Whipple’s Procedure?
Pancreaticoduodenectomy
How would you examine an inguinal hernia?
Gloves
Pt standing, inspect
Palpate from Pt’s side. Find midpoint of inguinal ligament. Ask pt to cough. Feel for previous mesh
Auscultate for bowel sounds. No = likely omentum
Ask pt to reduce. Attempt to block deep ring
Repeat with patient lying down.
What might cause hepatomegaly?
4 Cs
3 Is
HVO
Cancer, Cirrhosis, Chronic Liver, CCF
Infection, Immune, Infiltrative (amyloidosis)
Haem: Leukaemia/Lymphoma
Vascular (Budd-Chiari)
Other: COPD (chest expansion)
What might cause Hyposplenism?
Coeliac
IBD
Splenectomy
Operation?
Splenectomy?
What can cause enlarged kidneys?
Bilateral - PKD, Hydronephrosis, Amyloidosis, normal if slim
Unilateral - RCC, Cyst, Hydronephrosis
Investigate ?PKD?
Urine dip
FBC/U&Es/Bone Profile
Abdo USS for cysts
Echo for MV prolapse
CT/MRI for berry aneurysms
What can cause CKD?
DM
HTN
Renal artery stenosis
Glomerulonephritis
SLE
Amyloidosis
What are the main complications of dialysis?
CVD
Malnutrition
Infection
What can cause Ascites?
3Cs
Cirrhosis
CCF
Carcinomatosis
How would you manage ascites?
Fluid restrict
Low Na
Spironolactone
Therapeutic Paracentesis
How would you manage chronic liver disease?
Conservative - Dietician, toxin cessation, vaccines
Medical - Chloestyramine for pruritus, laxatives, ABX if risk of SBP
Surgical - TIPS, Liver transplant
Typical IBD presentation?
Hands - Clubbing, Leukonychia
Eyes - Pale, episcleritis
Abdo - Laparotomy scars, stoma, tender on palpation
Signs to look out for in Chronic liver disease?
Hands - Palmar erythema, spider naevi, dupuytren’s contracture
Signs of decompensation (Asterixis, Bruising, altered consciousness)
Hepatomegaly, Ascites, Prominent abdo veins if portal htn
