Short case - Gastroenterology

Question 1

Skin findings to look for

Answer 1

Pigmentation -Haemochromatosis, Addison’s disease
Freckle like spots on mouth, buccal mucosa fingers, toes - Peutz-Jeghers
Brown-black velvety elevations of epidermis on axillae and nape of neck - Acanthosis nigricans
Multiple small telangiectasia - Hereditary haemorrhagic telangiectasia
Petechiae
Scratch marks - bile cholestasis
Spider naevi
Campbell de Morgan spots

Question 2

Gastro exam - hands

Answer 2

Leukonychia - hypoalbuminaemia
Clubbing - cirrhosis
Palmar erythema - reddening of thenar and hypothenar eminences
Anaemia
Dupuytrens contracture

Question 3

Differentials for palmar erythema

Answer 3

Cirrhosis
Pregnancy
Thyrotoxicosis
Rheumatoid arthritis
polycythaemia
Chronic inflammatory states
Leukaemia

Question 4

Differentials for spider naevi

Answer 4

Campbell de Morgan spots (non blanching)
Venous stars
Telangiectasia

Question 5

Gastro - exam eyes

Answer 5

Anaemia
Scleral icterus
Kayser-Fleischer rings of Wilson's disease
Xanthelesma of Biliary cirrhosis
Iritis of IBD
Periorbital purpura of amyloidosis

Question 6

Gastro - mouth and face

Answer 6

Parotid enlargement 
Faetor hepaticus
Ligua nigra tongue
Geographical tongue
Leukoplakia
Glossitis
Gum hypertrophy
Angular stomatitis
Aphthous ulceration
Candidiasis

Question 7

Differentials for gum hypertrophy

Answer 7

Phenytoin
Cyclosporin
Pregnancy
Gingivitis
Leukaemia

Question 8

Differentials for pigmented lesions of mouth

Answer 8

Drugs - antimalarials, OCP - black/brown areas of tongue anywhere
Addison’s disease - blotches of dark brown pigment
Peutz-Jeghers
Malignant melanoma
Haemochromatosis -blue-grey pigmentation of hard palate
Lead, bismuth - lingula nigra

Question 9

Differentials for bilateral parotid enlargement

Answer 9

Alcohol associated parotitis
Severe dehydration
Malnutrition
Mumps
Sarcoidosis or lymphoma
Mikulicz syndrome - early sjogren's syndrome

Question 10

Differentials for unilateral parotid enlargement

Answer 10

Salivary calculus blockage

Parotid tumour/tumour infiltration

Question 11

General inspection of abdomen

Answer 11

Distension
Surgical scars
Gynaecomastia
Prominent veins
Caput medusa
Sister Joseph nodule
Cullen's sign - discolouration of umbilicus
Grey turner sign - skin discoloration at flanks
Striae
Movement of abdomen and liver

Question 12

Differentials for palpable liver

Answer 12

Hepatomegaly

Ptosis

Question 13

Differentials for liver ptosis

Answer 13

Obstructive airways disease
Subdiaphragmatic collection
Riedel’s lobe

Question 14

Differentials for massive hepatomegaly

Answer 14

Metastasis
Alcoholic liver disease
Myeloproliferative disease
Right heart failure
Hepatocellular cancer

Question 15

Differentials for mild hepatomegaly

Answer 15

Metastasis
Alcoholic liver disease
Myeloproliferative disease
Other haematological disease - chronic leukaemia, lymphoma
Right heart failure
Hepatocellular cancer
Fatty liver
Hepatitis
Biliary obstruction
Hydatid disease
Haemachromatosis
Amyloidosis
Granulomatous infiltration

Question 16

Differentials for tender liver

Answer 16

Hepatitis
Right heart failure
Hepatic vein thrombosis (Budd Chiari syndrome)
Hepatic abscess
Biliary obstruction/cholangitis

Question 17

Differentials for pulsatile liver

Answer 17

Tricuspid regurgitation
Hepatocellular cancer
Vascular abnormalities

Question 18

Courvoisier’s law

Answer 18

If the patient is jaundiced and gallbladder palpable, it is unlikely to be gallstones
Consider pancreatic or lower biliary tree obstruction

Question 19

Differentials for gallbladder enlargement with jaundice

Answer 19

Carcinoma of head of pancreas
Carcinoma of ampulla of Vater
In situ gallstone formation in the CBD
Mucocele of the gallbladder due to stone in Hartman’s pouch and CBD

Question 20

Differentials for gallbladder enlargement without jaundice

Answer 20

Acute cholecystitis
Mucocele or empyema of gall bladder
Carcinoma of gall bladder

Question 21

Causes of hepatosplenomegaly

Answer 21

Chronic liver disease with portal hypertension
Haematological disease -MPD, leukaemia/lymphoma
Infection- viral hepatitis, CMV, EBV
Infiltration - amyloid, sarcoid
Connective tissue diseae - SLE
Acromegaly
Thyrotoxicosis

Question 22

Causes of unilateral palpable kidney

Answer 22

Renal cell carcinoma
Hydronephrosis or pyonephrosis
Polycystic kidneys
Acute renal vein thrombosis
Acute pyelonephritis
Renal abscess
Single functioning kidney

Question 23

Causes of bilateral palpable kidney

Answer 23

Polycystic kidneys
Hydronephrosis or pyonephrosis bilaterally
Nephrotic syndrome, bilateral renal vein thrombosis
Acromegaly
Infiltrative disease - amyloid, lymphoma

Question 24

Most significant signs of ascites

Answer 24

1. fluid wave
2. Oedema
3. Shifting dullness

Question 25

High Serum Ascites to Albumin Gradient

Answer 25

``` Cirrhosis Alcoholic hepatitis Budd-Chiari syndrome or veno-occlusive disease Fulminant hepatic failure Congestive cardiac failure Myxodema ```

Question 26

Low Serum Ascites to albumin gradient

Answer 26

Peritoneal analysis Tuberculosis Pancreatitis Nephrotic Syndrome

Question 27

Cruveilhier-Baumgarten syndrome

Answer 27

Venous hum at the umbilicus due to dilated abdominal wall veins

Question 28

Causes of pre-sinusoidal portal hypertension

Answer 28

Portal vein compression (lymphoma etc) Intravascular clotting (PCV) Umbilcal vein phlebitis

Question 29

Causes of intrahepatic portal hypertension

Answer 29

Cirrhosis Sarcoid, lymphoma or leukaemic infiltrates Congenital hepatic fibrosis

Question 30

Causes of post-sinusoidal portal hypertension

Answer 30

Hepatic vein outflow obstruction/Budd chiari syndrome Venoocclusive disease (acute GVHD) CCF Constrictive pericarditis

Question 31

Causes of hepatic vein outflow obstruction

Answer 31

``` Myeloproliferative disease Cancer (kidney pancreas, liver) OCP Trauma Fibrous membrane Schistosomiasis Paroxysmal nocturnal dyspnoea ```

Question 32

Precipitants of encephalopathy

Answer 32

``` Hypokalaemia - diarrhoea, diuretics, vomiting Gastrointestinal bleeding Infection Constipation Acute liver cell decompensation Sedatives Metabolic disturbances Large protein load ```

Question 33

Signs of chronic liver disease in hands

Answer 33

``` Palmar erythema Leukonychia Asterixis Bruising Scratch marks clubbing ```

Question 34

Signs of chronic liver disease in face and chest

Answer 34

``` Jaundice, scleral icterus Fetor hepaticus Spider naevi Gynaecomastia Loss of body hair Bruising, scratch marks Pectoral muscle wasting ```

Question 35

Signs of chronic liver disease in abdomen

Answer 35

``` Ascites Hepatomegaly ascites Portal hypertension (splenomegaly, caput medusae, prominent abdominal veins) Testicular atrophy Oedema of legs muscle wasting Bruising and scratch marks ```

Question 36

Diagnosis of clinical cirrhosis

Answer 36

Two or more of: - Spider naevi - Palmar erythema - Splenomegaly or ascites - abdominal vein distension