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The abdomen Flashcards

1
Q

What is the normal liver span?

A

About 12.5cm

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2
Q

What is the differential for massive hepatomegaly?

A

Metastases
Alcoholic liver disease with fatty infiltration
Myeloproliferative disease
Right heart failure
Hepatocellular carcinoma

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3
Q

What is the differential for moderate hepatomegaly?

A

The massive causes earlier in their course (mets, AFLD, myeloproliferative disease, right heart failure, HCC) AND
Metabolism associated fatty liver disease
Other haematological disorders (CML, lymphoma)
Haemochromatosis

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4
Q

What is the differential for mild hepatomegaly?

A

Early course of the massive and moderate hepatomegaly causes.
Hepatitis
Cirrhosis
Biliary obstruction
Graulomatous disorders
Hydatid disease
Amyloidosis and other infiltrative diseases
HIV
Ischaemia

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5
Q

What is the differential for a firm and irregular liver?

A

Cirrhosis
Metastatic disease
Cysts (ADPKD for e.g.)
Granulomas
Hydatid disease
Amyloid
Lipoidoses

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6
Q

What is the differnetial list for a tender liver?

A

Hepatitis
Rapid liver enlargement (e.g. right heart failure, budd-chiari syndrome)
HCC

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7
Q

What is the differential for a pulsatile liver?

A

Tricuspid regurgitation
HCC
Vascular abnormalities affecting the liver

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8
Q

What are the differentials for bilateral renal masses?

A

Polycycstic kidneys
Hydronephrosis or pyonephrosis
Hypernephroma (bilateral RCC)
Acute renal vein thrombosis
Amyloid, lymphoma or other infiltrative disease
Acromegaly
In thin patients, early diabetic nephropathy leads to mild enlargement

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9
Q

What are the possible causes of unilateral renal masses?

A

Renal cell carcinoma
Hydronephrosis or pyonephrosis
Polycystic kidneys with assymmetrical enlargement
Acute renal vein thrombosis
Solitary kidney

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10
Q

What’s a differential for right iliac fossa masses?

A

Appendiceal abscess
Carcinoma of the caecum
Crohn’s disease
Pelvic kidney
OVarian tumour or cyst
Carcinoid tumour
Amoebiasis
Psoas abscess
Ileocaecal TB

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11
Q

What’s a differential for right iliac fossa masses?

A

Appendiceal abscess
Carcinoma of the caecum
Crohn’s disease
Pelvic kidney
OVarian tumour or cyst
Carcinoid tumour
Amoebiasis
Psoas abscess
Ileocaecal TB

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12
Q

What are the possible causes of left iliac fossa masses?

A

Faeces
Carcinoma of sigmoid or descending colon
Diverticular disease
Ovarian tumour or cyst
Psoas abscess

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13
Q

What are the possible causes of upper abdominal masses?

A

Retroperitoneal lymphadenopathy
Abdominal aortic aneurysms
Carcinoma of the stomach
Pancreatic pseudocyst or tumour
Carcinoma of transverse colon

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14
Q

What are the possible causes of massive splenomegaly?

A

Chronic myeloid leukaemia
Myelofibrosis
Primary lymphoma of spleen, heairy cell leukaemia, malaria, kal-azar

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15
Q

What are the causes of moderate splenomegaly?

A

Massive causes early in their courses
Portal hypertension
Lymphoma
Leukaemia
Thalassaeia
Storage diseases (e.g. Gaucher’s disease)

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16
Q

What are the possible causes of mild splenomegaly?

A

The causes of massive and moderate splenomegaly, early in their course
Polycythaemia vera
Essential thrombocythaemia
Haemolytic anaemia
Megaloblastic anaemi9a
Infection (infectious mononucleosis, hepatitis, or infective endocarditis)
Connective tissue disease or vasculitis (RA, SLE, PAN)
Infiltration (amyloidosism, sarcoidosis)

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17
Q

What are the distinguising features on exam of a spleen?

A

No palpable upper border
Notch
Moves with respiration
No resonance over splenic mass
Not ballotable
Friction rub over the spleen on auscultation

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18
Q

Where should you ausculatate on the abdomen?

A

Liver, spleen and renal area for bruits and venous hums. Then the gut for ?bowel sounds

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19
Q

What are the most common causes of a systolic bruit heard over the liver?

A

HCC
Acute alcoholic hepatitis

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20
Q

What causes a friction rub over the liver?

A

Tumour
Recent iver biopsy
Infarction
Gonococcal perihepatitis

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21
Q

What causes a friction rub over the spleen?

A

Infarction

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22
Q

What are the chest wall features of chronic liver disease?

A

In men - gynaecomastia, hair loss, spider naevi
In women - breast atrophy

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23
Q

Why do a cardiac exam if cirrhosis is suspected?

A

Restrictive pericarditis leads to cirrhosis

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24
Q

Why examine the lungs if you find ascites on an abdominal exam?

A

For pleural effusion

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25
Why look at the eyes when suspecting chronic liver disease?
Kayser-Fleischer rings Jaundice Xanthelasma (common in advanced primary biliary cholangitis) Anaemia
26
Other than the eyes, what should be looked at on the face of patients suspected to have chronic liver disease?
?Parotid enlargement (alcoholis) ?Angular stomatitis ?Atrophic glossitis ?Fetor hepaticus (ammonia)
27
What should be looked for in the arms of patients suspected of having chronic liver disease?
Spider naevi Hepatic flap Leukonychia - Terry's nails are characterised by 2/3 or more leukonychia nails. Typical of cirrhosis. Palmar erythema (increased eostrogen) Dupuytren's contractures (alcohol use or trauma) Arthopathy - ?haemochromatosis
28
What are the most common neurological disease findings associated with alcoholism?
Peripheral neuropathy Proximal myopathy Cerebellar syndrome Wernicke's encephalopahy (which inlcudes bilateral VI nerve palsies) Korsakoff's psychosis
29
What should you ask to add onto the end of an abdominal exam when time runs out?
Rectal exam Testicular exam including hernia exam Urinalysis Temperature chart
30
If you suspect acute polycystic kidney disease, how should you proceed?
Blood pressure Urinalysis Look for evidence of anaemia (conjunctival pallor, palmar crease pallor) Look for evidence of polycythaemia (facial flushing) Ensure to feel for nodular liver border indicating liver cysts, and splenic cysts Look for third nerve palsy ?unruptured berry aneurysm Lower limbs ?oedema (should be included in any abdo exam Neck scars ?parathyroidectomy ?central venous cathetar Fistular?
31
If a nodular liver suspicious for malignancy is felt, how should you proceed?
Lymph node exam: axillar, cervical, supraclavicular, inguinal, epitrochlear Breast exam Thorax for signs of lung malignancy
32
What does a scar hear indicate?
Nephrectomy scar, likley due to autosomal dominant polycystic kidney disease or malignancy
33
What are cevron/mercades benz/rooftop scars used for?
Liver transplant, gasstrectomy, oesophagectomy, bilateral adrenalectomy, hepatic resections, pancreatic surgery, combined liver/kidney surgery.
34
What exam findings should be looked for it is suspected the patient is a transplant recipient?
Cushingoid Thin skin Striae Proximal myopathy Tremor (Cyc A/Tac/MMF) Gingival hyperplasia (cyc A) Arthraliga (mTOR) Acne vulgaris (which is just acne, mTOR) Lymphadenopathy (PTLD) Warts Skin cancers
35
How should assess kidney graft function if asked?
CBE for anaemia Renal function bloods Calcium and phosphate CXR for volume overload Bicarb and pH for acidosis Imaging if concern for calculi
36
What are the clinical findings for haemochromatosis?
Bronzing Arthopathy - esp degenerative arthritis of the MCP joints of the index and middle fingers Testicular atrophy (due to iron deposition in the pituatary gland) Dilated cardiomyopathy Glycosuria (resulting from diabetes mellitus)
37
What is Felty's syndreome?
Rheumatoid arthritis manifestation that includes arthopathy, splenomegaly and neutropoenia. Autoantibodies to histones and other components of neutrophil NETs cause neutrophil sequestration to the spleen - leading to neutropoenia and splenomegaly.
38
If haematological malignancy is suspected, what should be looked for in the mouth?
Ulcers, enlarged lymphatic tissue (tonsils and adenoids), atrophic glossitis, angular stomatitis, gum hypertrophy.
39
What is the differential for combined hepatosplenomegaly?
Chronic liver disease with portal hypertension Haematological disease (myeloproliferative disease, lymphoma, leukaemia, pernicious anaemia, sickle cell anaemia) Infection (viral hepatitis, mononucleosis) Infilitration (sarcoid/amyloidosis) Connective tissues disease (SLE) Acromegaly Thyrotoxicosis
40
What is the proceed if haematological malignancy is suspected from the abdominal exam?
Inguinal nodes Femoral chain Spring pelvis Hands and nails Epitrochlear nodes Sit up Go to back Head and neck nodes Press on spine and shoulders Come to front Axillary nodes Press sternum Ask to examine fundi
41
What are the differentials for lymphadenopathy?
Lymphoma Leukaemia Mets Infection Connective tissue disease Infilitrations Phenytoin (pseudolymphoma)
42
At what concentration of bilirubin is jaundice normally evident?
>40micromols/L (twice the ULN)
43
What is Zieve's syndrome?
Binge drinking syndrome - Coombs-negative haemolysis, cholestatic jaundice, transietn hyperlipidaemia. The mechanism is likely related to lipid accumulation in RBC membranes due to increased blood ethanol concentration.
44
What is the underlying deficiency that is likely associated with leukonychia?
Hypoalbuminaemia
45
Which way does blood flow into collatertal abdominal wall veins in portal hypertension?
Away from the umbilicus. Helpful to differentiate from IVC obstruction if you test a vein below the umbilicus - IVC obstruction will fill upwards fast, portal hypertension will flow downwards fast.
46
What does blood flow upwards when milking abdominal wall collateral vessels indicate?
Inferior vena cava obstruction
47
Where is a venous hum from portal hypertension best heard?
The epigastrium
48
What is Budd-Chiari syndrome?
Occlusion, regardless of the mechanis, of the liver outflow. Recall that liver outflow is via the right, middle and left hepatic veins into the inferior vena cava.
49
How might you detect Budd-Chiari syndrome clinically?
Absence of hepatojugular reflux
50
Differential diagnosis in cirrhosis?
Viral (B, C) Autoimmune (PBC, PSC, Autoimmune Hepatitis) Metabolic (MAFLD, Haemachromatosis, alpha 1 antitrypsin deficiency, Wilson's disease, CF) Grugs (MTX, isoniazid, amiodarone, phenytoin)
51
What are the consequences of portal hypertension?
Varicies Ascites Splenomegaly Thrombocytopoenia
52
What are the consequences of liver dysfunction?
Coagulopathy Encephaloptahy Jaundice Hypoalbuminaemia
53
What are the causes of decompensation of liver disease?
Infection SBP Hypokalaemia (reduces amonia clearance) GI bleeding Sedative HCC
54
What is primary biliary cholangitis (formerly primary biliary cirrhosis)?
Autoimmune disease targeting the interlobular bile duct. Natural history is the development of cirrhosis, however ursodeoxycholic acid has led to normal life expectancy.
55
What is the epidemiology of primary biliary cholangitis?
Typically woman between the age of 30 and 65
56
What are the typical exam findings in patients with primary biliary cholangitis?
Hyperpigmentation - melanin deposits (unclear mechanism) Xantholasma/xanthomata Xerosis Scratch marks from puritis Fungal infections of the feet or nails Jaundice is a very late findings
57
What are the classical laboratory findings in patients with primary biliary cholangitis?
Elevate ALP Positive AMA (antimitochondial antibodies) in almost all patients Positive ANA in about 70% of patients -- multiple nuclear dots pattern (ENA Sp100) -- rim-like membranous pattern (ENA gp210, nucleoporin p62 or lamin B receptor) -- sometimes SSA or DS-DNA abs Hyperlipidaemia Increased serum IgM
58
What are the other diseases associated with primary biliary cholangitis?
Sjogren's - most common Autoimmune thyroid disease Inflammatory arthropathies
59
What is the classic epidemiology of people with primary sclerosing cholangitis?
Mostly men in around the 40s.
60
What are the classic laboratory findings for patients with primary sclerosing cholangitis?
Atypical perineuclear ANCA (P-ANCA) positive Increased IgM (40-50%) Increased IgG (~30%) Raised ALP/GGT/Bilirubin Absent AMA
61
What is the most important disease association with primary sclerosing cholangitis?
Up to 90% of patients with PSC have ulcerative colitis. However, only 5% of patients with UC have PSC.
62
What are the most common causes of ascites?
Cirrhosis Malignancy Heart failure TB Pancreatitis
63
What investigations should be done if ascites is found?
Diagnostic abdominocentesis - alabumin and total protein for SAAG - PMN count for ?SBP - MCS - cytology ?malignancy Abdo US - hepatic vein and portal vein doppler - hepatomegaly character - ?splenomegaly Bloods - LFTs, coags, FBC (esp. platelets)
64
What is SAAG?
Serum ascites albumin gradient = Serum albumin - ascitic fluid albumin SA-AG > 11g/L suggests as a transudate SA-AG <11g/L suggests exudate
65
What are the hepatic manifestations of sickle cell disease?
Gall stone disease due to chronic haemolysis with pigment stones Sickle hepatic crisis - due to sickle thrombosis causing sinusoidal obstruction. Presents with right upper quadrant pain, jaundice, tender hepatomegaly. Intrahepatic cholestasis - due to cickle thrombosis in susoids, causing hepatocyte swelling and intrahepatic biliary obstruction. Associated liver diseases - iron overload due to transfusions, viral hepatitis from blood transfusions.
66
What is the most likely cause of massive splenomegaly in the absence hepatomegaly or lymphadenopathy or RA signs suggest?
Myeloproliferative disease (e.g. CML/myeloproliferative disease). With hepatomegaly suggests portal hypertension. With lymphadenopathy suggests lymphoproliferative disease. With RA suggests Felty's disease.
67
What's the cause of hepatomegaly in haematological malignancy?
Extramedullary haematopoiesis.
68
What is the classic gene mutation associated with chronic myeloid leukaemia?
BCR-ABL translocation (Philidelphia chromosome) in ~95% of cases.
69
How is haemochromatosis inherited?
HFE gene - autosomal recessive.
70
What type of heart failure to patients with haemochromotosis get?
Restrictive or dilated cardiomyopathy. Can see it on cMRI.
71
What needs to be treated in patients with primary biliary cholangitis?
Supplementation of fat soluble vitamins (ADEK) Treatment of associated osteoporosis Treatment of hypercholesterolaemia Treatment of liver disease with ursodeoxycholic acid Treatment of pruritis with cholestyramine, rifampicin or naltrexone. Treatment of fatigue Transplantation consideration
72
If a renal transplant is located, what should be commented on when describing graft function?
Mental status Asterixis Exrcoriation marks Tachypnoea Pericardial rub Pallor
73
Where will a tunnelled venous catheter be?
Subclavicular region - go into the subclavian vein
74
What is the ideal PTH in chronic kidney disease?
2-9x the ULN.
75
What are the indications for renal replacement therapy?
Pericarditis Pleuritis Volume overload refractory to diuretics Hypertension refractory antihypertensives Refractory hyperkalaemia Refractory acidosis Encephalopathy or decline in mental status due to uraemia Removal of toxins
76
What is the definition of nephrotic syndrome?
>3.5g proteinuria per 24hrs
77
What are the causes of nephrotic syndrome?
Minimal change disease Focal segmental glomerulosclerosis Membranous glomerulonephritis Membranoproliferative glomerulnephritis (myeloma, hep c or b, cryoglobulinaemia, SLE, Sjogren's, RA, C3G, DDD, post-infectious)
77
What are the causes of nephrotic syndrome?
Minimal change disease Focal segmental glomerulosclerosis Membranous glomerulonephritis Membranoproliferative glomerulnephritis (myeloma, hep c or b, cryoglobulinaemia, SLE, Sjogren's, RA, C3G, DDD, post-infectious)
78
What is the antibody associated with 80% or primary membraneous nephropathy cases?
Anti-M-type phospholipase A2 receptor.
79
What are the complications of nephrotic syndrome?
Oedema Hypertension Hypercholesterolaemia Thrombosis Infection
80
How is haemoglobin impacted in autosomal dominant polycystic kidney diseaes?
Early, the kidneys produce more erythropoeitin, and patients become polycythaemic At times, cysts can rupture, leading to blood loss and reudction in haemoglobin. At later stages, when renal function fails, EPO production reduces and patietns require darbapoeitin.
81
What percentage of patients with polycystic kidney disease also have hepatic cysts?
~70%
82
What are the subtypes of ADPKD?
ADPKD1 - 90% or cases - chromosome 16 - more severe. ADPKD2 - 10% of cases - chromosome 4 - less severe.
83
What does flink pain indicate in a patient with ADPKD?
Cyst torsion, haemorrhage or infection. Renal calculi
84
What needs to be considered when treating cyst infection?
Cyst penetration requires abx that a lipophilic. Fluroquinolones are a good choice.
85
What are the causes of right upper quadrant mass?
Liver Right kidney Riedel's lobe of liver (normal variant that is lateral to the gall bladder) Gall bladder (moves with respiration) Colon
86
What are the causes of a left upper quadrant mass?
Spleen Left kidney Colon Pancreas Stomach
87
What are the causes of a right lower quadrant mass?
Colon Small instestine Appendix Pelvic mass
88
What are the causes of a left lower quadrant mass?
Sigmoid colon - diverticular disease or lesion Pelvic mass
89
What are the autosomal dominant hereditary conditions that pre-dispose patiente to colorectal cancer?
Hereditary nonpolyposis colorectal cancer (aka HNPCC aka Lynch Syndrome) Familial adenomatous polyposis (FAP) Peutz-Jeghers Syndrome
90
What are the most common types of small bowel cancers?
Neuroendocrine tumour Lymphoma Adnenocarcinoma GIST

BPT Clinical Exam Prep (8 decks)

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