1
Q
Referred pain
A
- pain arising from an internal organ but located at a different site : abdominal or chest wall, shoulder, jaw,
- ie Right Shoulder pain may be from acute cholelithiasis ( Gall bladder stones ), testicular pain may be from renal colic or appendicitis
2
Q
Grey Turner
A
- Massive non-traumatic ecchymosis ( bruising ) on abdomen , and flank from infiltration of extraperitoneal tissue
- Associated with hemorrhagic pancreatitis ,
- Retroperitoneal hematoma Also strangulated bowel
3
Q
Cullen’s
A
- Blue color at umbilicus secondary to hemoperitoneum
4
Q
Ileus : Inhibition of peristalsis
A
Causes :
- peritonitis
- mesenteric thrombosis
- enterocolic ulceration
- Total Obstruction
5
Q
Auscultation of abnormal bruits
A
- Listen over abdominal aorta : Bruit if aneurysm ( use Bell )
- Bruits over renal , iliac , femoral arteries
- Due to turbulent blood flow in a dilated , or constricted , or torturous vessel
- Renal : renal artery stenosis , heard as a systolic murmur like sound above and slightly to left of Umbilicus
6
Q
Abnormal liver
A
Hepatomegaly
- early Cirrhosis
- Hepatocellular Carcinoma
- Cholangiocarcinoma
- Lymphoma,
- Liver metastasis
- Adenoma,Hemangioma
- Abscess, Cysts ,
- Congestive Heart Failure
Tenderness
- Hepatitis
- Infection
- Inflammation
- Congestive heart failure
7
Q
Gall bladder and ducts
A
- May be tender if inflamed or calculi
- Enlarged: carcinoma of gall bladder
- Enlargement with jaundice : Cancer of head of pancreas
8
Q
Splenomegaly
A
- Infiltrative Diseases : • Lymphoma,
- Metastatic cancer,
- Amyliodosis,
- Gaucher’s disease ,
- Myeloproliferative diseases with extramedullary hematopoiesis
9
Q
Abnormal kidneys
A
- Costovertebral tenderness ( CVAT ) : place hand over area of kidney and strike your hand with your fist : tenderness is abnormal , due to infection , calculi
- Palpable kidney: Malignancy , Hydronephrosis, cysts
- Bilateral enlargement , palpable abdominally suggest polycystic kidney disease ( PCOD )
10
Q
Blood in stool
A
Lower GIT: Hematochezia -> Bright Red Blood per Rectum
Etiology ( Cause ) :
- Hemorrhoids ; on tissue , or wiping , on stool
- Colon tumors
- Diverticular disease
- Ulcerative colitis
Upper GI bleeding
- Melena ; Black Tarry stool
- May be malodorous from the blood
- Etiology : Upper GI Tract : Ulcers , Varices , Mallory Weiss Tears ( mucosal esophageal tear after vomiting ) , Duodenal erosions , Tumor, Vascula
11
Q
Radiation of ab pain
A
Pain of aortic aneurysm, renal and pancreatic pain - may radiate to the back.
Renal colic - may radiate to the groin.
Diaphragmatic irritation (often due to peritonitis - may cause shoulder tip pain.
Gallbladder pain - may radiate to **scapula. **
12
Q
NON-GIT causes of acute ab pain
A
- Ectopic pregnancy – lower abdominal pain, missed period, positive pregnancy test, nausea/vomiting and/or diarrhea
- Dissecting/rupture aortic aneurysm – tearing pain in flank or back, nausea/vomiting and/or dizziness, hemodynamically compromised
- Renal colic – loin to groin pain, dysuria and/or hematuria, nausea and vomiting
13
Q
Caues of chronic ab pain
A
- Inflammatory bowel disease - generalized abdominal pain, diarrhea (may be bloody), weight loss
- Peptic ulcer disease – epigastric pain which may be related to meals, bloating and abdominal distension, heartburn
- Diverticulosis – left lower quadrant pain, constipation, rectal bleeding, fever and unwell when complicated by diverticulitis
- Irritable bowel syndrome (a diagnosis by exclusion) – generalized abdominal pain, bloating, changeable bowel habit,
- Non-specific abdominal pain
- GI/ovarian malignancy
14
Q
Diffuse ab pain
A
- Peritonitis
- Septicemia
- Diabetic acidosis
- Sickle cell crisis: starts extrab becomes ab)
- Gastroenteritis
- Ovarian cancer
- Intestinal obstruction: start diffuse then becomes localized
- Opiate withdrawal
- Shingles
- Munchhausen syndrome
15
Q
A
nl galbladder
- Look hyper-echoic (hyper-echogenic) structure
16
Q
A
Acute cholecystitis
- Thickening of gallbladder wall
- Fluid surrounding wall of gallbladder
Murphy’s sign: below right costal margin in mid-clavicular line, insert tips of fingers while patient takes a deep breath
(+) sign: tenderness & a sudden cessation of inspiratory effort (patient gasps) –inflamed gall bladder
- Boa’s sign
- lightly scratch skin right below right scapula
- (+) sign: uncomfortable sensation perceived by scratching
- Note: do NOT always see sign even if they DO have it
17
Q
Gallstones
A
- can be asx but RUQ pain = cholecystitis
- most common presentations are biliary colic (56%) and acute cholecystitis (36%). Other presentations include pancreatitis, obstructive jaundice, cholangitis, empyema and gallstone ileus.
18
Q
Acute cholecystitis
A
- “fair, fat, fertile, female and forty’ is only part of the story. Typically related to gallstones disease. Other risk factors include:
- Increasing age.
- +ve family history.
- Sudden weight loss - e.g., after obesity surgery.
- Loss of bile salts - e.g., ileal resection, terminal ileitis.
- Diabetes - as part of the metabolic syndrome.
- Oral contraception-particularly in young women.
- Right upper quadrant or epigastric pain
- Pain steady, severe, prolonged without improvement
- Radiate to the right back
- Often precipitated by fatty food ingestion an hour or so prior
- Associated symptoms of nausea, vomiting, anorexia fever
- On examination - appears ill, lie still, fever, tachycardia
- Tender Right upper quadrant with guarding
- Acalculous cholecystitis – occurs in critically ill patient and has a high morbidity and mortality
- C&C:
- Gangrenous cholecystitis
- Cholecystoenteric fistula
- Emphysematous cholecystitis
19
Q
Peripheral signs of Ab disease: Hands
A
- Clubbing – Shamroth’s sign; (chronic liver dz, chronic diarrhea, heart & lung dz chronic hypoxemia + inflam)
- Koilonychia – spoon nails; indicate Fe deficiency anemia, Plummer-Vinson syndrome
- Leukonychia – white spots on nails; indicate Vit deficiency or liver pathology; hypoalbuminemia d/t nephrotic syndrome, protein malabsorption/wasting
- Dupuytren’s contracture – fibrotic bands across ring & little finger into palms; due to advanced liver cirrhosis
- Pallor of nails
- Palmar erythema – flushing of palm; due to incr estrogen levels as a result of liver pathology, portal HTN
- Flapping tremor (asterixis) – w/arms stretched & hands flexed; indicates (hepatic encephalopathy d/t liver cirrhosis -> unable to metab NH4; renal failure -> azotema; hypercapnia; Wilson’s diease)
20
Q
Peripheral signs of Ab Dz: Mouth
A
- Fetor hepatica – smell of ammonia in hepatic encephalopathy
- Glossitis – smooth beefy tongue – inflam + loss of papillae due to Vit deficiencies (A, B complex, C) o Candidiasis – white patch that can scrape off
- Ulcerations – Crohn’s dz
- Pigmentations – Peutz Jegher syndrome, familiar polyposis
- Leukoplakia – pre-malignant white patch; can’t scrape
21
Q
Colour discoloration in ab
A
- Bruises – periumbilical color change & bluish discoloration of flanks; seen in hemorrhagic pancreatitis & due to intraperitoneal hemorrhage
- Cullen’s sign – hematoma around umbilicus; seen in hemorrhagic pancreatitis
- Grey Turner’s sign – hematoma on flanks; seen in hemorrhagic pancreatitis
- Melanin – racial; seen in Addison’s disease & pregnancy
- Heavy metals – iron (seen in haemochromatosis or bronze diabetes) or arsenic
- Jaundice – lemon yellow (in haemolytic anaemia) to green (in obstructive jaundice)
22
Q
Acute appendicitis
A
- Tenderness & rebound tenderness in right iliac fossa (McBurney’s point)
- Rovsing’s sign: pain in right iliac fossa when applying pressure in left iliac fossa
23
Q
Friction rubs
A
- Listen over hepatic and splenic areas
- Grating sounds with respiratory variation‐ inflammation of the peritoneal surface disease
24
Q
Venous hum
A
- listen over epigastric and umbilical area (porta hepatis)
- soft humming noise with both diastolic and systolic components‐increased collateral circulation between porta l and systemic systems‐ hepatic cirrhosis
CPD F2014
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