DPD interactive cases > Abdomen (3) > Flashcards

Abdomen (3) Flashcards

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1
Q

What are the ABCDEFGHIJL of liver disease?

A 
Asterixis 
Bruising
Clubbing/Caput Medusae
Dupuytren's Contracture
Erythema/Excoriaiton marks
Fetor
Gynaecomastia
Hair loss 
Icterus
Jaundice 
Leuconychia
Spider Naevi (will refill from centre)
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2
Q

What is Dupuytren’s contracture caused by?

A

It is thickening of the palmar fascia and it is associated with alcoholic liver disease (CLD, ETOH, Familial)

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3
Q

What is leuconychia a sign of?

A

Hypoalbuminaemia (decreased liver function)

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4
Q

What abdominal condition/treatment can cause gum hypertrophy?
What other thing can you find in the mouth?

A

Ciclosporine (following renal transplant)

Pigmentation

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5
Q

6 Fs of abdominal distension

A 
Fat 
Flatus
Fetus
Fluid 
Faeces
Fucking cancer (Foreign obstruction?)
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6
Q

What is caput medusa? How do you differentiate from IVC obstruction?

A

Distended superficial umbilical veins due to portal hypertension
If it is occluded and released, direction of blood flow in the dilated veins below the umbilicus is towards the legs and towards head if above umbilius (sun)
IVC: opposite flow

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7
Q

Right Subcostal (Kocher’s)(surgical incision) is made for what operation?

A

Biliary surgery

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8
Q

Mercedez-Benz (surgical incision) is made for what operation?

A

Liver transplant

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9
Q

Midline Laparotomy (surgical incision) is made for what operation?

A

GI/Major abdominal surgery/vascular

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10
Q

McBurney’s (Gridiron)(surgical incision) is made for what operation?

A

Appendicectomy

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11
Q

J-shaped (surgical incision) is made for what operation?

A

Renal transplant

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12
Q

Pfannenstiel (low transverse) (surgical incision) is made for what operation?

A

Gynaecological procedures

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13
Q

Inguinal (surgical incision) is made for what operation?

A

Hernia repair

Vascular access

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14
Q

Loin (surgical incision) is made for what operation?

A

Nephrectomy

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15
Q

Describe how you would complete the abdominal examination of a patient.

A

Full history
DRE
Urinalysis
Examination of hernial orifices and external genitalia

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16
Q

List some causes of hepatomegaly.

A

Cancer
Cirrhosis (early stage; alcoholic)
Cardiac – congestive cardiac failure, constrictive pericarditis
Infiltration – fatty infiltration, haemochromatosis, amyloidosis, sarcoidosis and lymphoproliferative disease

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17
Q

Broadly speaking, what are the common aetiologies of liver disease?

A 
Alcohol
Autoimmune 
Virus 
Drugs 
Biliary disease
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18
Q

List some causes of splenomegaly.

Mnemonic: HHII

A

Portal Hypertension (e.g. in chronic liver disease)

Haematological (e.g. haemolytic anaemia,
leukaemia, lymphoma, myeloma)

Infection (e.g. malaria, schistosomiasis, glandular fever, TB, leishmaniasis, infective endocarditis)

Inflammation

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19
Q

What are the two most common differentials for epigastric pain?

A

Pancreatitis

Peptic ulcer disease

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20
Q

What is an important condition to consider in a patient with epigastric pain, radiating to the back who is also tachycardic and hypotensive?

A

Ruptured aortic aneurysm

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21
Q

What are the two types of abdominal pain?

A

Constant – due to inflammation

Colicky – due to obstruction of viscus

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22
Q

What organs can cause abdominal pain? (6)

A

Stomach (Gastritis - ETOH, retrosternal pain)
Pancreas (Acute pancreatitis - consider gallstones and alcohol consumption); if loss of function: exocrine (steatorrhea, malabsorption), endocrine: DM
Heart (MI)
Aorta (Ruptured AAA)
Liver (Hepatitis)
Gallbladder (Cholecystitis)

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23
Q

Stomach related abdominal pain causes

A

Peptic ulcer disease (NSAID use)

GORD (better with antacids)

Gastritis (retrosternal, history of alcohol abuse)

Malignancy

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24
Q

What is a key difference between acute pancreatitis and chronic pancreatitis?

A

In chronic pancreatitis, serum amylase is NORMAL

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25
What presenting symptom do you find in chronic pancreatitis that is unlikely to occur in acute pancreatitis?
Weight loss
26
List features of chronic pancreatitis that distinguish it from acute pancreatitis.
Chronic pancreatitis causes loss of endocrine and exocrine function Weight loss Steatorrhoea Diabetes mellitus
27
What is the diagnostic test for chronic pancreatitis?
Faecal elastase – low in chronic pancreatitis
28
How can appendicitis cause RUQ pain?
Retrocaecal appendix
29
List causes of RUQ pain that 7 organs:
Gallbladder - Cholecystitis - Cholangitis - Gallstones (normal CRP) Liver - Hepatitis - Abscess (Bacterial, malignant) Lungs - Basal pneumonia Appendix - Appendicitis - Retrocaecal appendicitis (going up and backwards, inflamed). Stomach and Pancreas - Peptic ulcer disease - Pancreatitis Kidney - Pyelonephritis (also causes extreme tenderness over the renal angle - when percussing)
30
List some GI causes of RIF pain
``` Appendicitis Mesenteric adenitis (particularly important in children) - US to look at LN Colitis (IBD) Malignancy IBS ```
31
List some gynaecological causes of RIF/LIF pain.
Ovarian cyst rupture, torsion or bleed Ectopic pregnancy Salpingitis
32
List two main causes of Suprapubic pain.
Cystitis (UTI) | Urinary retention
33
List some GI causes of LIF pain.
Diverticulitis Colitis (IBD) Malignancy Faecal impaction
34
List the differential diagnosis of a patient with diffuse abdominal pain.
``` Obstruction Infection – peritonitis, gastroenteritis Inflammation – IBD Ischaemic – (mesenteric ischaemia) Medical ```
35
List medical causes of diffuse abdominal pain
``` DKA Addison’s disease Hypercalcaemia Porphyria Lead poisoning ```
36
What is porphyria?
One of a group of rare disorders due to inborn errors of metabolism in which there are deficiencies in the enzymes involved in the biosynthesis of haem. The accumulation of the enzyme’s substrate gives rise to symptoms. (Acute abdo pain, muscle weakness)
37
When do patients with mesenteric ischaemia tend to experience diffuse abdominal pain?
Post-prandial
38
Draw the mesenteric arteries.
Pic | Blockage = ischaemia
39
What can cause a high amylase?
Any cause of acute abdomen
40
How is spontaneous bacterial peritonitis (SBP) diagnosed?
Ascites neutrophils > 250/mm3
41
What are the three main signs of decompensated liver disease?
Ascites Encephalopathy Jaundice
42
What is the main sign of ascites on examination?
Shifting dullness
43
Describe some features of obstruction on examination.
Nausea/vomiting Not opening bowels High-pitched tinkling bowel sounds
44
Why is it important to ask a patient with suspected bowel obstruction about previous abdominal surgery?
Previous abdominal surgery increases the risk of adhesions forming, which can cause obstruction
45
What cause abdominal distension? (6F)
``` Flatus (due to obstruction; tender irreducible femoral hernia in the groin) Fat Fluid Fetus Faeces “Fatal growth” (often a neoplasm) ```
46
What was the old way of differentiating between causes of ascites?
Transudate vs Exudate
47
What is the new way of differentiating between causes of ascites?
Based on albumin gradient | Albumin gradient = serum albumin – ascites albumin
48
List causes of ascites that has a HIGH albumin gradient (> 11 g/L).
``` Portal hypertension Constrictive pericarditis Cardiac failure Cirrhosis (decreased albumin production) Budd Chiari Syndrome (hepatic/portal vein thrombosis) ``` Ascites albumin is low Increased hydrostatic pressure --> fluid leaves into peritoneal cavity
49
List causes of ascites that has a LOW albumin gradient (< 11 g/L).
Indicates a high protein level in ascites - inflammatory proteins ``` Nephrotic syndrome (serum albumin is lost, so gradient is low) TB Pancreatitis Cancer Peritonitis ```
50
What gives faeces its brown colour?
Stercobilinogen
51
Which enzyme conjugates bilirubin?
Glucuronyl transferase
52
What happens to bilirubin after it has been conjugated?
It is excreted into the bile | It moves to the intestines where it gets converted to urobilinogen and stercobilinogen
53
State two causes of unconjugated hyperbilirubinaemia.
Haemolysis | Gilbert’s syndrome (defective conj)
54
Explain why patients with hepatocellular jaundice will produce dark urine.
The damage to the liver cells leads to leakage of conjugated bilirubin from the hepatocytes The conjugated bilirubin is soluble and excreted in the urine, causing dark urine
55
List some causes of hepatitis.
Alcohol Autoimmune Drugs Viruses
56
Explain why patients with post-hepatic jaundice will have pale stools and dark urine.
- Obstruction means that conjugated bilirubin cannot be excreted into the duodenum - Conjugated bilirubin leaks into the circulation and is renally excreted, producing dark urine - Conjugated bilirubin does NOT reach the intestines and, so, is not converted to stercobilinogen so the stools are pale (BR is metabolised into S by GI bacteria)
57
List some causes of post-hepatic jaundice.
Gallstones in the common bile duct Stricture Cancer of the head of the pancreas
58
State Courvoisier’s law.
A palpable gallbladder in the presence of painless jaundice is unlikely to be due to gallstones (more likely due to cancer)
59
The elevation of which liver enzymes suggest pathology in the biliary tree?
ALP + GGT
60
``` What is the tumour marker for the following cancers: Pancreatic Colorectal Liver Ovarian ```
Pancreatic: CA19-9 Colorectal: CEA Liver: a-fetoprotein Ovarian: CA125
61
What is Trousseau’s sign of malignancy?
Episodes of thrombophlebitis that are recurrent or appearing in different locations over time It can be an early sign of gastric or pancreatic malignancy
62
List the 5 causes of bloody diarrhoea.
``` Infective colitis Inflammatory colitis Ischaemic colitis Diverticulitis Malignancy ```
63
What are the main pathogens associated with infective colitis? CHESS
``` Campylobacter jejuni Haemorrhagic E. coli Entamoeba histolytica Salmonella Shigella ```
64
List some extra-gastrointestinal manifestations of inflammatory bowel disease.
Eyes: episcleritis, scleritis, uveitis Skin: erythema nodosum, pyoderma gangrenosum
65
List two common causes of bloody diarrhoea in the elderly.
Ischaemic colitis | Diverticulitis
66
What causes leadpipe sign on AXR?
Inflammatory bowel disease (featureless colon)
67
What is the diameter of the colon in a patient with toxic megacolon?
More than 6 cm | Also systemically unwell - TC, htn, fever
68
What is another name for overflow diarrhoea?
Spurious diarrhoea | Faecal impaction/loading
69
What may elderly patients with constipation present with?
Confusion
70
Describe the management of an acute GI bleed.
``` ABC IV access Fluids Group & Save/Crossmatch OGD – find the underlying cause ```
71
What additional measures will be used for variceal bleeds?
Antibiotics (e.g. tazocin, ciprofloxacin) – because of bacterial translocation --> improves mortality Terlipressin – causes splanchnic vasoconstriction
72
Describe the management of acute abdomen.
``` NBM Fluids Analgesia Anti-emetics Antibiotics - cover Anaerobes (Metronidazole, Cef) Monitor vitals and urine output ```
73
Which two antibiotics are commonly used in the management of acute abdomen?
``` A cephalosporin (e.g. cefuroxime) Cover anaerobes (metronidazole) ```
74
What other investigations are important in patients with acute abdomen?
FBC – raised WCC suggests infective process U&Es – allow assessment of renal function and hydration status CRP – marker of inflammation Clotting – surgeons need to know about bleeding tendency before an operation Erect CXR – check for air under the diaphragm
75
List some important investigations for patients with jaundice.
FBC – low Hb may be due to haemolytic anaemia LFTs – important if liver pathology is suspected Abdominal ultrasound – performed after fasting because gallstones are better visualised in a distended, bile-filled gallbladder. Dilatation of the ducts would suggest obstruction.
76
Describe the investigations that will be undertaken in a patient presenting with dysphagia and weight loss.
OGD and biopsy
77
Describe the investigations that will be undertaken in a patient presenting with PR bleeding and weight loss.
Colonoscopy
78
What is Pabrinex and what is it given for?
Water-soluble vitamin supplements given in chronic liver disease It contains thiamine, which is necessary to prevent Wernicke’s encephalopathy
79
Summarise the management of ascites.
Ascitic Tap and send to lab for WCC --> SBP? Diuretics (spironolactone, + furosemide if periph oe) Dietary sodium restriction Fluid restriction in patients with hyponatraemia Monitor weight daily Therapeutic paracentesis (with IV 2% human albumin)
80
Explain how cirrhosis leads to secondary hyperaldosteronism.
Cirrhosis causes vasodilation, which results in the body producing more renin and aldosterone to promote fluid retention Spironolactone and furosemide helps counteract this effect
81
Describe the management of a patient with hepatic encephalopathy.
Lactulose Phosphate enemas Avoid sedation (e.g. benzodiazepines) Treat infections (e.g. SBP) Exclude GI bleed (an occult GI bleed can precipitate encephalopathy) Treat non-liver causes (constipation, drug)
82
Why is lactulose used in patients with hepatic encephalopathy?
It is an osmotic laxative that reduces GI transit time such that bacteria doesn’t have enough time to produce toxic metabolites that can be absorbed and cause encephalopathy
83
What would you expect the urea of an alcoholic patient to be?
Alcoholic patients tend to have low urea (~ 1 mmol/L) | Urea=7 is significant for patient with CLD (increased due to protein meal e.g. digesting GI Bleed)
84
What could cause urea to rise?
Digestion of red blood cells (due to a GI bleed)
85
List three major complications of abdominal surgery and describe their features.
``` Wound infection – erythematous, discharge Anastomotic leak – diffuse abdominal tenderness, guarding, rigidity, hypotensive/tachycardic Pelvic abscess (e.g. post-appendicectomy) – pain, fever, sweats, mucus diarrhoea ```
86
Describe the appearance of a perianal abscess and state how you would treat it.
Tender, red swelling around the anus | Treated with incision and drainage
87
Describe the presenting symptoms of an anal fissure and state how you would treat it.
Rectal pain during defecation Stool coated with blood Treatment: advice regarding diet (increase fluids and fibre), GTN cream (analgesic)
88
Describe the presentation of IBS.
``` Recurrent abdominal pain Bloating Relief with defecation Change in frequency/form of stool Can be diarrhoea predominant or constipation predominant ```
89
What is a key difference between the pattern of symptoms of IBD and IBS?
IBS patients will not have rectal bleeding, anaemia, weight loss or nocturnal symptoms
90
Describe the treatment of IBS.
``` Diet and lifestyle modification Symptomatic treatment: - Abdo pain – antispasmodics - Laxatives for constipation - Anti-diarrhoeals (loperamide 2mg oral PO) ```
91
How should Coeliac disease be excluded?
Tissue transglutaminase (tTG) test
92
What could you see if the patient was on Renal Replacement Therapy?
AV Fistulae
93
What causes thumbprinting?
Inflammation of BW (IBD), shows mucosal oedema
94
Prescribe for non-bleeding ulcer, H Pylori -ve
Omeprazole 20mg oral 3x/day | 2nd line: H2 antagonist - cimetidine, ranitidine (-dine)
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