The abdomen Flashcards
What is the normal liver span?
About 12.5cm
What is the differential for massive hepatomegaly?
Metastases
Alcoholic liver disease with fatty infiltration
Myeloproliferative disease
Right heart failure
Hepatocellular carcinoma
What is the differential for moderate hepatomegaly?
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
What is the differential for mild hepatomegaly?
Early course of the massive and moderate hepatomegaly causes.
Hepatitis
Cirrhosis
Biliary obstruction
Graulomatous disorders
Hydatid disease
Amyloidosis and other infiltrative diseases
HIV
Ischaemia
What is the differential for a firm and irregular liver?
Cirrhosis
Metastatic disease
Cysts (ADPKD for e.g.)
Granulomas
Hydatid disease
Amyloid
Lipoidoses
What is the differnetial list for a tender liver?
Hepatitis
Rapid liver enlargement (e.g. right heart failure, budd-chiari syndrome)
HCC
What is the differential for a pulsatile liver?
Tricuspid regurgitation
HCC
Vascular abnormalities affecting the liver
What are the differentials for bilateral renal masses?
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
What are the possible causes of unilateral renal masses?
Renal cell carcinoma
Hydronephrosis or pyonephrosis
Polycystic kidneys with assymmetrical enlargement
Acute renal vein thrombosis
Solitary kidney
What’s a differential for right iliac fossa masses?
Appendiceal abscess
Carcinoma of the caecum
Crohn’s disease
Pelvic kidney
OVarian tumour or cyst
Carcinoid tumour
Amoebiasis
Psoas abscess
Ileocaecal TB
What’s a differential for right iliac fossa masses?
Appendiceal abscess
Carcinoma of the caecum
Crohn’s disease
Pelvic kidney
OVarian tumour or cyst
Carcinoid tumour
Amoebiasis
Psoas abscess
Ileocaecal TB
What are the possible causes of left iliac fossa masses?
Faeces
Carcinoma of sigmoid or descending colon
Diverticular disease
Ovarian tumour or cyst
Psoas abscess
What are the possible causes of upper abdominal masses?
Retroperitoneal lymphadenopathy
Abdominal aortic aneurysms
Carcinoma of the stomach
Pancreatic pseudocyst or tumour
Carcinoma of transverse colon
What are the possible causes of massive splenomegaly?
Chronic myeloid leukaemia
Myelofibrosis
Primary lymphoma of spleen, heairy cell leukaemia, malaria, kal-azar
What are the causes of moderate splenomegaly?
Massive causes early in their courses
Portal hypertension
Lymphoma
Leukaemia
Thalassaeia
Storage diseases (e.g. Gaucher’s disease)
What are the possible causes of mild splenomegaly?
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)
What are the distinguising features on exam of a spleen?
No palpable upper border
Notch
Moves with respiration
No resonance over splenic mass
Not ballotable
Friction rub over the spleen on auscultation
Where should you ausculatate on the abdomen?
Liver, spleen and renal area for bruits and venous hums. Then the gut for ?bowel sounds
What are the most common causes of a systolic bruit heard over the liver?
HCC
Acute alcoholic hepatitis
What causes a friction rub over the liver?
Tumour
Recent iver biopsy
Infarction
Gonococcal perihepatitis
What causes a friction rub over the spleen?
Infarction
What are the chest wall features of chronic liver disease?
In men - gynaecomastia, hair loss, spider naevi
In women - breast atrophy
Why do a cardiac exam if cirrhosis is suspected?
Restrictive pericarditis leads to cirrhosis
Why examine the lungs if you find ascites on an abdominal exam?
For pleural effusion
Why look at the eyes when suspecting chronic liver disease?
Kayser-Fleischer rings
Jaundice
Xanthelasma (common in advanced primary biliary cholangitis)
Anaemia
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)
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
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
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
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?
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
What does a scar hear indicate?
Nephrectomy scar, likley due to autosomal dominant polycystic kidney disease or malignancy
What are cevron/mercades benz/rooftop scars used for?
Liver transplant, gasstrectomy, oesophagectomy, bilateral adrenalectomy, hepatic resections, pancreatic surgery, combined liver/kidney surgery.
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
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
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)