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PACES 2024 > Abdomen > Flashcards

Abdomen Flashcards

(61 cards)

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1
Q

General inspection findings in chronic liver disease?

A
  • Jaundice
  • Bruising (thrombocytopenia)
  • Scratch marks (pruritus)
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2
Q

Hand findings in chronic liver disease?

A

Asterixis
Clubbing
Dupuytren’s contracture
Palmar erythema
Leukonychia (white spots due to hypoalbuminaemia)

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3
Q
A

Terry nails secondary to hypoalbuminaemia
- causes: Liver cirrhosis, CKD, Heart failure, protein-losing enteropathy, iron deficiency anaemia

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4
Q

Face findings in chronic liver disease?

A
  • Scleral icterus
  • Parotid enlargement (2’ alcoholism)
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5
Q

Chest findings in chronic liver disease?

A
  • Gynaecomastia
  • Spider naevi (5 or >)
  • Scanty axillary hair
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6
Q

Why does gynaecomastia occur in liver disease or cirrhosis?

A
  • increased production of androstenedione by adrenal glands
  • increased aromatisation of androstenedione -> oestrogens
  • loss of clearance of adrenal androgens by the liver
  • rise in SHBG
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7
Q
A

Leukonychia

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8
Q

Abdominal findings in chronic liver disease?

A

Hepatomegaly (may be small in advanced cirrhosis)
Splenomegaly 2’ portal hypertension
Kidneys not ballotable
Shifting dullness +ve (ascites)
Caput medusae 2’ portal hypertension

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9
Q

Lower limb findings in chronic liver disease?

A

bilateral oedema (2’ hypoalbuminaemia)

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10
Q

After abdominal examination in chronic liver disease, how to complete examination?

A
  • examine genitalia for testicular atrophy (in males)
  • perform a DRE
  • examine cervical and inguinal lymph nodes
  • look at vital signs including temperature
  • take a full history (including history of ethanol ingestion, hep B/C infection)
  • take a drug history (drug causes: methotrexate, amiodarone, methyldopa)
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11
Q

Complications of chronic liver disease?

A

(A) portal hypertension: splenomegaly, ascites, varices
(B) hypoalbuminaemia: leukonychia, pitting oedema
(C) coagulopathy
(D) hepatic encephalopathy
(E) SBP: tender abdomen
(F) HCC: lymphadenopathy, cachexia
(G) Hepatorenal syndrome

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12
Q

Important negatives to present in chronic liver disease patient?

A

no evidence of:
- hepatic encephalopathy: coherent with no asterixis
- SBP: non tender abdomen, afebrile
- HCC/ mets: no lymphadenopathy

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13
Q

Examination findings for chronic liver disease to suggest hep C/B?

A

Tattoos
Needle track marks e.g. IVDU

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14
Q

Examination findings in chronic liver disease patient suggesting alcoholism as cause?

A
  • Dupuytrens contractures
  • Parotidomegaly
  • Rhinophyma
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15
Q

Examination findings in chronic liver disease patient suggesting Wilson’s disease as cause?

A

Kayser Fleischer rings
Chorea-athetoid movements

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16
Q
A

Kayser-Fleischer rings
in Wilson’s disease

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17
Q

Aetiology of chronic liver disease?

A
  1. Alcohol
  2. Hep B/ C
  3. NAFLD

Inherited:
4. Wilson’s disease
5. Hereditary haemochromatosis (AR)
6. alpha 1 antitrypsin deficiency

Autoimmune
7. Autoimmune hepatitis
8. PBC

  1. Drug induced
  2. Cryptogenic
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17
Q

Aetiology of chronic liver disease?

A
  1. Alcohol
  2. Hep B/ C
  3. NAFLD

Inherited:
4. Wilson’s disease
5. Hereditary haemochromatosis (AR)
6. alpha 1 antitrypsin deficiency

Autoimmune
7. Autoimmune hepatitis
8. PBC

  1. Drug induced
  2. Cryptogenic
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18
Q

Causes of decompensated liver cirrhosis?

A

infection
bleeding GI tract
dehydration
electrolyte imbalance e.g. hypoNa
drugs: diuretics, barbiturates
constipation

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19
Q

investigations in chronic liver disease?

A

FBC: macrocytic anaemia, thrombocytopenia
Renal panel
LFT: albumin, bilirubin, transaminitis
Coagulation profile INR

Imaging
US HBS: to confirm cirrhosis, evaluate for splenomegaly, ascites or elevated portal pressures

Determine aetiology:
Hep B/ C screen
Autoimmune workup
Serum caeruloplasmin

Surveillance/ evaluate for complications:
Endoscopic evaluation for varices
US HBS for suspicious nodules + AFP -> KIV triphasic CT liver/ MRI liver or biopsy

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20
Q

Management of chronic liver disease?

A

Treat underlying cause: e.g. Stop drinking
Hep A and B vaccinations
Prevent constipation and decompensation: lactulose
B blockers for varices: carvedilol

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21
Q

Treatment of Hepatitis B

A

Entecavir, lamivudine, adefovir

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22
Q

Treatment of Hepatitis C

A

Ribavarin (oral antiviral 500mg BD) + pegylated alpha IFN (180mcg sc weekly)
- 24 or 48 week course

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23
Q

Treatment of autoimmune hepatitis

A

steroids, azathioprine

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24
Treatment of Wilson's disease?
penicillamine, traimeterene, zinc
25
treatment of haemochromatosis
venesection
26
Mx of BGIT in cirrhotic patients?
ABC, urgent fluid and blood products resus Urgent endoscopy for diagnostic and therapeutic purposes: variceal band ligation -> if fails x2, for TIPS Correct coagulopathy: PCT/ Plt/ FFP transfusions (aim Hb 8-9, not too high as will elevate portal pressure), IV Vit K Lower portal pressure by decreasing splanchnic circulation: IV somatostatin, octreotide or terlipressin Prevent encephalopathy: ensure BO 3x/day IV ceftriaxone - prophylaxis for SBP from gut translocation of bacteria IV PPI
27
Indication for treatment of hepatitis B infection?
- serum Hep B virus DNA level > 10^5 copies/mL + ALT >2 xULN - if cirrhosis present: just HBV DNA level > 10^5 copies/ mL
28
Treatment end point for Hepatitis B infection?
- virological: HBeAg seroconversion + reduction of HBV DNA level to < 10^5 copies/mL - biochemical: normalisation of ALT values
29
Indication for treatment of chronic hepatitis C?
- proven Hepatitis C infection (Anti HCV Ab/ HCV RNA) - abnormal LFTs - evidence of chronic hepatitis on liver biopsy - no contraindications (eg. clinical decompensated liver disease 2' hep C, organ transplant)
30
HBsAg, Anti-HBs, Anti-HBc negative
susceptible individual - should get vaccination
31
HBsAg negative, Anti-HBs + Anti-HBc positive
Immune due to previous infection
32
HBsAg + Anti-HBc negative, Anti-HBs positive
Immune due to hepatitis B vaccination
33
HBsAg +, Anti-HBs -, Anti-HBc +, IgM anti-HBc +
Acute Hep B infection
34
HBsAg +, Anti-HBs -, Anti-HBc +, IgM anti-HBc -
Chronic Hep B infection
35
HBsAg -, Anti-HBs -, Anti-HBc +
Four possibilities: 1. Resolved infection (most common) 2. False-positive anti-HBc, thus susceptible 3. "Low level" chronic infection (thus HBsAg -) 4. Resolving acute infection
36
Markers of synthetic function of the liver?
albumin INR bilirubin
37
Causes of normal ratio transaminitis e.g. ALT>>AST
1. acute viral hep A/B/C/E 2. drug induced including TCM 3. Autoimmune: raised IgM, globulin fraction 4. Ischaemic 5. Acute alcohol intoxication
38
Causes of reversed ratio transaminitis e.g. AST> ALT
1. Alcoholism: also with raised GGT 2. Liver cirrhosis 3. Infiltrative disease: e.g. infiltrative HCC, cholangioCa
39
why screen for HIV in hepatitis C patients?
co-infection increases risk of early cirrhosis
40
How to complete examination after differential diagnosis of liver mets on examination?
- DRE: rectal or prostate primary - examine lymph nodes - Respiratory examination (lung primary) - Breast examination in female - examine for lumbosacral spinal tenderness (to suggest bony involvement)
41
Hepatomegaly (irregular), cachexia, no peripheral stigmata of chronic liver disease?
Liver mets (most commonly 2' spread followed by liver primary)
42
Most common primary sources of liver mets?
colorectal stomach lungs breast
43
differential diagnosis of irregular, hard liver
polycystic liver - also look for ballotable kidneys!
44
General inspection findings in patient with a transplanted kidney?
Cushingoid appearance Hirsutism (cyclosporin) Pallor
45
Arm examination findings in kidney transplant?
AVF - working? Bruises, thin skin, proximal myopathy (2' steroids) Leukonychia, nail bed pallor (anaemia) Uraemic flap Fine tremor (cyclosporin)
46
Head/face examination findings of kidney transplant patient?
Gum hypertrophy (cyclosporin) Oral thrush (immunocompromised) Uraemic fetor Eyes: conjunctival pallor
47
Neck examination findings of kidney transplant patient?
JVP - look for fluid overload
48
Chest examination findings of kidney transplant patient?
- previous scars from tunnelled dialysis catheter - parathyroidectomy scar
49
Abdominal examination findings in kidney transplant patient?
- Transplant scar + palpable superficially placed mass in RIF/LIF (firm, smooth, non tender, bruit?) - Nephrectomy scar (e.g. when removing PCK) - previous TK catheter scar for PD (usually periumbilical/ infraumbilical) - Ballotable kidneys (polycystic kidneys) - hepatomegaly (PCKD) - insulin injection marks, lipodystrophy (DM) - purple striae (2' steroids)
50
Kidney transplant - reverse J scar + right infraumbilical scar from previous Tenkhoff catheter
51
Leg examination findings in kidney transplant patient?
- peripheral oedema - diabetic dermopathy - amputations (PVD in DM)
52
How to complete examination after conducting abdominal examination in a kidney transplant patient
- cardiovascular examination for pericardial rub - respiratory examination for bibasal crepitations to suggest fluid overload - examine for lymphadenopathy (post transplant lymphoproliferative disease) - look at vitals (Blood pressure) - full history taking (e.g. symptoms of uraemia, family history of PCKD) - urinalysis for haematuria - ? fundoscopy for hypertensive or diabetic retinopathy
53
important negatives to present for patient with kidney transplant?
- pt clinically not uraemic (no asterixis/ rub) or overloaded (euvolamic) - transplant non tender
54
Complications of ESRF
- hypoalbuminaemia (leukonychia) - anaemia (conjunctival pallor) - fluid overload - uraemia
55
complications of drug therapy for kidney transplant patients?
- steroid use: cushingoid appearance, purple striae, proximal myopathy, thin skin - cyclosporin: fine tremors, gum hypertrophy, hirsutism - tacrolimus: fine tremor - infection (fever)
56
aetiology of ESRF?
1) diabetes - most common cause of ESRF locally 2) PCKD - ballotable kidneys 3) HTN - 2nd most common cause 4) Glomerulonephritis
57
how to complete the examination in patient with polycystic kidneys?
- cardiovascular examination for pericardial rub, raised JVP, associated valvular problems (e.g. MVP, AR) - respiratory examination for bibasal creps - neuro exam: for cranial nerve palsies or long tract signs to suggest intracranial berry aneurysm - vitals: BP - urine dip for haematuria/ proteinuria - family history of similar disease
58
causes of pain over polycystic kidneys?
- Rupture of cyst - bleed into cyst - infection of cyst/ UTI - renal stones - malignant transformation into RCC -> investigate with CT scan
59
Renal and extra renal complications of polycystic kidney disease?
renal: ESRF, RCC, infection, hypertension Extra renal: cysts in liver/ spleen/ pancreas/ ovaries, cardiac with MVP/ AR CNS: intracranial berry aneurysm -> SAH
60
differentials of bilateral ballotable kidneys
- obstructive uropathy 2' bladder outlet obstruction with bilateral hydronephrosis - amyloidosis - bilateral renal cell carcinoma - tuberous sclerosis with angiomyolipoma - Von Hippel Lindau disease

PACES 2024 (14 decks)

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