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Kirstin Blackie Nima Mohan. Medical Abdomen. Be aware of common conditions presenting with abdominal symptoms Understand important factors in the history, examination, investigation and management of common abdominal pathologies. Objectives. Causes of Abdo Pain.

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Kirstin blackie nima mohan

Kirstin Blackie

Nima Mohan

Medical Abdomen


Objectives

Objectives



Case study

Mr C, 35 year old man, presents to his GP with mild abdominal pain and yellowing of the whites of his eyes (noticed by his girlfriend who is a nurse).

  • What other symptoms would you want to ask about?

Case Study


Signs and symptoms of liver pathology

  • Abdominal pain (RUQ) abdominal pain and yellowing of the whites of his eyes (noticed by his girlfriend who is a nurse).

  • Jaundice

  • Nausea, vomiting Weight loss

  • Abdo distension

  • Haematemesis and malaena

  • Breast swelling, tesicular atrophy

  • Confusion

  • Spider naevi

  • Palmar erythema

  • Dupuytrens contracture

  • Hepatomegaly, Spenomegaly

Signs and Symptoms of Liver pathology


Case study cont

Case study cont:


Risk factors for liver disease

  • High Alcohol intake tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

  • Blood-to-blood contact (IVDU, Tattoos, infected transfusions, needlestick injuries)

  • Unprotected sex

  • Drugs (prescribed, OTC, herbal)

  • Travel

  • Family history of liver disease (autoimmune hepatitis, Wilson’s disease)

    Mr C is in monogamous sexual relationship with girlfriend for 2 months– she is on OCP. No barrier contraception.

    Drinks approximately 30 units alcohol / week. Denies any other risk factors.

  • What first line investigations would you like to do?

Risk factors for liver disease


Liver function tests

  • Viral hepatitis: tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

    • ALT greatly raised (10-100x upper limit of normal)

  • Alcoholic hepatitis

    • ALT moderately raised (2-10x upper limit of normal)

  • Drug induced hepatitis

    • Mixed picture: raised hepatic (AST, ALT) and Cholestatic (Alk Phos and GGT) markers

      Abnormal clotting (prolonged PT or INR) may indicate acute liver failure

Liver Function Tests


Drugs commonly associated with hepatitis

  • Acute hepatocellular damage: tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

    • Paracetamol (dose related)

    • Alcohol (dose related)

    • TB drugs

    • Anticonvulsants

    • Azathioprine

    • Methotrexate

  • Chronic active hepatitis

    • Nitrofurantoin

    • Isoniazide

  • Intrahepatic cholestasis

    • Azathioprine

    • Oestrogens

    • erythromycin

Drugs commonly associated with Hepatitis


Other causes: EBV, CMV, paravirus B19, dengue, yellow fever. tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.


Hepatitis e endemic area s
Hepatitis E endemic area tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever. s


Mr c and his girlfriend are both tested for viral hepatitis

  • Girlfriend tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

  • Mr C

Mr C and his girlfriend are both tested for viral hepatitis


Hepatitis B Serological Markers tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.


What are the differential diagnoses? tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

65 year old man who hasn’t been to his GP in years comes into A+E with an uncomfortable swollen abdomen


5 fs of distended abdomen

  • Fat tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

  • Faeces

  • Fluid

  • Foetus

  • Flatus

How would you examine for fluid (ascites)?

5 Fs of distended abdomen


Shifting dullness
Shifting Dullness tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

Does the presence of ascites prove that this patient has liver disease?


What are the possible causes of ascites
What are the possible causes of ascites? tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.


Cirrhosis common end point of many disease processes

  • Alcohol excess tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

  • Hepatitis B

  • Hepatitis C

  • Non-alcoholic Fatty Liver disease / Non-alcoholic Steatohepatitis

  • Haemachromatosis

  • Primary Biliary Cirrhosis

  • Primary Scelosis Cholangitis

  • Autoimmune hepatitis

  • Wilson’s disease and other inherited metabolic disorders

Cirrhosis: common end point of many disease processes


How would you investigate decompensated liver disease

Bloods: tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.

likely increased biliruben, AST, ALT, alk phos, GGT;

Decreased albumin, increased PT/INR (reduced synthetic function);

Decreased WCC and platelets (hypersplenism);

Look for the cause: serology, autoantibodies, iron studies

Imaging: liver US and doppler, MRI

Ascitic tap:

Biopsy: confirm clinical diagnosis

How would you investigate decompensated liver disease?


Us liver

US liver


Complications of cirrhosis

  • Anaemia (folate deficiency, hypersplenism) Compatible with cirrhosis. Doppler shows signs of portal hypertension.”

  • Thrombocytopenia (hypersplenism)

  • Coagulopathy (reduced production of clotting factors) – can lead to DIC

  • Oesophageal varices

  • Spontaneous Bacterial Peritonitis

  • Hepatic encephalopathy

  • Hepatocellular carcinoma

Complications of Cirrhosis


How would you manage this patient

  • Patient education and support Compatible with cirrhosis. Doppler shows signs of portal hypertension.”

  • Treat underlying cause

  • Adequate nutrition (calorie and protein intake)

  • Careful prescribing

  • Therapeutic ascetic tap

  • Alcohol abstinence (also important in non-alcohol induced cirrhosis)

    • Alcohol dependent individuals will require: Chlordiazepoxide, Thiamine, Vitamin B

  • Monitoring for further complications:

    • oesophageal varicies or HCC

  • ?transplant

How would you manage this patient?


Case study1

“A 17 year old girl presents to the GP with a 8 week history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

What other questions would you askher???

Case Study


She denies...... history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

  • jaundice, dyspepsia, vomiting, malena, constipation, ulcers

  • Changes in appetite

  • Changes in mensustral cycle

  • urinary symptoms

  • No recent travel

  • No changes / alterations to her diet

She reports .......

  • Fatigue – low energy levels

  • SOBOE

  • Palpitations

  • Frequent Pyrexia

  • Abdominal pain – generalised cramps

  • Diarrhoea – no blood or mucus

  • Weight Loss


What are you going to do next

  • Clinical Examination history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

  • Investigations

    Urine Dip and MSU

    Bloods :

    FBC, U&E's , CRP, ESR, LFT's, TFT's, Electrolytes, Anti -TTG, Blood Cultures??

    Stool culture

  • Imaging

What are you going to do next??


  • Clinic history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

On examination ......

  • Tachycardic – 101 regular, good volume.

  • normotensive – 110/76

  • CPT > 3 sec

  • Pale conjunctive

  • Cardio- respiratory examination - NAD

  • Diffuse tenderness in the abdomen

  • normal PR

    What is your immediate management plan?


WHAT TYPE OF IMAGING? history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”NAME OF SIGN?WHAT DISEASE? 5 OTHER EXTRA INTESTINAL MANIFESTATIONS OF THIS DISEASE?


EXTRA INTESTINAL MANIFESTATIONS history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

  • EYES : episcleritis, uveitis

  • MOUTH: Apthous ulcers, angular stomatitis

  • JOINTS : sero-negative arthropathies (anklysing spondylitis, sacroilietis)

  • KIDNEYS : stones fistula, hydronephrosis

  • SKIN: Eryhthemna nodosum, phlebitis, pyoderma gangrenosum


  • Clinic history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”


Primary sclerosing cholangitis

Strongly association with UC (less with CD) history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

  • Inflammation, fibrosis and stricture of the intra/ extra hepatic ducts.

  • Signs of Live failure

  • LFTS- Raised Alkaline Phosphatase, Bilirubin, hypergamaglobinumina

  • ANA, ANCA, SMA +VE

  • Poor prognosis – often need transplant and increases risk of cholangiocarcinoma

Primary Sclerosing Cholangitis


Management

MEDICAL MANAGEMENT history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

Treatment of exacerbations :

  • Mild – oral steroids (Prednislone PO / PR)

  • Severe – IV Hydrocortisone and Antibiotics

    Maintenance therapy :

  • Maintain adequate nutrition

  • To prevent exacerbations

  • 5-ASA's (Mesalazine)

  • Azothioprine

  • Anti- TNF antibodies

    (INFLIXIMAB)

Management


Surgical management

  • Surgical management of complications history of fatigue. She also reports frequent episodes of pyrexia and intermittent episodes of diarrhoea over this period. Over the last 48 hours she has had 14 episodes of watery diarrhoea”

  • Surgical management of the condition

Surgical Management


Case study2

A 25 year old girl presents with a 8 week history of generalised abdominal cramps and diarrhoea. They are loose stool, no blood or mucus and can occur 8-10 times a day. She also reports that she is frequently tired and stressed.

  • What else do you want to know???

CASE STUDY


Irritable bowel syndrome

Incidence: common (female 20 -40) ; 40 % people attending secondary care

6 months of symptoms before diagnosis

Can be predominantly constipation or predominantly diahorrea.

Abdominal pain/ Bloating

Anxiety / depression

Incomplete emptying/ incontinence/ urgency

Constitunal symptoms : tiredness, lethargy, arthalgia, urinary symptoms, dyspurunina.

RED FLAG SYMPTOMS:

Bleeding, Nocturnal symptoms, weight loss, Age > 50

Irritable bowel Syndrome


Treatment options

Reassurance and support secondary care

Address / Treat underlying medical issues

Lifestyle advice :

  • Dietary modification – excluding food groups.

  • Smoking and alcohol

    Symptomatic relief :

  • Bloating – Peppermint oil

  • Constipation – increase fibre and fluid intake

  • Antispasmodics – mebevrine

Treatment Options


Case study3

“A 65 year old man presents with a 4 day history of black tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.

He also reports that he has a back ache for the past fortnight and has been taking OTC painkillers for it and would like you to prescribe some more”

Case Study


Causes of upper gi bleeding

Common causes: tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.

  • Ulcers – Peptic ulcers (40%)

  • Varices – Secondary to portal hypertension (17%)

  • Gastritis / gastric erosion

  • Duodenitis

  • Oesphagitis

Rarer causes:

  • Mallory -Weiss tears

  • Angiodysplasia

  • Bleeding Disorders

  • Peutz- Jeugher's Syndrome

  • Osler – Webb – Rendu Syndrome

Causes of Upper GI bleeding


Examination investigation

On Examination: tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.

  • He is tachycardic, at 111 bpm / regular and borderline hypotensive 105/72.

  • He is tender in the epigastrium and peri-umbilically. There is some voluntary guarding. Bowel sounds are normal.

  • DRE – Malodorous black tarry stool. No fresh blood.

    Investigations:

  • Bloods : Hb -10.0 , Urea -21 , Creatnine 66, WCC- 7.0, platelets- 260, CRP – 2.2, LFT's – NAD.

  • AXR – NAD

  • Erect CXR – No free air under the diapgram

Examination / Investigation


Management1

Bleep : RR -30 BP- 90 /66 , HR -122, CRT > 3, Sats – 94% tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.

  • A - No airway compromise

  • B – O2, ABG

  • C – IV access + Fluid Challenge (which??), Bloods. IV PPI, erect CXR, AXR

  • D – GCS, Pupils , Glucose

  • E - everything else: check notes,

    CALL FOR HELP

    RE- ASSESS

Management


Rockall score

Rockall Score


Bleeding secondary to ulcers

  • This is a sign of decompensation tarry stools. He reports that they are becoming more frequent and loose. He also reports nausea and one episode of vomiting this morning.

  • ABC approach

  • IV Terlipressin (+ \ - Propanalol)

  • Clotting abnormality – correct it

  • Octreotide ( often given by seniors)

  • Secondary prevention (propanolol)

  • ABC approach

  • IV PPI

  • Endoscopy: CAUTERISTION or CLIPPING of the ulcer

Bleeding secondary to varicies

Bleeding secondary to ulcers


Management of variceal bleeding

Management of Variceal Bleeding


A catheter into the hepatic vein, guidewire was passed into a portal vein branch. The tract was dilated with a balloon, and contrast injected. A metallic stent placed over the wire

TIPS


Thank you any questions
THANK YOU a portal vein branch. The tract was dilated with a balloon, and contrast injected. A metallic stent placed over the wireANY QUESTIONS??


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