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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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objectives
Be aware of common conditions presenting with abdominal symptoms
  • Understand important factors in the history, examination, investigation and management of common abdominal pathologies.
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)
  • 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
Has recently has ‘flu’ – has felt generally unwell, tired and vaguely nauseated. He is unsure but thinks he may have had a mild fever.
  • What risk factors would you ask about?
Case study cont:
risk factors for liver disease
High Alcohol intake
  • 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:
    • 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:
    • 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
5 fs of distended abdomen
Fat
  • Faeces
  • Fluid
  • Foetus
  • Flatus

How would you examine for fluid (ascites)?

5 Fs of distended abdomen
shifting dullness
Shifting Dullness

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

cirrhosis common end point of many disease processes
Alcohol excess
  • 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:

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
“fibrotic, structurally abnormal nodules in liver …. Compatible with cirrhosis. Doppler shows signs of portal hypertension.”US liver
complications of cirrhosis
Anaemia (folate deficiency, hypersplenism)
  • 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
  • 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
slide26
She denies......
  • 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
  • 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??
slide28

Clinic

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?

slide30
WHAT TYPE OF IMAGING?NAME OF SIGN?WHAT DISEASE? 5 OTHER EXTRA INTESTINAL MANIFESTATIONS OF THIS DISEASE?
slide31

EXTRA INTESTINAL MANIFESTATIONS

  • 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
primary sclerosing cholangitis
Strongly association with UC (less with CD)
  • 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

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
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

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:

  • 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:

  • 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%

  • 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
Pre-scope score : predicts the morbidity and mortality
  • Post -scope score : predicts the risk of re-bleeding
Rockall Score
bleeding secondary to ulcers
This is a sign of decompensation
  • 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
Sengstaken Blakemore Tube : Balloon Decompression
  • TIPS : Trans-jugular intrahepatic porto systemic shunt
Management of Variceal Bleeding
slide47

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
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