1. Kirstin Blackie Nima Mohan
Medical Abdomen
Kirstin Blackie
Nima Mohan

2. Objectives
Be aware of common conditions presenting with abdominal symptoms
Understand important factors in the history, examination, investigation and management of common abdominal pathologies.

3. Causes of Abdo Pain

4. What other symptoms would you want to ask about?
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?

5. 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

6. 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?

7. 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?

8. Liver Function Tests Viral hepatitis: Alcoholic 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

9. 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
Oestrogens
erythromycin

10. Other causes: EBV, CMV, paravirus B19, dengue, yellow fever.
Hep A
Hep B
Hep C
Hep D
Hep E
Route of transmissio n
Faecal-oral (contaminate d water/food, oro-anal sex)
Blood products, body fluids, sexual contacts
Blood products
As for Hep B
Contaminated water
People at risk
Childcare workers, MSM
vertical transmission, sexual partners, healthcare workers, Tattoos, body piercings, blood transfusions, IVDU
IVDU, tattoos
Less commonly: vertical transmission, sexual transmission
Those at risk of Hep B or with chronic Hep B
Travel to endemic areas, and sporadic outbreaks associated with poor sanitation eg refugee camps
Potential for chronic infection
none
Common in infants (90%), rarer in adults (10%)
80% develop chronic infection
Co-infection with Hep B
Incubation period
3 weeks (range 2-7)
10 weeks
(range 4-26)
7 weeks
(range 2-21)
5 weeks
(range 3-7)
(range 3-8)
Other causes: EBV, CMV, paravirus B19, dengue, yellow fever.

11. Hepatitis E endemic areas

12. Mr C and his girlfriend are both tested for viral hepatitis

13. Hepatitis B Serological Markers

15. What are the differential diagnoses?
65 year old man who hasn’t been to his GP in years comes into A+E with an uncomfortable swollen abdomen
What are the differential diagnoses?

16. 5 Fs of distended abdomen
Fat
Faeces
Fluid
Foetus
Flatus
How would you examine for fluid (ascites)?

17. Shifting Dullness
Does the presence of ascites prove that this patient has liver disease?

18. What are the possible causes of ascites?

19. 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

21. 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

22. US liver
“fibrotic, structurally abnormal nodules in liver …. Compatible with cirrhosis. Doppler shows signs of portal hypertension.”

23. 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

24. 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

25. What other questions would you ask her???
Case Study
“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 ask her???

26. 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

27. 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

28. What is your immediate management plan?
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?
WCC
15.9 HB
8.2
MCV 89
Platelets
289
ESR
HIGH
CRP
110
urea 17
creatnine K+
4.6
na+
135
LFT's
NAD
TFT's
Cultures
No growth

29. RADIOLOGICAL FEATURES
CROHN'S DISEASE
ULCERATIVE COLITIS
CLINICAL FEATURES
Abdominal pain
peri-anal disease
Constitutuional Symptoms
Gastro-inestinal bleeding
Diahorrea < 6 episodes /day
Rectal Spasm
EXAMINATION FEATURES
RIF mass
Per-anal skin tags
Fistulas
Scars / Stomas – ileostomy / colostomy bags.
RADIOLOGICAL FEATURES
Fistula formation
Asymetrical / skip lesions
Rose thorn ulcers
Ileal involvement
Rectal involvement
Superficial ulcers
ENDOSCOPIC
FEATURES
Cobble stone mucosa
Transmural disease
Granluoma formation
Stricture formation
Superficial ulceration
Stud ulcers
Pseudopolyps.
Crypt abscesses
COMPLICATIONS &
PROGNOSIS
Fistula formation – perianal
Toxic megacolon – perforation
Small bowel obstruction
Malignancy
Large Bowel obstruction
Toxic Megacolon
Primary sclerosing cholangitis.
Increased Risk of Malignancy

30. WHAT TYPE OF IMAGING. NAME OF SIGN. WHAT DISEASE
WHAT TYPE OF IMAGING? NAME OF SIGN? WHAT DISEASE? 5 OTHER EXTRA INTESTINAL MANIFESTATIONS OF THIS DISEASE?

31. 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

32. RADIOLOGICAL FEATURES
CROHN'S DISEASE
ULCERATIVE COLITIS
CLINICAL FEATURES
Abdominal pain
peri-anal disease
Constitutuional Symptoms
Gastro-inestinal bleeding
Diahorrea < 6 episodes /day
Rectal Spasm
EXAMINATION FEATURES
RIF mass
Per-anal skin tags
Fistulas
Scars / Stomas – ileostomy / colostomy bags.
RADIOLOGICAL FEATURES
Fistula formation
Asymetrical / skip lesions
Rose thorn ulcers
Ileal involvement
Rectal involvement
Superficial ulcers
ENDOSCOPIC
FEATURES
Cobble stone mucosa
Transmural disease
Granluoma formation
Stricture formation
Superficial ulceration
Stud ulcers
Pseudopolyps.
Crypt abscesses
COMPLICATIONS &
PROGNOSIS
Fistula formation – perianal
Toxic megacolon – perforation
Small bowel obstruction
Malignancy
Large Bowel obstruction
Toxic Megacolon
Primary sclerosing cholangitis.
Increased Risk of Malignancy

33. Clinic

34. 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

35. 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)
Goals of treatment
1) to achieve the best possible clinical, laboratory, and histological control of the inflammatory disease with the least adverse effects from medication;
(2) to promote growth with adequate nutrition; and
(3) to permit the patient to function as normally as possible (eg, in terms of school attendance, participation in activities).

36. Surgical Management Surgical management of complications
Surgical management of the condition

37. What else do you want to know???
CASE STUDY
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???

38. Irritable bowel Syndrome
Incidence: common (female ) ; 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

39. 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

40. Case Study
“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”

41. 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

42. 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 , 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

43. Management CALL FOR HELP RE- ASSESS
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

44. Rockall Score Pre-scope score : predicts the morbidity and mortality
Post -scope score : predicts the risk of re-bleeding

45. Bleeding secondary to ulcers
ABC approach
IV PPI
Endoscopy: CAUTERISTION or CLIPPING of the ulcer
Bleeding secondary to varicies
This is a sign of decompensation
ABC approach
IV Terlipressin (+ \ - Propanalol)
Clotting abnormality – correct it
Octreotide ( often given by seniors)
Secondary prevention (propanolol)

46. Management of Variceal Bleeding
Sengstaken Blakemore Tube : Balloon Decompression
TIPS : Trans-jugular intrahepatic porto systemic shunt

47. 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
A catheter into the hepatic vein and after needle puncture, a guidewire was passed into a portal vein branch. The tract was dilated with a balloon, and contrast injected. A self-expandable metallic stent placed over the wire
TIPS

48. THANK YOU ANY QUESTIONS??