Presentation on theme: "Medical Abdomen Kirstin Blackie Nima Mohan. Objectives Be aware of common conditions presenting with abdominal symptoms Understand important factors in."— Presentation transcript:
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?
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
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?
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?
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
Other causes: EBV, CMV, paravirus B19, dengue, yellow fever. Hep AHep BHep CHep DHep 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 BContaminated 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 noneCommon in infants (90%), rarer in adults (10%) 80% develop chronic infection Co-infection with Hep B none Incubation period 3 weeks (range 2-7) 10 weeks (range 4-26) 7 weeks (range 2-21) 5 weeks (range 3-7) 5 weeks (range 3-8)
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
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
US liver “fibrotic, structurally abnormal nodules in liver …. Compatible with cirrhosis. Doppler shows signs of portal hypertension.”
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
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
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???
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
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? Clinic WCC15.9 HB8.2 MCV89 Platelets289 ESRHIGH CRP110 urea17 creatnine110 K+4.6 na+135 LFT'sNAD TFT'sNAD CulturesNo growth
CROHN'S DISEASEULCERATIVE 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
WHAT TYPE OF IMAGING? NAME OF SIGN? WHAT DISEASE? 5 OTHER EXTRA INTESTINAL MANIFESTATIONS OF THIS DISEASE?
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
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)
Surgical Management Surgical management of complications Surgical management of the condition
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???
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
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
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”
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
Management 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 Bleep : RR -30 BP- 90 /66, HR -122, CRT > 3, Sats – 94%
Rockall Score Pre-scope score : predicts the morbidity and mortality Post -scope score : predicts the risk of re-bleeding
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) Bleeding secondary to varicies ABC approach IV PPI Endoscopy: CAUTERISTION or CLIPPING of the ulcer
Management of Variceal Bleeding Sengstaken Blakemore Tube : Balloon Decompression TIPS : Trans-jugular intrahepatic porto systemic shunt
TIPS 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