Medical Abdomen

1. Kirstin Blackie Nima Mohan Medical Abdomen

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

3. Causes of Abdo Pain

4. 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

5. 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

6. 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:

7. 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

8. 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

9. 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

10. Other causes: EBV, CMV, paravirus B19, dengue, yellow fever.

11. Hepatitis E endemic areas

12. Girlfriend • Mr C 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

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

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

18. What are the possible causes of ascites?

19. 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

21. 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?

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

23. 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

24. 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?

25. “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

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. 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??

28. 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?

30. 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

33. Clinic

34. 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

35. 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

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

37. 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

38. 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

39. 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

40. “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

41. 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

42. 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

43. 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

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

45. 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

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

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 TIPS

48. THANK YOUANY QUESTIONS??