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ABDOMINAL EXAMINATIONAND DRE Anya Olsen and Olivia Owen Going to go over abdominal exam In the middle some cases: LFT/abdominal history and examination Abdominal x ray 1 ABDOMINAL EXAM • Introduction • Inspection • Palpation • Percussion • Auscultation • Other areas • Summary and offer additional tests Briefly mention same as last time start in hands, move up to neck/face then do chest abdomen and then back 2 INTRODUCTION • Hand hygiene/PPE • Introduce self • Name and role • Confirm patient identity • Name and DOB • Explain examination • Gain consent • Position the patient (45 degrees INITIALLY, flat for palpation!!!) • Obtain adequate exposure (whole torso) • Ask about pain (get them to point to area) Already went through this so can read over it if they need to/same as previous notes REMEMBER for palpation in the abdominal examination the patient needs to be flat!!!! 3 GENERAL INSPECTION • What do we look for? 4 GENERAL INSPECTION • Patient’s bedside • Stoma bag,drains,feeding tubes,other equipment,mobility aids,vital signs, fluid balance,prescriptions • Patient • Discomfort, distensionr( memberthe 6 Fs!),colour, scars, jaundice, hyperpigmentation, oedema, cachexia, hernius, le wasting, scratch marks, spider naevi,tattoos Stoma bag– note the location of the bag! Colostomies often left iliac fossa, ileostomies usually right iliac fossa Drains – note location and contents Distension– fat, fluid,faeces, flatus, foetus, f'in big mass– can anyone write in the chat what these are Scars – previousabdo surgery Colour– pallor suggesting underlyinganaemia could be due to chronic GI bleed ( .g. ulcer, malignancy) Jaundice – yellow pigmentation of skin and whites of eyes due to hyperbilirubinemia (acute hepatitis, liver cirrhosis, cholangitis, pancreatic cancer– painless!) Hyperpigmentation of skin– haemochromatosis Oedema – often associated with liver cirrhosis Cachexia – ongoing muscle loss, associated with malignancy or advanced liver failure Hernia – cough they become more pronounced 5STOMAS– BRIEF EXAMINATION 1 Site Spout • Left iliac fossa–colostomy • Spouted–ileostomy (or urostomy).Small bowel contents are an irritant to the skin,so by spouting it reduces the chance of contact • Right iliac fossa–ileostomy with the skin • Could be a urostomy anywhere, check the contents of the bag for confirmation • Flush – colostomy https://www.aboutkidshealth.ca/Article?contentid=1027&language=English https://geekymedics.com/stom-examination-osce-guide/ https://www.convatec.com/ostomy/patiensupport-information/education/ostomy- basics/ 6STOMAS– BRIEF EXAMINATION 2 Contents of stoma bag Number of lumens • Ileostomy is generally watery and gree• Loop – two lumens (this is often done to relieve a distal obstruction or divert thefaeces from a new distalanastamosis) • Colostomy is thick and sludgy (likf eces) • Urostomy is for urine • End – one lumen Palpation • Palpate around the area for tenderness • Observe any skin changes (erythema, ulceration,fistulation) Stomas can be temporary or permanent! https://www.aboutkidshealth.ca/Article?contentid=1027&language=English https://geekymedics.com/stom-examination-osce-guide/ https://www.convatec.com/ostomy/patiensupport-information/education/ostomy- basics/ 7 HANDS (1) • Inspect • What do we look for? 8HAND SIGNS Clubbingcan indicate GI malignancPalmar erythema is due to high Dupuytren's contracturebdominal IBD,coeliac disease,liver cirrhosoestrogenlevels (reduced metabolism ins are liver disease,heavy alcohol and lymphoma of GI tract liver disease e.g.,cirrhosis) consumption,high cholesterol,diabetes Leukonychiaassociated with Koilonychia and Palla r associated with iron deficiencynaemia hypoalbuminaemidue to decreased (causes = reduced dietary intake,increased demands,malabsorptionproduction in end stage liver disease (or e.g.,coeliac,Crohn’s,increased loss e.g.,malignancy/menorrhagia)protein losing enteropathy) Protein-losing enteropathy (PLE)occurs when albumin and other protein-rich materials leak into your intestine Albumin is the most abundant protein in your blood. It has many functions, including transporting hormones and retaining water in your bloodstream. https://www.verywellhealth.com/whats-clubbing-2249079 https://dermnetnz.org/topics/palmarrythema https://www.emedicinehealth.com/how_do_you_get_dupuytrens_contracture/articl e_em.htm https://www.msdmanuals.com/professional/multimedia/image/koilonychia https://www.newsmedical.net/health/Types-of-Leukonychia.aspx https://stock.adobe.com/hu/search/images?k=pallor 9 HANDS (2) • Palpation • Assesstemperature of hands and arms • Look forfine tremorand flapping tremor • What might aflapping tremor indicate? • Measureright radial pulse (rate and rhythm) • Checktemperatureusingthermometer Hepatic encephalopathy 10 ARMS • Inspection • This is a good place to offer temperature and BP • Injection marks • Lines • Fistulas • Bruising • Excoriations Bruising– underlying clotting abnormalities secondary to liver disease .g. cirrhosis 11HANDANDARM SIGNS Flapping tremorin an abdominal Temperatu– cool hands Excoriationsscratch marks indicate exam is generally due to hepatic suggests poor peripheral perfuspatient might be trying to relieve pruritus encephalopathy ( yperammonaemiaor Think infection ifpyrexic (itchiness) this may suggest cholestasis uremia secondary to renal failure. A respiratory cause = type 2 resp failure (CO2 retention) Arteriovenous fistulais Track mark IVsdrug use used for dialysis in patients increases risk of hepatitis B/Cth end stage renal failure https://twitter.com/wblmd/status/1010588800647680000?lang=gl https://runningmagazine.ca/sections/training/wha-t e-ideal-temperature-for- running/ https://www.msdmanuals.com/home/speciasubjects/recreational-drugs-and- intoxicants/injection-drug-use https://www.shutterstock.com/search/excoriation https://www.verywellhealth.com/arteriovenoufistula-5116891 12 FACE • What do we look for? • Eyes? • Mouth? 13 FACE • Inspection:eyes • Pallor, jaundice, corneal arcus, xanthelasma, Kays-ereischer rings,perilimbal injection • Inspection:mouth • Angular stomatitis, glossitis, oral candidiasis, aphthous ulceration, hyperpigmented macules 14EYE SIGNS Jaundicesuggestive of liver Kayser-Fleischer ringis copper Conjunctival pallor disease or gall bladder deposition around the cornea as a suggestive of anemia obstruction result ofWilson's disease Corneal arcus Xanthelasma Perilimbal injectiionsign of Both of theseare suggestive ofhypercholesterolaemia anterior uveitis which can be associated with IBD https://link.springer.com/article/10.1007/s1160021-06981-5 https://www.nhs.uk/conditions/jaundice/ Corneal arcus: https://webeye.ophth.uiowa.edu/eyeforum/atlas/pages/Arcus/index.htm Xanthelasma: https://www.aao.org/eyehealth/diseases/whatis-xanthelasma https://en.wikipedia.org/wiki/Kayse –rFleischer_ring https://wikem.org/wiki/Uveitis 15MOUTH SIGNS Angular stomatitis as a wide range of causes including iron deficiencyanaemia Oral candidiasisis a fungal Glossitis– smooth erythematous infection commonly associated enlargement.Can be associated with with immunosuppression B12, folate and iron deficiency due to malabsorption Aphthous ulcersare typically benign but can be Hyperpigmentedmacules associated with iron,B12 and are pathognomicfor Peutz- folate deficiency as well as Jegherssyndrome causing Crohn's polyps in GI tract Peutz-Keghers= incredibly rare, autosomal dominant, having lots of polyps can increase bowel cancer risk https://www.britannica.com/science/thrus-h edicine https://en.wikipedia.org/wiki/Angular_cheilitis https://en.wikipedia.org/wiki/Glossitis https://en.wikipedia.org/wiki/Aphthous_stomatitis https://www.clinicaladvisor.com/slideshow/clinic- luiz/oral-hyperpigmentation/ 16 CHEST • Inspection • Gynecomastia • Loss of axillary body hair • Spider naevi 17INSPECTION OF CHEST- FINDINGS Hair loss (axillary)s also caused due Spider naeviare also caused by an Gynaecomastiais to increased levels of circulating increase in circulatingoestrogen. enlargement of male breast oestrogen. Can also be caused by tissue caused by increased malnourishment. If you press thecentrethey should oestrogenlevels due to liver blanch. cirrhosis (reduced metabolism). They are a normal finding in Iatrogenic causes:digoxin and pregnancy or women on the COCP.If spironolactone 5 or more are present,then it is likely to be pathological and associated with liver disease. https://www.yorkshirebreastclinic.com/malereast-gynaecomastia.html https://www.menshealth.com/grooming/a22239311/armph itair-shaving/ https://www.sciencephoto.com/media/260006/view/spid- raevus 18 ABDOMEN – INSPECTION • Scars • Masses • Distension • Visible peristalsis • Caput medusae • Striae • Hernias • Cullen or GreyTurner's sign 19SCARS INABDOMINAL EXAM https://medschool.co/signs/abdomina-scars 20INSPECTION OFABDOMEN FINDINGS Abdominal distension Can be due to 6 Fs • Fat • Fluid • Faeces • Flatus • Foetus Caput medusaeare engorged • F'in big mass periumbilical veins associated with Visible peristalsisindicates portal hypertension e.g.,liver cirrhosis intestinal obstruction Abdominal striae Cullen's (A) and (stretch marks) GreyTurner's (B) caused by rapid are associated with growth e.g.,pregnancy, intrabdominal ascites,malignancy, bleeding such as Cushing's disease, hemorrhagic obesity pancreatitis Grey turners sign = bleeding in flanks Tracking of blood from pancreas https://radiopaedia.org/cases/portah l ypertensionwith-caput-medusae?lang=us https://en.wikipedia.org/wiki/Abdominal_distension https://www.nejm.org/doi/full/10.1056/NEJMicm2007997 https://www.shutterstock.com/search/striae https://www.degruyter.com/document/doi/10.7556/jaoa.2016.081/html 21HERNIAS–TYPES Inguinal hernia • Protrusion of abdominal contents through superficial inguinal ring. • Location:superomedial to pubic tubercle Femoral hernia • Occur below inguinal ligament with contents passing through femoral canal. Bordered by sharp edge of lacunar ligament soigher riskof strangulation and obstruction. • Location:inferolateral to pubic tubercle,medial to femoral pulse Umbilical hernia • Occur at umbilicus, quite common.They can be large but low risk for strangulation. • Location:umbilical region Incisional hernia • Occur at sites of previous operations due to a compromise in tissue integrity. • Location:present as a bulge or protrusion at site of previous surgical incision (anywhere) https://my.clevelandclinic.org/health/diseases/1575hernia 22 ABDOMEN – PALPATION (1) • Lay the patient flat • Ask if the patient has pain (point to where) • Start away from area of pain and do this area last • Kneel by patient • Look at patients face • Superficial palpation in 9 regions,followed by deep palpation in 9 regions • Feeling for tenderness,guarding,rebound ten, ovsings sign,masses Guarding: involuntary tensing in abdominal muscles occurring on palpation generally associated with peritonitis (appendicitis, diverticulitis) Rebound tenderness: whenbdo wall has been pressed slowly then released rapidly this causes sharp abdominal pain. Can be associated with peritonitis Rovsing'ssign: palpation of LIF causes pain in RIF. Indicates peritoneal inflammation in right or left iliac fossa Masses and tenderness: note if on light or deep palpation and what quadrant they were in 23LIGHT PALPATION DEEP PALPATION TENDERNESS: look at the patients face/ ask the MASSES: patient to let you know if they feel any pain Comment on • Location GUARDING: involuntary contraction of abdominal • Size muscles on palpation • Shape Associated with peritonitis • Consistency • Mobility REBOUNDTENDERNESS • Pulsatility(AAA?) Sharp pain on removal of hand after palpation Associated with peritonitis ROVSING’s SIGN Palpation of LIF causes RIF Associated with appendicitis and peritonitis MASSES Palpable on light palpation if large or superficial 24 ABDOMEN – PALPATION (2) • Palpate for organomegaly • Liver (and Murphy's sign) • Kidney • Spleen • Bladder • Abdominal aortic aneurysm 25 ABDOMEN - PERCUSSION • Percuss for evidence of organomegaly, urinary retention, ascites • Liver • Spleen • Bladder • Flanks– shifting dullness Shifting dullness attempts to identify any ascites present. Start at umbilicus and percuss laterally to flank. If any dullness noted this may be due to ascites. If there is get the patient to roll on to the opposite side and wait 30 seconds. If ascites was present when you percuss from the flank back to the umbilicus it should now be resonant 26PALPATION/PERCUSSION FIND-I1 GS Murphy's sign Hepatomegaly If you can feel liver edge,comment on: Place hands right costal margin, mid Enlarged kidneys • How far below costal margin clavicular line at liver edge and get patiRight kidney here has obstructive renal stone. • Consistency (nodular = cirrhosis) to take a deep breath. Always describe size and consistency • Tenderness (hepatitis, cholecystitis) • Pulsatility (tricuspid regurgitation) If patient stops mid breath due to pain thCauses: suggests cholecystitis and is Murphy's sigBilaterally enlarged, ballotable kidneys = Causes: hepatitis, malignancy, anything thap sitive polycystic kidneys or amyloidosis causes cirrhosis (Wilson's, Unilaterally enlarged, ballotable kidney = renal haemochromatosis,AIH,PBC),leukaemia, tumour,renal stone obstruction causing myeloma, glandular fever, haemolytic anaemia,tricuspid regurgitation hydronephrosis Causes of hepatomegaly includes anything that causes cirrhosis 27PALPATION/PERCUSSION FIND-I2 GS Enlarged bladder Splenomegaly AAA Patients who are regularly passing urine In normal individuals you should not Note the movement of your will not have a palpable bladder. feel the spleen.This is an excessively fingers. If it is distended it will be in the suprapubic enlarged spleen due to B cell • Healthy– hands should move area arising from behind the pubic lymphoma. superiorly with each symphysis and is a result of urinary Causes: portal hypertension secondary pulsation obstruction/retention to liver cirrhosis,haemolytic anaemia, • AAA– hands move congestive heart failure,splenic outwards = expansile mass metastases, glandular fever, haematological malignancies https://onlinelibrary.wiley.com/doi/full/10.1002/jgf2.413 https://www.stanfordchildrens.org/en/topic/default?id=abdominalaorticaneury- m 85-P08247 https://teachmesurgery.com/urology/presentations/acu-urinary-retention/ 28 What is the most likely diagnosis? A.Alcoholic hepatitis B.Pancreatic cancer C.Primary biliary cirrhosis D.Paracetamol overdose E. Gallstones B pancreatic cancer Courvoisier's sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree. (or ampulla of duodenum) Alcoholic hepatitis and primary biliary cirrhosis are a reasonable differentials. However, an examination finding of a painless, enlarged gallbladder makesboth of these differentials less likely. The scenario does not suggest paracetamol overdose, as this would not cause a painless, palpable gallbladder. Furthermore, jaundice is not usually seen in paracetamol overdose 29 What is the most likely diagnosis? A.Alcoholic hepatitis B.Pancreatic cancer C.Primary biliary cirrhosis D.Paracetamol overdose E. Gallstones B pancreatic cancer Courvoisier's sign states that in a patient with a painless, enlarged gallbladder and mild jaundice the cause is unlikely to be gallstones. Furthermore, it is more likely to be a malignancy of the pancreas or biliary tree. (or ampulla of duodenum) Alcoholic hepatitis and primary biliary cirrhosis are a reasonable differentials. However, an examination finding of a painless, enlarged gallbladder makesboth of these differentials less likely. The scenario does not suggest paracetamol overdose, as this would not cause a painless, palpable gallbladder. Furthermore, jaundice is not usually seen in paracetamol overdose 30 A.Primary biliary cirrhosis B.Acute pancreatitis C.Cholecystitis D.Ascending cholangitis E.Viral hepatitis D This patient has Charcot's triad of fever, right upper quadrant pain and jaundice suggesting that ascending cholangitis is the most likely diagnosis especially with the history of confirmed gallstones. Treatment is with intravenous antibiotics. Discuss (6)Improve 31 A.Primary biliary cirrhosis B.Acute pancreatitis C.Cholecystitis D.Ascending cholangitis E.Viral hepatitis D This patient has Charcot's triad of fever, right upper quadrant pain and jaundice suggesting that ascending cholangitis is the most likely diagnosis especially with the history of confirmed gallstones. Treatment is with intravenous antibiotics. Discuss (6)Improve 32 ABDOMEN - AUSCULTATION • With diaphragm for bowel sounds • Bell for aortic and renal bruits 33BOWEL SOUNDS Ileus Normal Obstruction There would be no bowel sounds present. Should hear a gurgling This is a small bowel obstructioMust listen for 3 minutes to confirm You should hear a tinkling sound This is due to disruption of the normal propulsive ability due to a malfunction in peristalsis.This could be due to electrolyte abnormalities or recent abdominal surgery. https://radiopaedia.org/cases/normaa lbdominal-x-ray-1 https://radiopaedia.org/articles/sma-lb l owel-obstruction https://undergradimaging.pressbooks.com/chapter/ileus/ 34 What is the most likely diagnosis? A.Diverticulitis B.Small bowel obstruction secondary to a strangulated inguinal hernia C.Linitusplasticaof the stomach D.Large bowel obstruction secondary to volvulus E. Ovarian cancer with associated ovarian torsion B The CT shows multiple dilated loops of small bowel. CT is more sensitive than radiographs and will also demonstrate the cause in around 80% of cases. There are variable criteria for maximal small bowel obstruction, but 3.5 cm is a conservative estimate of dilated bowel. 35 What is the most likely diagnosis? A.Diverticulitis B.Small bowel obstruction secondary to a strangulated inguinal hernia C.Linitusplasticaof the stomach D.Large bowel obstruction secondary to volvulus E. Ovarian cancer with associated ovarian torsion B The CT shows multiple dilated loops of small bowel. CT is more sensitive than radiographs and will also demonstrate the cause in around 80% of cases. There are variable criteria for maximal small bowel obstruction, but 3.5 cm is a conservative estimate of dilated bowel. 36BRUITS Aortic Renal Can be associated with abdominal aortic anCan be associated with renal artery stenosis https://geekymedics.com/peripheravascularexamination/ https://www.clicktocurecancer.info/physicae lxamination/auscultationlln.html 37 BACK • Renal angle tenderness • Cervical lymph nodes 38BACK FINDINGS Costovertebral angle tenderness (renal) Can be due to kidney stone,ureteric stone, Lymphadenopathy ureteropelvic obstruction,kidney abscess,urinary tract infection,vesicoureteral reflux disorders(lupus,rheumatoid arthritis), malignancy,medications(allopurinol,atenolol, cephalosporins,penicillin,phenytoin),or they can be benign Supraclavicular node (Virchow's node) On the left due to gastric cancer! You can press on a renal angle because if a patient has pyelonephritis this will be painful enough Cervical LN palpation - No spider fingers - Use pads of fingers and circular motions - Palpateall of the areas - Submental – submandibular – tonsillar/parotid (behind angle of mandible– pre- auricular– post-auricular– occipital – anterior and posterior cervical– supraclavicular (ask patient to bring ear to shoulder) https://slideplayer.com/slide/8877401/ https://www.bsuh.nhs.uk/library/w- ontent/uploads/sites/8/2020/06/Paediatric guidelines-Lymphadenopath-ynd-lymphadenitis.pdf 39 LEGS • Inspection/palpation • Ankle oedema 40LEG SIGNS Pedal/ankle oedeisaue to hypoalbuminaemia (liver cirrhosis,protein losing enteropathy) https://en.wikipedia.org/wiki/Edema 41 OTHER AREAS • BP • Temperature • DRE • Hernia exam • External genitalia exam • https://geekymedics.com/bimanual aginal-examination/ • https://geekymedics.com/testicularxamination-osce-guide/ 42 TO COMPLETE THE EXAMINATION • Explain the examination is over and thank the patient • Allow the patient to redress • Dispose of PPE and wash your hands • Summariseyour findings(1 minutes) 43 EXAMPLE SUMMARY Today I did an abdominal examination on -XeXrX -old.On general examination there was no signs of distension or jaundice and no medical equipment around the bed.On peripheral inspection there was no clubbing,palmar erythema or leukonychia.There was no flapping tremor and the pulse was XX beats per minute and regular. On inspection of the face there was no corneal arcus,oral candidiasis or angular stomatitis.On inspection of the chest and abdomen there was no hair loss, gynaecomastia or spider naevi.On palpation,both superficial and deep,there were no masses or tenderness with Murphy's sign negative.On percussion was no organomegaly with no urinary retention.No kidney tenderness,aorta was palpable but not expansile.On auscultation bowel sounds were present and no renal or aortic bruits present.There was ankle oedema and no lymphadenopathy.I would also offer DRE,external genitalia,hernia exam,bloods (LFTs,U&Es,FBC,CRP),AXR. 44 DIGITAL RECTAL EXAMINATION • Equipment:gloves,apron,lubricant,paper towels • Key things in the introduction are EXPLANATION, CHAPERONE, CONSENT and MAINTAINING DIGNITY • “Today I need to perform a rectal examination.This will involve me inserting a finger into your anus to feel for any abnormalities.It shouldn’t be painful,but it will feel a little uncomfortable. You can ask me to stop at any point.” • State that there will be another member of staff present • Check the patient understands what you said and that they have consent • Allow the patient to undress in private and provide them with a blanket or towel to cover with,only remove this when necessary and check with the patient first 45DRE SIGNS– 1 Inspection • Excoriation: anal pruritus caused by haemorrhoids, faecal incontinence or constipation • Skin tags: benign, can be associated with IBD • External haemorrhoids (piles)below dentate line, appear as a lump just inside/outside anal verge • Anal fissure: small tear in anal canal, generally in posterior midline. Often secondary to constipation and are painful • External bleeding: due to external haemorrhoids, anal cancer of brisk GI bleeding • Anal fistula: abnormal channel between anal canal and perianal skin. May have pus and surrounding inflammation.Causes are perianal Crohn's, chronic anal abscess and diverticulitis Get patient to cough and inspect for: • Anal prolapse : mass of concentric rings of mucosa will protrude • Internal haemorrhoids above dentate line, are bluish, bulging vessels. Often asymptomatic http://www.kirurgiskklinik.com/en/patieni formation/hemorrhoids https://mehtaperturk.com/en/anafissure-symptoms/ 46DRE SIGNS– 2 Prostate examination • Comment on size, symmetry and texture • Should be walnut sized with palpable midline sulcus,symmetrical with consistency similar to tip of nose Anal canal examination • Note the size, location and texture or any rectal lumps (tumour, polyp, internal haemorrhoid) • Check for any hard stool which indicates constipation • Location of any tenderness (anal fissure,thrombosed internal haemorrhoids) Anal tone assessment • Get patient to bear down • Reduce anal tone includes spinal cord pathology (cauda equina syndrome),IBD and previous rectal surgery Final steps • Check finger for blood or mucous • Dark sticky blood =malaenadue to UGI bleed (stomach ulcer) • Fresh red = lower GI blood (rectal malignancy,fissure) • Excess mucous = IBD (UC) Dr SarahHearnshaw Consultant Gastroenterologist Royal Victoria Infirmary Newcastle upon Tyne– malaena https://www.baus.org.uk/patients/conditions/9/prostate_symptoms_bladder_outlet _obstruction/ 47 DRE – TO COMPLETE • Thank the patient • Provide them with paper towels to clean up • Allow them to redress in private • Summarize findings • Document the examination including the chaperones name and how the patient consented e.g.,verbal consent/ written consent • Abdominal examination, FIT testing, colonoscopy and CT scan might be relevant to offer 48CASES 49 A.Low urea B.High urea C.Low potassium D.High sodium E. Low creatinine High urea = protein meal– either high protein diet or UGI bleed. Latter occurs as a result of gut bacteria breaking down blood proteins. Naproxen increases risk of gastric bleeds. Investigations support anaemia 50 A.Low urea B.High urea C.Low potassium D.High sodium E. Low creatinine High urea = protein meal– either high protein diet or UGI bleed. Latter occurs as a result of gut bacteria breaking down blood proteins. Naproxen increases risk of gastric bleeds. Investigations support naemia 51A.Chronic alcohol abuse B.Gallstones C.Hepatitis infection D.Inflammatory bowel disease E. Smoking cigarettes 52 A.Chronic alcohol abuse B.Gallstones C.Hepatitis infection D.Inflammatory bowel disease E. Smoking cigarettes The most common cause of chronic pancreatitis is alcohol excess This is a typical history of chronic pancreatitis- abdominal pain following meals, pancreatic enzymes,steatorrhoea, and diabetes. By far the most common cause of chronic pancreatitis is alcohol abuse, leading to chronic inflammation affect both the exocrine and endocrine functions of the pancreas. 53A.Peptic ulcer B.Gallstones C.Hepatocellular carcinoma D.Hepatitis D super infection E. Alcoholic liver disease 54 A.Peptic ulcer B.Gallstones C.Hepatocellular carcinoma D.Hepatitis D super infection E. Alcoholic liver disease Hepatitis D superinfection isan differential for chronic hepatitis B patients with acute flare up Hepatitis D should be remembered as a possibility in Hep B patients with risk factors such as intravenous drug use (IVDU). Hepatocellular carcinoma is an important differential diagnosis in any patient with chronic liver disease, but the short duration of symptoms, young age of the patient, and lack of weight loss make it less likely although still important to rule out. Peptic ulcers are common but often related to alcohol / NSAID use rather than IVDU. Alcoholic liver disease is also less likely given lack of alcohol history. Gallstones would typically cause colicky pain after eating. 55 Most likely diagnosis? A.Oesophagitis B.Oesophagealcancer C.Peptic ulcer D. GORD E.Lung cancer Oesophageal cancer 56 Most likely diagnosis? A.Oesophagitis B.Oesophagealcancer C.Peptic ulcer D. GORD E.Lung cancer Oesophageal cancer 57 LFTS (FYI) Bilirubin ALT vs ALP • Hyperbilirubinaemiacauses jaundice • ALT – hepaTocellularinjury • Normal urine + stools = pr-eepatic • More thanTENfold increase inALT indicates hepatocellular injury • Dark urine + normal stools = hepatic • ALP – cholestasis(P for Pause) • Dark urine + pale stools = poshepatic (obstructive) • More thanTHREEfold increase inALP indicates cholestasis Unconjugatedhyperbilirubinaemi auses • Only ALP rise = bony metastases, vit D deficiency, recent bone • Haemolysis,impaired hepatic uptake,impaired fracture,renal osteodystrophy conjugation GGT Conjugatedhyperbilirubinaemi auses • If rise inALP,check GGT as can suggest biliary epithelial damage • Hepatocellular injury, cholestasis and bile flow obstruction. Isolated bilirubin rise • Can be raise due to alcohol and drugs e.g. phenytoin • Gilbert's syndrome,haemolysis • Markedly raised ALP with raised GGT = cholestasis (normally) https://geekymedics.com/interpretatio- f-liver-function-tests-lfts/ 58 QUESTIONS? Someone asked on the feedback form what to expect in the OSCE for data interp How does it work with showing signs– are you meant tocome up witha differential Data interp: what to revise, what often comes up, how it went for me Key organisms to know? 59 SOURCES https://teachmesurgery.com/examinations/gastrointestinal/stoma/ https://geekymedics.com/abdominal xamination/ https://geekymedics.com/herni-examination-osce-guide/ https://geekymedics.com/stom-examination-osce-guide/ https://geekymedics.com/rectal xamination-pr/ 60
