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ALL YOU NEED TO KNOW ABOUT Abdominal Pain and LFs’ Amelia Snook and Prisha Pahariya Here’s what we do: ■ Weekly tutorials open to all! 18:00 every Thursday ■ Focussed on core presentations and If you’re new here… teaching diagnostic technique from a clinical perspective ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats! Learning Objectives 01 02 03 04 Identify the aetiology, Consider the differences Know the indications of Understand how to investigation and signs, •Initial vs gold-standard of symptoms and signs you to present your findings (as awareness of management •Initial vs definitive management might look for). in a CPSA/OSCE conditions that present with scenario). abdominal pain.Some relevant UKMLA Conditions ■Acute cholangitis ■Alcoholic hepatitis ■Biliary atresia ■Cirrhosis ■Gallstones and biliary colic ■Hepatitis ■Substance use disorderSome ■ This is to see what you know already – we quick -fire will speak about the answers at the end and see if your answers change! questions ■are more likely to learn that way. unsure – you to start… ■A 40-year-old woman has come into the GP complaining of pain in her right side. She says that it comes and goes, but is especially bad just after eating. It has been going on for a few months, and she also mentions that she has gained a lot of weight recently, now with a BMI of 34. SBA 1 What is the most likely diagnosis? ■A) Acute pancreatitis ■B) Biliary colic ■C) Cholecystitis ■D) Gastro-oesophageal reflux disease ■E) Peptic ulcer ■ A 65-year-old man presents to the emergency department complaining of extreme pain, feeling like his insides have (SOCRATES!), he tells them that the pain appears to go through to his back. The man is becoming more confused and is sweating profusely, and subsequently collapses inthe ED. What is the definitive management for this condition? SBA 2 ■ A) Oral ibuprofen ■ B) IV labetalol ■ C) IV 0.9% sodium chloride ■ D) Oral aspirin ■ E) Laparotomy ■ A 24-year-old presents to the Emergency Department after her partner noticed that she had turned yellow. She is very other problems recently. You investigate by sending offed no LFTs and receive the following results:  ALT: 40 U/L. AST:25 SBA 3 U/L. ALP: 45 umol/l. GGT: 25 U/L. Total protein: 6.5 g/dL. results are normal. What is the most likely diagnosis?d ■ A) Acute cholecystitis Test Reference range ALT 3-40 iu/l ■ B) Pancreatic cancer ■ C) Gilbert’s AST 3-30 iu/l ALP 30-100 umol/l ■ D) Hepatitis C ■ E) Hepatocellular carcinoma GGT 8-60 u/l Bilirubin 3-17 umol/l Albumin 35-50 g/lSome key conceptsQuestions to ask for abdominal pain Two of the most important things: 1. Onset of pain - acute, subacute, chronic 2. Site of pain - based on the nine regions History - Age and gender - Pain onset - Characterisation - Colicky? - Severe pain on movement? - Tearing pain? - Constant dull pain? - Constant sharp pain?What are the key differentials for abdominal pain? Gastrointestinal ● Gastroduodenal: peptic ulcer disease, gastritis, gastric cancer, GORD ● Intestinal: appendicitis, diverticulitis, gastroenteritis, strangulated hernia, Crohn’s, ulcerative colitis, irritable bowel syndrome, volvulus, intussusception, mesenteric adenitis, bowel ischaemia ● Hepatobiliary: cholecystitis, cholangitis, biliary colic, hepatitis, hepatic abscess, hepatic congestion (e.g. heart failure) ● Pancreatitis: acute pancreatitis, chronic pancreatitis, pancreatic cancer Renal and urinary e.g. cystitis, pyelonephritis, Gynaecological e.g. ruptured ectopic pregnancy, ovarian torsion Vascular e.g. AAA, aortic dissection, ischaemic colitis Other e.g. sickle cell crisis, adrenal insufficiencyWhat are the functions of the liver? HINT: There are 5! 4. Synthetic 1. a. Removes toxins and byproducts b. Fat-soluble vitamins (DrAKE) c. Clotting factors (vitamin K -> 1972) 2. Metabolic a. Mand amino acidss, fats b. Conjugates bilirubin 5. Detoxification d. Binsulinown hormones such as e. Converts toxic ammonia into 3. a. Glycogen, iron and copper urea for excretion(Brief) Anatomy of the biliary tree and gallbladder Common risk factors for gallbladder disease mnemonic: Fair, female, fat, fertile and 40Understanding the causes of JaundiceLFTsWhy are LFT s checked? To investigate patients To monitor patients with with suspected liver confirmed liver disease disease (e.g. cirrhosis) To monitor the effects of As part of baseline potentially hepatotoxic screening for patients medications presenting with a wide range of symptoms.What do Test Reference range LFT s include? ■ Alanine transaminase ALT 3-40 iu/l (ALT) and Aspartate AST 3-30 iu/l aminotransferase (AST) ■ Alkaline phosphatase ALP 30-100 umol/l Gamma-glutamyltransfer ase (GGT) GGT 8-60 u/l ■ Bilirubin ■ Albumin Bilirubin 3-17 umol/l Albumin 35-50 g/lLocation: AL T , AST , ALP and GGT ■ ALT – found in the liver parenchymal cells (more specific) ■ AST – found in liver parenchymal cells, myocardium, skeletal muscle, kidneys and brain ■ ALP – found in bile duct and bone ■ GGT – found in bile duct What is it? What is it a marker of? What does an isolated bilirubin rise without Bilirubin further LFT derangement suggest? • Breakdown product of haemoglobin, released What is it? into the blood when RBCs haemolyse • Marker of severity of acute cholestatic What is it a marker of? pathology and acute hepatocellular liver injuries. What does an isolated bilirubin rise without further • Pre-hepatic jaundice or Gilbert’s disease LFT derangement suggest?Source: http://medicalstudentsharing.blogspot.com/2017/07/bilirubin-results-interpretation-made.html What does albumin demonstrate? • Synthetic function of the liver, e.g. in hepatocellular injuries, synthetic functions of the liver become impaired 🡪 liver cannot produce albumin 🡪 studies are also undertaken as well and Albumin What does may show prolonged prothrombin time albumin (since clotting factors are created by the demonstrate? liver). • This may be impaired even if ALT/AST is normal (often in chronic hepatocellular pathology, such as cirrhosis, ALT/AST may return to normal). Fill in the gaps: Question 1 Acute hepatocellular damage Cholestasis ALT AST ALP GGT Bilirubin Fill in the gaps: Question 1 Acute hepatocellular damage Cholestasis ALT ↑↑ Normal or ↑ AST ↑↑ Normal or ↑ ALP Normal or ↑ ↑↑ GGT Normal or ↑ ↑↑ Bilirubin Range from normal to ↑↑ Range from normal to ↑↑ Fill in the gaps: Question 2 Laboratory Hepatocellular Cholestatic Mixed test disease disease disease ALT ALP ALT/ALP Fill in the gaps: Question 2 Laboratory Hepatocellular Cholestatic Mixed test disease disease disease ALT Raised at least Normal Raised at 2-fold least 2-fold Raised at Raised at ALP Normal least 2-fold least 2-fold ALT/ALP 5+ <2 2-5 How do you interpret Liver Function T ests (LFT s)? Use the reference ranges to help you. >10-fold increase in ALT, <3-fold increase in ALP Hepatocellular injury. ALT/AST enters the circulation when hepatocytes burst/die <10-fold increase in ALT, >3-fold increase in ALP Cholestasis. ALP/GGT produced by cells in the biliary tree. Take longer than transaminase to rise. Mixed picture. Cholestasis + hepatocellular injury Isolated ALP rise without GGT rise Bone pathology: bone cancer, vitamin D deficiency, recent bone .ALP produced in the bone. GGT increase Rise caused by biliary epithelial damage in bile flow obstruction. Rise also seen with alcohol + phenytoin. How do you interpret Liver Function Tests (LFTs)? AST>ALT Alcohol-related injury ALT>AST Ischaemic liver, viral hepatitis, drug-injury hepatitis ALT in 1000s Acute viral hepatitis, ischaemia, paracetamol Y our turn to practice. Imagine you are in a CPSA/OSCE scenario. Present the results of the LFTs. Suggest a list of possible differentials. Unmute yourself or write your thoughts in the chat. Remember that mistakes are the only way you learn.Case 1 th You are a 4 year medical student in General Practice who has been asked to see Lily, a 44-year-old woman, presenting with right-sided aching abdominal pain. Please answer the following questions: ■ What questions would you ask her? ■ What examinations might you do? ■ What investigations might you request? – Bedside? – Imaging? – Special tests? Amelia Snook and Prisha Test Reference range Lily, 44 years-old, BMI 31, PC: dull ALT 3-40 iu/l aching pain on right side of tummy AST 3-30 iu/l ALP 30-100 umol/l Bili 17 ALT 72 GGT 8-60 u/l U/l U/L Bilirubin3-17 umol/l Albumin 35-50 g/l AST 32 ALP 89 U/L U/L Non-alcoholic Alb fatty liver disease Plt 313 (NAFLD) 40g/dL Non-alcoholic fatty liver disease (NAFLD) WHAT WOULD YOU DO HOW WOULD YOU EXPLAIN WHAT IS THE MANAGEMENT NEXT? THIS CONDITION TO A STRATEGY? PATIENT?Case 2 You are a 4 year medical student in A&E who has been asked to see Mr Smith, a 47-year-old man, brought in by his wife Mrs Smith. Mr Smith has presented with acute onset abdominal pain. Please take a focused history and interpret his investigations. You will then be asked to present your case to the examiner. Amelia Snook and Prisha Pahariya Pain related questions (SOCRATES) •Site: •RUQ tenderness •Onset: •started last night after a takeaway •C•‘Comes and goes and is a dull ache’ •Radiation: What are some •‘Sometimes goes to the back’ •Associated Symptoms: •Feeling quite nauseous, dark urine and pale stools questions that •Timing: •constant pain you might ask •Exacerbating factors: •“tried to have some fries for lunch and it made it worse” in a focused •Severity: •8/10 history? Screening for other risk factors •Recent ERCP or other surgeries? •Recent illness or infections? •Hepatotoxic medications e.g. paracetamol •Safety netting: chest pain, palpitations, breathlessness Amelia Snook and Prisha Pahariya Other key symptoms to ask in a GI history • Dysphagia •Heartburn •Dyspepsia •Nausea and vomiting •Change in bowel habit - onset, consistency, frequency, additional features, associated symptoms •Bleeding • Upper GI bleeding (vomiting bright red blood or ‘coffee ground’ material), melaena Other • Lower GI bleeding (passing bright red blood, may be seen on wiping with toilet paper) questions to •Jaundice •Weight loss ask Alcohol use - of 3-4 units in any one dayen and women is 14 units/week with a max - Units of alcohol = alcohol percentage (%) x quantity (litres) - E.g. 44% x 0.75 = 33 units a day Amelia Snook and Prisha Pahariya What further tests and investigations might you order? Examination Slightly more (O/E) Bedside tests invasive • scratch marks • Temperature: • Blood gases on arms, scleral 39.1, BP: 90/60, • FBC: raised icterus, RUQ Pulse: 137bpm, WCC tenderness, PaO2: 99% • CRP: raised patient finding it • Urine dipstick, • LFTs: next slide difficult to follow ECG instructions Amelia Snook and Prisha Pahariya Hepatitis What are your Pancreatitis differentials Peptic ulcer disease currently? Mirizzi syndrome Hepatic abscess Amelia Snook and Prisha PahariyaLFTs – What is your Test Reference range ALT 3-40 iu/l diagnosis? AST 3-30 iu/l ALP 30-100 umol/l Bili 100 ALT 100 GGT 8-60 u/l U/l U/L Bilirubin3-17 umol/l Albumin 35-50 g/l AST 80 ALP 400 U/L U/L Alb PT : Acute Cholangitis slightly 40g/dL prolonged A reminder of the patient’s presentation… -O/E: - scratch marks on arms, scleral icterus, RUQ tenderness, patient finding it difficult to follow instructions -Bedside tests: - Temperature: 39.1, BP: 90/60, Pulse: 137bpm, PaO2: 99% Acute Cholangitis symptoms: - Charcot’s triad: Jaundice, Fever, RUQ - Reynold’s pentad: Charcot’s triad + Confusion + Hypotension Amelia Snook and Prisha Pahariya Sepsis secondary to acute cholangitis -O/E: - scratch marks on arms, scleral icterus, RUQ tenderness,patient finding it difficult to follow instructions -Bedside tests: - Temperature: 39.1, BP: 90/60, Pulse: 137bpm, PaO2: 99% Acute Cholangitis symptoms: - Charcot’s triad: Jaundice, Fever, RUQ - Reynold’s pentad: Charcot’s triad + Confusion + Hypotension Amelia Snook and Prisha Pahariya • Managed using A-E approach Management Sepsis • fluids and broad-spectrum IV Abx – what would you treat first? Acute • Laparoscopic Cholangitis cholecystectomy Amelia Snook and Prisha PahariyaReturning to those ■your answers. if you want to change any of quick-fire questions…SBA 1 ■A 40-year-old woman has come into the GP complaining of pain in her right side. She says that it comes and goes but is especially bad just after eating. It has been going on for a few months, and she also mentions that she has gained a lot of weight recently, now with a BMI of 34. What is the most likely diagnosis? ■A) Acute pancreatitis ■B) Biliary colic ■C) Cholecystitis ■D) Gastro-oesophageal reflux disease ■E) Peptic ulcerSBA 1 ■A 40-year-old woman has come into the GP complaining of pain in her right side. She says that it comes and goes but is especially bad just after eating. It has been going on for a few months, and she also mentions that she has gained a lot of weight recently, now with a BMI of 34. What is the most likely diagnosis? ■A) Acute pancreatitis ■B) Biliary colic ■C) Cholecystitis ■D) Gastro-oesophageal reflux disease ■E) Peptic ulcerSBA 2 ■ A 65-year-old man presents to the emergency department complaining of extreme pain, feeling like his insides have (SOCRATES!), he tells them that the pain appears to go through to his back. The man is becoming more confused and is sweating profusely, and subsequently collapses inthe ED. What is the definitive management for this condition? ■ A) Oral ibuprofen ■ B) IV labetalol ■ C) IV 0.9% sodium chloride ■ D) Oral aspirin ■ E) LaparotomySBA 2 ■ A 65-year-old man presents to the emergency department complaining of extreme pain, feeling like his insides have (SOCRATES!), he tells them that the pain appears to go through to his back. The man is becoming more confused and is sweating profusely, and subsequently collapses inthe ED. What is the definitive management for this condition? ■ A) Oral ibuprofen ■ B) IV labetalol ■ C) IV 0.9% sodium chloride ■ D) Oral aspirin ■ E) LaparotomySBA 3 ■ A 24-year-old presents to the Emergency Department after her partner noticed that she had turned yellow. She is very other problems recently. You investigate by sending offed no LFTs and receive the following results:  ALT: 40 U/L. AST:25 U/L. ALP: 45 umol/l. GGT: 25 U/L. Total protein: 6.5 g/dL. Test Reference range results are normal. What is the most likely diagnosis?d ALT 3-40 iu/l ■ A) Acute cholecystitis AST 3-30 iu/l ■ B) Pancreatic cancer ALP 30-100 umol/l ■ C) Gilbert’s GGT 8-60 u/l ■ D) Hepatitis C ■ E) Hepatocellular carcinoma Bilirubin 3-17 umol/l Albumin 35-50 g/lSBA 3 ■ A 24-year-old presents to the Emergency Department after her partner noticed that she had turned yellow. She is very other problems recently. You investigate by sending offed no LFTs and receive the following results:  ALT: 40 U/L. AST:25 U/L. ALP: 45 umol/l. GGT: 25 U/L. Total protein: 6.5 g/dL. Test Reference range results are normal. What is the most likely diagnosis?d ALT 3-40 iu/l ■ A) Acute cholecystitis AST 3-30 iu/l ■ B) Pancreatic cancer ALP 30-100 umol/l ■ C) Gilbert’s GGT 8-60 u/l ■ D) Hepatitis C ■ E) Hepatocellular carcinoma Bilirubin 3-17 umol/l Albumin 35-50 g/lTHANKS FOR W A TCHING! Tutor 1: Amelia Snook Tutor 2: Prisha Pahariya Please fill out the feedback form on Medall and see you next week!