Sandbox:Akshun

Revision as of 17:30, 5 December 2017 by Akshun Kalia (talk | contribs)
Jump to navigation Jump to search

{familytree | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}










 
 
 
 
 
 
 
 
A01
 
C01
 
 
 
 
C02
 
 
 
 
C03
Classification of pain in the abdomen based on etiology Disease Clinical manifestations Diagnosis Comments
Symptoms Signs
Abdominal Pain Fever Rigors and chills Jaundice Diarrhea GI Bleed Hypo-

tension

Guarding Rebound Tenderness Bowel sounds Lab Findings Imaging
Abdominal causes Inflammatory causes Pancreato-biliary disorders Acute suppurative cholangitis RUQ + + + + + + N
  • Abnormal LFT
  • WBC >10,000
Ultrasound shows biliary dilatation/stents/tumor Septic shock occurs with features of SIRS
Acute cholangitis RUQ + + N Ultrasound shows biliary dilatation/stents/tumor Biliary drainage (ERCP) + IV antibiotics
Acute cholecystitis RUQ + + Hypoactive Ultrasound shows gallstone and evidence of inflammation Murphy’s sign
Acute pancreatitis Epigastric + ± ± + + N
  • Ultrasound shows evidence of inflammation
  • CT scan shows severity of pancreatitis
Pain radiation to back
Chronic pancreatitis Epigastric ± + N
  • Pancreatic function test
CT scan
  • Calcification
  • Pseudocyst
  • Dilation of main pancreatic duct
Predisposes to pancreatic cancer
Pancreatic carcinoma Epigastric - - + + - - - - N

Skin manifestations may include:

Primary biliary cirrhosis RUQ/Epigastric + + in late presentation N
  • Increased AMA level, abnormal LFTs
Primary sclerosing cholangitis RUQ + + N ERCP and MRCP shows
  • Multiple segmental strictures
  • Mural irregularities
  • Biliary dilatation and diverticula
  • Distortion of biliary tree
The risk of cholangiocarcinoma in patients with primary sclerosing cholangitis is 400 times higher than the risk in the general population.
Cholelithiasis RUQ/Epigastric ± ± N to hyperactive for dislodged stone Ultrasound shows gallstone Fatty food intolerance
Gastric causes Peptic ulcer disease Diffuse ± + in perforated + + N
  • Ascitic fluid
    • LDH > serum LDH
    • Glucose < 50mg/dl
    • Total protein > 1g/dl
Air under diaphragm in upright CXR Upper GI endoscopy for diagnosis
Gastritis Epigastric ± + in chronic gastritis N H.pylori infection diagnostic tests Endoscopy H.pylori gastritis guideline recommendation
Gastroesophageal reflux disease Epigastric N Esophageal manometry Gastric emptying studies Endoscopy for alarm signs
Gastric outlet obstruction Epigastric Hyperactive Succussion splash
Gastroparesis Epigastric - - - - - ± - - Hyperactive/hypoactive
  • Hemoglobin
  • Fasting plasma glucose
  • Serum total protein, albumin, thyrotropin (TSH), and an antinuclear antibody (ANA) titer
  • HbA1c
  • Scintigraphic gastric emptying
  • Succussion splash
  • Single photon emission computed tomography (SPECT)
  • Full thickness gastric and small intestinal biopsy
Gastrointestinal perforation Diffuse + ± ± +, depends on site + + ± Hyperactive/hypoactive
  • WBC> 10,000
Air under diaphragm in upright CXR Hamman's sign
Dumping syndrome Lower and then diffuse + + Hyperactive
  • Glucose challenge test
  • Hydrogen breath test
  • Upper GI series
  • Gastric emptying study
Postgastrectomy
Intestinal causes Acute appendicitis Starts in epigastrium, migrates to RLQ + +in pyogenic appendicitis + in perforated appendicitis + + Hypoactive Ultrasound shows evidence of inflammation Nausea & vomiting, decreased appetite
Acute diverticulitis LLQ + ± ± Hematochezia + in perforated diverticulitis + + Hypoactive CT scan and ultrasound shows evidence of inflammation History of constipation
Inflammatory bowel disease Diffuse ± ± ± Hematochezia N/ Hyperactive String sign on abdominal x-ray in Crohn's disease

Extra intestinal findings:

Irritable bowel syndrome Diffuse ± + N Tests done to exclude other diseases as it diagnosis of exclusion Tests done to exclude other diseases as it diagnosis of exclusion Symptomatic treatment
Whipple's disease Diffuse ± ± + ± N Endoscopy is used to confirm diagnosis.

Images used to find complications

Extra intestinal findings:
Toxic megacolon Diffuse + + + ± Hypoactive CT scan shows:

Ultrasound shows:

  • Loss of haustra coli of the colon
  • Hypoechoic and thickened bowel walls with irregular internal margins in the sigmoid and descending colon
  • Prominent dilation of the transverse colon (>6 cm)
  • Insignificant dilation of ileal bowel loops (diameter >18 mm) with increased intraluminal gas and fluid
Tropical sprue Diffuse + + N Barium studies show dilation and edema of mucosal folds Steatorrhea- 10-40 g/day (Normal=5 g/day)
Celiac disease Diffuse + Hyperactive USG
  • Bull’s eye or target pattern
  • Pseudokidney sign
Gluten allergy
Infective colitis Diffuse + + Hematochezia + in fulminant colitis ± ± Hyperactive CT scan
  • Bowel wall thickening
  • Edema
Colon carcinoma Diffuse/localized - - - ± + ± - -
  • Normal
  • Hyperactive if obstruction present
  • CBC
  • Carcinoembryonic antigen (CEA)
  • Colonoscopy
  • Flexible sigmoidoscopy
  • Barium enema
  • CT colonography 
PILLCAM 2: A colon capsule for CRC screening may be used in patients with an incomplete colonoscopy who lacks obstruction
Hepatic causes Viral hepatitis RUQ + + + in Hep A and E + in fulminant hepatitis +in acute + N
  • Abnormal LFTs
  • Viral serology
USG Hep A and E have fecoral route of transmission and Hep B and C transmits via blood transfusion and sexual contact.
Liver masses RUQ + + in Liver abscess ± + in Hepatocellular carcinoma + in sepsis + in Liver abscess + in Liver abscess N
  • CBC
  • LFTs
USG
Liver abscess RUQ + + + ± - + + ± Normal/hypoactive
  • US
  • CT
Hepatocellular carcinoma/Metastasis RUQ + - + - - - - -
  • Normal
  • Hyperactive if obstruction present
  • US
  • CT
  • Liver biopsy

Other symptoms:

Budd-Chiari syndrome RUQ ± ± + in liver failure leading to varices N
Findings on CT scan suggestive of Budd-Chiari syndrome include:
Ascitic fluid examination shows:
Hemochromatosis RUQ + in cirrhotic patients N
  • >60% TS
  • >240 μg/L SF
  • Raised LFT
    Hyperglycemia
Ultrasound shows evidence of cirrhosis Extra intestinal findings:
  • Hyperpigmentation
  • Diabetes mellitus
  • Arthralgia
  • Impotence in males
  • Cardiomyopathy
  • Atherosclerosis
  • Hypopituitarism
  • Hypothyroidism
  • Extrahepatic cancer
  • Prone to specific infections
Cirrhosis RUQ + varices + N USG
  • Stigmata of liver disease
  • Cruveilhier- Baumgarten murmur
Peritoneal causes Spontaneous bacterial peritonitis Diffuse + + + in cirrhotic patients + ± + + Hypoactive
  • Ascitic fluid PMN>250 cells/mm³
  • Culture: Positive for single organism
Ultrasound for evaluation of liver cirrhosis
Renal causes Pyelonephritis Lumbar region + ± - - - + ± ± Hypoactive
  • Urinalysis
  • Urine culture
  • Blood culture
  • CT
  • MRI
  • Renal punch positive
Renal colic Flank pain N Hematuria CT scan and ultrasound
Hollow Viscous Obstruction Small intestine obstruction Diffuse + + + ± Hyperactive then absent Leukocytosis with left shift indicates complications Abdominal X ray
  • dilated loops of bowel with air fluid levels
  • gasless abdonen
  • "Target sign"– , indicative of intussusception
  • Venous cut-off sign" – suggests thrombosis
Volvulus Diffuse +in perforated cases +in perforated cases + + Hyperactive then absent Leukocytosis CT scan and abdominal X ray
  • U shaped sigmoid colon
"Whirl sign"
Biliary colic RUQ + N Increased bilirubin and alkaline phosphatase Ultrasound Nausea & vomiting
Vascular Disorders Ischemic causes Mesenteric ischemia Periumbilical + if bowel becomes gangrenous + Hematochezia + if bowel becomes gangrenous + if bowel becomes gangrenous Hyperactive to absent CT angiography
  • SMA or SMV thrombosis
Also known as abdominal angina, worsens with eating
Acute ischemic colitis Diffuse + ± + Massive + + + Hyperactive then absent Leukocytosis Abdominal x-ray
  • Distension and pneumatosis

CT scan

  • Double halo appearance, thumbprinting
  • Thickening of bowel
Can lead to shock
Hemorrhagic causes Ruptured abdominal aortic aneurysm Diffuse ± Herald to massive + N Focused Assessment with Sonography in Trauma (FAST)  Unstable hemodynamics
Intra-abdominal or retroperitoneal hemorrhage Diffuse ± Massive + N Anemia CT scan History of trauma
Gynaecological Causes Tubal causes Torsion of the cyst RLQ / LLQ ± ± N Increased ESR and CRP Ultrasound Sudden onset & severe pain with nausea and vomiting
Acute salpingitis RLQ / LLQ + ± ± ± N Leukocytosis Pelvic ultrasound Vaginal discharge
Cyst rupture RLQ / LLQ + ± ± N Increased ESR and CRP Ultrasound Sudden onset sever pain with nausea and vomiting
Pregnancy Ruptured ectopic pregnancy RLQ / LLQ + + + N Positive pregnancy test Ultrasound History of missed period and vaginal bleeding
Extra-abdominal causes Pulmonary disorders Pleural empyema RUQ/Epigastric + ± N Thoracentesis Chest X-ray
  • Pleural opacity

USG

  • Localization of effusion
Physical examination
Pulmonary embolism RUQ/LUQ ± - - - - ± - - N
  • ABGs
  • D-dimer
Pneumonia RUQ/LUQ + + - - - + - - N/Hypoactive
  • ABGs
  • Eosinophilia
  • Pancytopenia
  • CXR
  • CT chest
  • Bronchoscopy
Cardiovascular disorders Myocardial Infarction Epigastric + in cardiogenic shock N Echocardiogram
  • Wall motion abnormality
  • Wall rupture
  • Septal rupture
Complications:

RUQ= Right upper quadrant of the abdomen, LFT= Liver function test, SIRS= Systemic inflammatory response syndrome, ERCP= Endoscopic retrograde cholangiopancreatography, N= Normal, AMA= Anti mitochondrial antibodies, LDH= Lactate dehydrogenase, GI= Gastrointestinal, CT= Computed tomography

Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
AST ALT ALK BLR Indirect BLR Direct Viral serology
Type of jaundice Pruritis Family history
Common bile duct stone Cholestatic Jaundice + -/+ N N N - Dilated ducts on sono CT/ERCP
Hepatitis A cholestatic type + - N N N + HAV- AB Abdominal ultrasound
EBV / CMV hepatitis + - N N N + Positive serology PCR or ELISA
Primary biliary cirrhosis + -/+ N/↑ N/↑ N - AMA positive Liver biopsy
Primary sclerosing cholangitis + -/+ N/↑ N/↑ N - Beading on MRCP Liver biopsy
Autoimmune hepatitis Hepatocellular Jaundice -/+ -/+ N ↑/N N - Anti-LKM antibody Liver biopsy
Disease History and clinical manifestations Diagnosis
Lab Findings Other blood tests Other diagnostic
AST ALT ALK BLR Indirect BLR Direct Viral serology
Type of jaundice Pruritis RUQ pain Fever Family history
Common bile duct stone Cholestatic Jaundice + + - -/+ N N N - Dilated ducts on sono CT/ERCP
Hepatitis A cholestatic type + + -/+ - N N N + HAV- AB Abdominal ultrasound
EBV / CMV hepatitis + + -/+ - N N N + Positive serology PCR or ELISA
Primary biliary cirrhosis + -/+ - -/+ N/↑ N/↑ N - AMA positive Liver biopsy
Primary sclerosing cholangitis + -/+ - -/+ N/↑ N/↑ N - Beading on MRCP Liver biopsy
Disease Signs and Symptoms Barium esophagogram Endoscopy Other imaging and laboratory findings Gold Standard
Onset Dysphagia Weight loss Heartburn Other findings Mental status
Solids Liquids Type
Plummer-Vinson syndrome
  • Gradual
+ - Non progressive +/- - Normal

Triad of

Esophageal stricture
  • Gradual
  • Sudden onset
+ +/- Progressive +/- +/- Normal
  • Sacculations
  • Fixed transverse folds
  • Esophageal intramural pseudodiverticula   
Diffuse esophageal spasm
  • Sudden
+ + Non progressive + + Normal
  • Nonperistaltic and nonpropulsive contractions
  • Corkscrew or rosary bead esophagus
  • Inconclusive
Achalasia
  • Gradual
+ + Non progressive +/- - Normal
  • "Bird's beak" or "rat tail" appearance
  • Dilated esophageal body
  • Air fluid level (absent peristalsis)
  • Absence of an intragastric air bubble
  • Residual pressure of LES > 10 mmHg
  • Incomplete relaxation of the LES
  • Increased resting tone of LES
  • Aperistalsis
Systemic sclerosis
  • Gradual
+ + Progressive +/- + Normal
  • Dysmotility
  • Peptic stricture (advanced cases)
Positive serology for
Zenker's diverticulum
  • Gradual
+ - +/- - Normal
  • Exclude the presence of SCC 
  • CT & MRI shows out-pouching over the posterior esophagus in the Killian's triangle
Esophageal carcinoma
  • Gradual
+ + Progressive + +/- Normal
  • CT and PET scan is an optional test for staging of the disease
Stroke

(Cerebral hemorrhage)

  • Sudden
+ + Progressive + +/- Impaired
Motor disorders

(Myasthenia gravis)

  • Gradual
+ + Progressive +/- Normal
  • Stasis in pharynx and pooling in pharyngeal recesses
  • Anti–acetylcholine receptor antibody test
GERD
  • Gradual
  • Sudden onset
+ - Progressive +/- + Normal
Esophageal web
  • Gradual
+ +/- Progressive - +/- Normal
  • Smooth membrane not encircling the whole lumen
Eosinophilic esophagitis

polyglandular autoimmune syndrome polyendocrine autoimmune syndrome

tryptophan hydroxylase presenting with malabsorption

      • Tyrosine hydroxylase presenting with alopecia areata
      • Liver presenting with autoimmune liver disease and chronic active hepatitis
      • Steroidal hormone–producing cell presenting with hypogonadism.


X linked polyendocrinopathy, immune dysfunction and diarrhea. This condition is very rare and generally presents in neonatal period with diabetes and malabsorption. Unlike type 1 and type 2 autoimmune polyglandular syndromes there is no association with HLA genotype. Mutation in FOXP3 gene is inherited as X linked and leads to loss of regulatory T cells and autoimmunity.

The term “polyendocrine” itself is a misnomer, in that not all patients have multiple endocrine disorders, and many have nonendocrine autoimmune diseases. Nevertheless, the recognition that patients in whom multiple autoimmune disorders are diagnosed may have a specific genetic syndrome, may be at increased risk for multiple autoimmune disorders, and may have relatives who have an increased risk should spur clinicians toward early diagnosis and treatment.

In the simplest hypothesis for understanding organ-specific autoimmunity, the initial step is the loss of immunologic tolerance to a peptide within a specific molecule found in the target organ. Clones of the CD4 T cells that recognize the peptide then expand, and the specific cytokines produced by the clonal CD4 T cells favor inflammation (as when type 1 helper T [Th1]–cell clones produce cytokines such as interferon-γ) or favor autoantibody-mediated disease (as is the case predominantly with type 2 helper T [Th2]–cell clones).9 The probability of T-cell autoreactivity is determined both in the thymus (the site of central tolerance) and in the periphery (the site of peripheral tolerance) and is strongly influenced by specific HLA alleles


TYPE 1 APS Mutations in the AIRE gene cause many autoimmune diseases, and affected patients are at risk for the development of multiple additional autoimmune diseases over time, including type 1A diabetes, hypothyroidism, pernicious anemia, alopecia, vitiligo, hepatitis, ovarian atrophy, and keratitis. Affected patients may also have diarrhea or obstipation that may be related to the destruction of gastrointestinal endocrine cells (enterochromaffin and enterochromaffin-like cells).39 Knockout of the AIRE gene in the mouse produces widespread autoimmunity, but the phenotype is relatively mild. SYMPTOMS TYPE1 Addison's disease develops in 80 percent of patients with autoimmune polyendocrine syndrome type I, and type 1A diabetes develops in 18 percent

PROGNOSISI TYPE 1 After diagnosis, patients with autoimmune polyendocrine syndrome type I require close monitoring. Monitoring can help prevent illness associated with delayed diagnosis of additional autoimmune diseases (e.g., Addison's disease and hypoparathyroidism, which can develop during adulthood) as well as oral cancer, which may develop if candidiasis is not treated aggressively, and infection due to asplenism, which is present in a subgroup of patients.

  • In patients with autoimmune polyendocrine syndromes who have a single disorder such as Addison's disease or type 1A diabetes, the prevalence of additional autoimmune disorders is 30 to 50 times that in the general population.60,61 The concurrence of more than one endocrinopathy presumably results from shared genetic susceptibility leading to loss of tolerance to multiple tissues


TYPE 2 Autoimmune polyendocrine syndrome type II (also called Schmidt's syndrome with Addison's disease plus hypothyroidism) is much more common and more varied in its manifestations than autoimmune polyendocrine syndrome type I.


TYpe 3 X-Linked Polyendocrinopathy, Immune Dysfunction, and Diarrhea. The syndrome of X-linked polyendocrinopathy, immune dysfunction, and diarrhea (known as XPID) is an extremely rare disorder characterized by fulminant, widespread autoimmunity and type 1A diabetes, which usually develops in neonates; it is often fatal. The disorder is also known as XLAAD (X-linked autoimmunity and allergic dysregulation) and IPEX (immune dysfunction, polyendocrinopathy, and enteropathy, X-linked)


Aldosterone Deficiency: Hyporeninemic hypoaldosteronism - Commonly seen in patients with renal insufficiency (diabetic kidney disease, chronic tubulointerstitial disease, or glomerulonephritis) and those that take certain medications (non-steroidal anti-inflammatory drugs, calcineurin inhibitors).[1] Angiotensin inhibitors - angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), direct renin inhibitors Heparin therapy (including low molecular weight heparin) - Heparin has a direct toxic effect on the adrenal zona glomerulosa cells which leads to a reduction in plasma aldosterone concentration.[9] Primary adrenal insufficiency (Addison’s disease) - Associated with the lack of cortisol and aldosterone. This can result from autoimmune adrenalitis, infectious adrenalitis, and other disorders.[14] Critical illness - There is decreased adrenal production of aldosterone and stress-induced hypersecretion of ACTH which can diminish aldosterone synthesis by diverting substrate to the production of cortisol. Congenital isolated hypoaldosteronism - Deficiency of enzymes required for aldosterone synthesis.[14] Pseudohypoaldosteronism type 2 (Gordon’s syndrome or familial hyperkalemic hypertension) - Abnormalities in WNK kinases in the distal nephron increase chloride reabsorption leading to reduced renal potassium secretion. Characterized by hypertension, hyperkalemia, metabolic acidosis, normal renal function, and low or low-normal plasma renin activity and aldosterone concentrations.[14][2] Aldosterone Resistance: Inhibitors of the epithelial sodium channel - Most commonly associated with the administation of potassium-sparing diuretics (spironolactone, eplerenone, amiloride) and certain antibiotics (trimethoprim, pentamidine). Pseudohypoaldosteronism type 1 - Characterized by marked elevations of plasma aldosterone levels. There is an autosomal recessive form, and an autosomal dominant or sporadic form. The autosomal dominant form tends to be associated with milder symptoms

Type of

Adrenal insufficiency

Skin Pigmentation ACTH  Normal ACTH
Addison disease + >60 ng/mL 5-30 ng/mL
Secondary /

tertiary adrenal insufficiency

- <5 ng/mL

Addison's disease must be differentiated from other diseases that cause hypotension, skin pigmentation, and abdominal pain such as myopathies, celiac disease, Peutz-Jeghers syndrome ,anorexia nervosa, syndrome of inappropriate anti-diuretic hormone (SIADH), neurofibromatosis, porphyria cutanea tarda, salt-depletion nephritis and bronchogenic carcinoma.[1][2]

Disease Differentiating symptoms Differentiating laboratory findings Gold standard test
Hypotension Abdominal pain Anorexia/

weight loss

Muscle weakness Hypoglycemia Skin pigmentation Other symptoms Hyponatremia Cortisol levels Other labs
Addison's disease + + + + + + - Low ACTH stimulation test
Myopathies

(polymyositis,

hereditary myopathies)

- - - + - Heliotrope rash and

Gottron's sign

- Normal - Muscle biopsy
Celiac disease - + + - - Dermatitis herpetiformis  - Normal - Abnormal small bowel biopsy
Syndrome of inappropriate anti-diuretic hormone

(SIADH)

- - - - - - - + Normal Water deprivation test
Neurofibromatosis - - + + - Axillary- and inguinal-area freckling - - - Biopsy of skin tissue
Peutz-Jeghers syndrome + + - Normal Colonic imaging showing the small intestinal polyps
Porphyria cutanea tarda - + - - - Blisters on sun-exposed sites - Normal or elevated High level of porphyrins in the urine
Salt-depletion nephritis + Flank pain - - - - + Elevated <15:1 BUN:CR
Bronchogenic carcinoma - - + - - + - Elevated Increased ACTH and

Hypokalemia

Cytological or histological evidence of lung cancer in sputum, pleural fluid, or tissue
Anorexia nervosa + - + + + - - Elevated - Psychiatric condition
  1. Selva-O'Callaghan A, Labrador-Horrillo M, Gallardo E, Herruzo A, Grau-Junyent JM, Vilardell-Tarres M (2006). "Muscle inflammation, autoimmune Addison's disease and sarcoidosis in a patient with dysferlin deficiency". Neuromuscul. Disord. 16 (3): 208–9. doi:10.1016/j.nmd.2006.01.005. PMID 16483775.
  2. Kumar V, Rajadhyaksha M, Wortsman J (2001). "Celiac disease-associated autoimmune endocrinopathies". Clin. Diagn. Lab. Immunol. 8 (4): 678–85. doi:10.1128/CDLI.8.4.678-685.2001. PMC 96126. PMID 11427410.