1. Huge Splenomegaly causes Hematological - CML ,CLL, Hairy Cell Leukamia, Primary Myelofibrosis , Thalasemia major

Liver – Portal Htn Infection – Typhoid, mononucleoisis, TB, infectious mononucleosis Tropical – Bilharzial, Malaria, Leishmania Systemic – Sarcoidosis, Amyloidosis, SLE Genetic – Gaucher’s Disease

2. Tender splenomegaly

Trauma Causes - Spleen injury

Infectious Disorders (Specific Agent) Bacterial endocarditis, subacuteHepatitis, viralInfectious mononucleosisTyphoid fever

Infected organ, Abscesses Splenic abscessSplenitis, nonspecific

Neoplastic Disorders - Lymphoma

Hereditary, Genetic - Sickle cell anemia

Anatomic, Foreign Body, Structural Disorders Spleen hematomaSpleen cyst

Arteriosclerotic, Vascular, Venous Disorders Hepatic vein occlusion/thrombusSplenic artery embolism

3. Types of pain in spleen Stitching pain – Inflammation Throbbing pain - Infarction Dragging pain - Congestion

4. Different effects of splenomegaly

Infection - Reduce the number of healthy red blood cells, platelets and white cells in bloodstream, frequent infections. Anemia and increased bleeding also are possible.

Ruptured spleen. – Massive bleeding & shock

5. Pulsating liver causes *most common - tricuspid incompetence (Rosenbach sign) Neoplasms -Hepatocellular carcinoma, haemangioma, haemangiosarcoma arteriovenous malformations

6. Peripheral sign of liver failure

Signs associated with the diagnosis

Clubbing Palmar erythema Spider nevi (angiomata) Gynaecomastia, Testicular atrophy Feminising hair distribution Small irregular shrunken liver Anaemia Caput medusae (recanalisation of the umbilical vein) (Distended abdominal veins)

Signs associated with decompensation

Drowsiness (encephalopathy) Hyperventilation (encephalopathy) Metabolic Flap/Asterixis (encephalopathy) Jaundice (excretory dysfunction) Ascites (portal hypertension and hypoalbuminaemia) Leukonychia (hypoalbuminaemia) Peripheral oedema (hypoalbuminaemia) Bruising (coagulopathy) Acid-base imbalance, most commonly respiratory alkalosis

Signs associated with the aetiology

Dupuytren's contracture (Alcohol) Parotidomegally (Alcohol) Peripheral neuropathy (Alcohol and some drugs) Cerebellar signs (alcohol and Wilson's disease) Hepatomegaly (alcohol, NAFLD, Haemochromatosis) Kayser-Fleisher Rings (Wilson's) Increased pigmentation of the skin (Haemochromatosis) Signs of Right Heart Failure7. Clinical finding in portal hypertension

Symptoms of liver disease Weakness, tiredness, and malaise Anorexia, weight loss Sudden and massive bleeding, with or without shock on presentation Nausea and vomiting Abdominal discomfort and pain Edema and abdominal swelling Pruritus - Usually associated with cholestatic conditions, such as extrahepatic biliary obstruction, primary

biliary cirrhosis, sclerosing cholangitis, cholestasis of pregnancy, and benign, recurrent cholestasis Spontaneous bleeding and easy bruising Symptoms of encephalopathy - disturbance sleep-wake cycle; deterioration in intellectual function, memory

loss, not oriented, personality changesImpotence and sexual dysfunction Muscle cramps - Common in patients with cirrhosis

The presence of complications of portal hypertension Hematemesis or melena – indicate gastroesophageal variceal bleeding or bleeding from portal gastropathy Mental status changes - portosystemic encephalopathy Increasing abdominal girth - May indicate ascites formation Abdominal pain and fever - May indicate spontaneous bacterial peritonitis, although this disease also

presents without symptoms Hematochezia - May indicate bleeding from portal colopathy

8. Hepatitis C Ix

9. Hepatic encephalopathy Definition : Worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood

Causes :Exact cause is unknown

Triggering Factor :

Dehydration Eating too much protein (ammonia) Electrolyte abnormalities (especially a decrease in potassium) from vomiting, or from treatments such

asparacentesis or taking diuretics ("water pills") Bleeding from the intestines, stomach, or esophagus Infections Kidney problems Low oxygen levels in the body Shunt placement or complications (See: Transjugular intrahepatic portosystemic shunt ) Surgery Use of medications that suppress the central nervous system (such as barbiturates or benzodiazepine

tranquilizers)

Signs & Symptoms West Haven classification system

Grade 0 - Minimal hepatic encephalopathy (also known as covert hepatic encephalopathy and previously known subclinical hepatic encephalopathy); lack of detectable changes in personality or behavior; minimal changes in memory, concentration, intellectual function, and coordination; asterixis is absent.

Grade 1 - Trivial lack of awareness; shortened attention span; impaired addition or subtraction; hypersomnia,

insomnia, or inversion of sleep pattern; euphoria, depression, or irritability; mild confusion; slowing of ability to perform mental tasks

Grade 2 - Lethargy or apathy; disorientation; inappropriate behavior; slurred speech; obvious asterixis;

drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time

Grade 3 - Somnolent but can be aroused; unable to perform mental tasks; disorientation about time and

place; marked confusion; amnesia; occasional fits of rage; present but incomprehensible speech Grade 4 - Coma with or without response to painful stimuli

Signs

Flapping Tremors Abnormal mental status – particularly cognitive Signs of liver disease – jaundice, ascites, musty odor of breath & urine

Exams and Tests

Complete blood count or hematocrit to check for anemia CT scan of the head or MRI EEG

Liver function tests Prothrombin time Serum ammonia levels Sodium level in the blood Potassium level in the blood BUN and creatinine (kidney)

DDX:

Alcohol intoxication Complicated alcohol withdrawal Meningitis Metabolic abnormalities such as low blood glucose Sedative overdose Subdural hematoma (bleeding under the skull) Wernicke-Korsakoff syndrome

Treatment

( medical emergency. Hospitalization is required)

1. Life support – stabilise, ABC, reduce brain swelling

2. Identify cause

Stop GIT bleeding Treat Infections, Kidney Failure, electrolyte abnormalities (esp K)

3. Diet counselling

decrease protein intake to lower ammonia production Lactulose may be given to prevent intestinal bacteria from creating ammonia, and as a laxative to

remove blood from the intestines.

4. Antibiotic – Neomycin,Rifaximin

5. Critically ill patients may need specially formulated intravenous or tube feedings.

6. Sedatives, tranquilizers, and any other medications that are broken down by the liver should be avoided if possible. Medications containing ammonium (including certain antacids) should also be avoided.

Complications Brain herniation Brain swelling Cardiovascular collapse Kidney failure Respiratory failure Sepsis Permanent nervous system damage (to movement, sensation, or mental state) Progressive, irreversible coma Side effects of medications

10. Gynecomastia causes

1. Recovery from malnutrition

2. Diseases

Disorders of the male sex organs ( decreased testosterone production and relatively high estrogen levels), as Klinefelter's syndrome

Testicular cancers Liver Cirrhosis Chronic renal failure Hyperthyroidism

3. Drugs

Diuretics - spironolactone Calcium channel blockers ACE inhibitor drugs - captopril antibiotics - Isoniazid, ketoconazole , metronidazole anti-ulcer drugs ranitidine, cimetidine anti-androgen or estrogen therapies for prostate cancer; methyldopa (Aldomet); highly active anti-retroviral therapy (HAART) for HIV disease diazepam drugs of abuse (alcohol, marijuana, heroin)

11. Spironolactone mechanism causing gynecomastia Spironolactone causes gynecomastia by displacing androgen from the androgen receptor and sexual-hormone-binding globulin, and by causing increased metabolic clearance of testosterone and higher estradiol production

12. Refractory ascites Defnition : ascites that does not recede or that recurs shortly after therapeutic paracentesis, despite sodium restriction and diuretic treatment.

Management

The maximal dose of spironolactone is 400 mg per day. Patients with refractory ascites should be considered for liver transplantation.

13. Ascites complication Dyspnea Pleural effusion Spontaneous bacteria peritonitis Hyponatremia Refractory ascites Hepatorenal syndrome Hernia Complications of paracenthesis

14. Ascites Ix Careful history and physical examination ultrasound of the abdomen and paracentesis should be considered- establish

etiology Endoscopic ultrasound - patients with suspected upper gastrointestinal

malignancy Aspiration of ascites too minimal to be seen with CT or ultrasound. Ascitic fluid tests should include white blood cell and red blood cell counts, total

protein, albumin, amylase, cytology, and bacterial culture. Lactate levels (increase in SBP

Diagnostic laparoscopy - helpful in tuberculous peritonitis and peritoneal malignancy

15. SAAG definition, equation, transudate & exudate causes The serum-ascites albumin gradient or gap (SAAG) is a calculation to help determine the cause of ascites

Formula

SAAG = (albumin concentration of serum) - (albumin concentration of ascitic fluid)

A gradient higher than > 1.1 gm/dL suggests portal hypertension

Lower <1.1gm/dl suggest malignancy/ pancreatitis

Important causes of high SAAG ascites (> 1.1 g/dL) include:

high protein in ascitic fluid (> 2.5): heart failure, Budd Chiari syndrome low protein in ascitic fluid (< 2.5): cirrhosis of the liver

Causes of transudative ascites

Hepatic cirrhosis Alcoholic hepatitis Heart failure Fulminant hepatic failure Portal vein thrombosis

Causes of exudative ascites

Peritoneal carcinomatosis Inflammation of the pancreas or biliary system Nephrotic syndrome Peritonitis Ischemic or obstructed bowel

16. Differentiate ascites and obesity by inspection  Ascites - A rounded, symmetrical contour of the abdomen with bulging of flank Obesity – No bulging of the flank

17. Causes of generalised abdominal distension Fat Food Fluid Foecal Fetus Flatus

18. Bilateral painless edema causes Acute kidney failure Cardiomyopathy (disease of heart tissue) Chronic kidney failure Chronic venous insufficiency (problem with leg veins returning blood to the heart) Heart failure Hormone therapy Lymphedema (blockage of lymph system) Nephrotic syndrome (damage to small filtering blood vessels in the kidneys) Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin, others) Pericarditis (swelling of the membrane surrounding the heart) Preeclampsia (pregnancy-induced high blood pressure) Pregnancy Prescription medications, including some drugs for depression, diabetes and high blood

pressure Prolonged sitting/standing

19. Diated vein around umbilicus + venous hum. What syndrome?

Courveilhier Baumgarten Syndrome

is a rare medical condition in which the umbilical or paraumbilical veins are distended, with an abdominal wallbruit (the Cruveilhier-Baumgarten bruit) and palpable thrill, portal hypertension with splenomegaly, hypersplenism and oesophageal varices, with a normal or small liver.

20. Causes of tender hepatomegaly

Tenderness of liver is due to stretching of Glisson's capsule. The common causes of tender hepatomegaly (enlarged liver) are - 1. Acute viral hepatitis 2. Liver abscess (pyogenic or amoebic) 3. Congestive Cardiac Failure (CCF) 4. Budd - Chiari syndrome 5. Hepatoma 6. Cholangio - hepatitis

21. Differentiate renal & splenic swelling

Palpable spleen Left kidney

1. It is in left hypochondrium 1. It is in left lumber region or loin

2. Moves with respiration towards right iliac fossa

2. Moves downward and forward

3. Well defined medial border 3. Round upper end

4. Notch is present 4. No notch present

5. Get above the swelling- possible 5. Get above the swelling- not possible

6. Insinuation of finger between the mass and left costal margin is not possible

6. Insinuation of finger between the mass and left costal margin is possible

7. On percussion: Dullness over the mass which is continuous with the left lower chest

7. On percussion: Colonic resonance oover the mass

8. The mass is palpable 8. The mass is palpable as well as ballotable.

22. Causes of epigastric pulsation Very thin person RV enlargement

Pulsatile hepatomegaly Right Sided HF Palpable Abdominal Aorta (e.g. aneurysm) Pulsation below the xiphoid process( subcostal area) Left atrium

enlargement

23. HCC Most common type of liver cancer. Most cases of HCC are secondary to either a viral hepatitis infection (hepatitis B or C) or cirrhosis.

The main risk factors for hepatocellular carcinoma are Alcoholism Hepatitis B Hepatitis C Aflatoxin Cirrhosis of the liver Hemochromatosis Wilson's disease 

Sign and symptoms Abdominal pain or tenderness, especially in the upper-right part Liver Disease signs and symptoms Easy bruising or bleeding Enlarged abdomen Yellow skin or eyes (jaundice)

Exams and Tests

Physical examination - enlarged, tender liver.

Tests

Blood test Ultrasound Abdominal CT scan Abdominal ultrasound Liver biopsy Liver enzymes (liver function tests) Liver MRI Serum alpha fetoprotein

Treatment

Surgery/ liver transplant Chemotherapy /Radiation treatments Sorafenib tosylate (Nexavar