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3. In what diseases can patients have variceal haemorrhage but not chronic liver disease? Portal hypertension can be divided into prehepatic, hepatic and posthepatic types (Table 12). 2) and for evidence of haematological disease: pallor/polycythaemia, indwelling OF PORTAL HYPERTENSION Prehepatic Hepatic Posthepatic Increased flow (eg arteriovenous fistula, massive splenomegaly) Portal or splenic vein thrombosis (eg pancreatitis, malignancy, sepsis, thrombophilia) Portal vein stenosis (eg post liver transplant) Presinusoidal (eg primary biliary cirrhosis, schistosomiasis, congenital hepatic fibrosis) Sinusoidal (eg cirrhosis, acute alcoholic hepatitis, fulminant hepatitis) Postsinusoidal (eg venoocclusive disease) Hepatic vein outflow obstruction (eg Budd–Chiari syndrome, heart failure, inferior vena cava web) Station 1: Abdominal Examination 25 GAH_C01 12/9/10 9:02 Page 26 GASTROENTEROLOGY AND HEPATOLOGY: PACES STATIONS AND ACUTE SCENARIOS tunnelled line (for chemotherapy), lymphadenopathy.

Patients with ileus, pseudo-obstruction or constipation are generally less unwell, although they may vomit (look for a sick bowl). Patients with ascites can be moribund (acute hepatitis, Budd–Chiari syndrome), quite well (chronic diuretic-resistant ascites) or anything in between. Massive organomegaly (hepatomegaly, splenomegaly, hepatosplenomegaly or very large kidneys) can also cause abdominal swelling. In the context of a PACES examination, ascites and organomegaly are much the most likely diagnoses.

Further discussion Abdominal examination may be completely normal in cases of inflammatory bowel disease, but it is likely that at least some features of the general or specific examination will be abnormal in a patient appearing in PACES (although a patient with no abnormal physical signs can be included). If you could feel a mass, what is the differential diagnosis of the findings? Could colorectal neoplasia mimic inflammatory bowel disease? As cancer can complicate longstanding active colitis, this is an important practical question and the presence of a mass would require investigation with CT and/or colonoscopy.

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