abdo Flashcards
(122 cards)
1
Q
Autodomal polycystic kidney disease main examination sign
A
Bilateral ballotable masses in the flanks which I am able to get above
does not move with respiration
2
Q
Autodomal polycystic kidney disease
BONUS examination signs
A
Hepato or splenomegaly - can have cysts in the liver, pancreas, spleen, epididymis or thyroid
Features of renal impairement - fluid status, RRT
Third cranial nerve palsy - given 5% prevelance of anneurysm, but >20% if over 60. Rupture is assx with uncontrolled hypertension
Loin pain may occur due to renal haemorrhage, calculi or infection
3
Q
inheritance of PKD
A
ADPKD type 1 - 80% have a mutational chromosome 16 (Sixteen/cysteen?)
ADPKD type 2 - 15% have a mutational chromosome 4 - (less severe, later onset, fever cysts)
ARPKD aka, infantile PKD - RECESSIVE. 30% die within first week. Mutations in PKHD1 chromosomal 6
4
Q
Management of PKD
A
• BP - ACEi, low salt. Limited evidence re high fluid low protein
• Mx of hyperlipidaemia
CKD is a major risk factor for ischaemic heart disease
• CKD stage 1–3 - vasopressin receptor antagonist, eg tolvaptan, may be of use
• Haemodialysis , can do at home sometimes
• Transplant list or donated from family
• Family testing and genetic counseling
5
Q
indications for nephrectomy in PKD
A
Avoid if possible
Consider if
• need to make room for transplant
• progression to renal cell carcinoma (although this is not common)
• chronic pain
• chronic infection
• large and significant haematuria
6
Q
incidence of PKD progression to renal cell carcinoma
A
about 50% higher than gen population, although this “is not a common sequeallae”
7
Q
in abdo exam don’t feel for…
A
hernias /inguinal lymphad
but do assess Axillary and Neck lymph nodes
8
Q
1-3 mm diameter macules which may become larger papules over time on trunk.
Typical bright cherry red colour but can appear blue or purple.
They are non-blanching
A
Campbell de Morgan Spots aka Cherry angioma
unknown eitology
9
Q
end of bed abdo exam
A
• Jaundice
• Tense ascites / caput medusae
• Tattoos?
• Nutritional status
• Scars?
• Meds?
10
Q
hands abdo exam
A
• Thinning of skin? - steroid use from liver transplant/autoimmune liver sisease
• Bruising - coagulopathy from liver failure
• Dupuytrens on palms - feel, then spread out palms of hands to look for subtle updrawing of ring finger
• Palmar erythema - could be a few things, incl chronic LD
• Leukonychia - hypoalbuminaemia
• Spoon nails (koilonychia) in IDA
• Fine tremor - alcohol withdrawal, tacrolimus tox
• hepatic flap of hepatic encephalopathy
11
Q
Palmar erythema
A
• Chronic liver disease
• Chronic hypoxia causing Polycythaemia
• Thyrotoxicosis
• Pregnancy
12
Q
Causes of Dupuytren’s contracture
A
Hereditary
Smoking
Alcohol and other liver disease
Epilepsy (probably due to Meds)
Diabetes (~20%, no relationship with diabetic control)
SHADE mnemonic
13
Q
Leukonychia
A
double white transverse line = Hypoalbuminaemia, liver disease, malnutrition
Half and half nail = CKD
14
Q
Mercedes Benz scar
A
liver transplantation
Can also be done with J shaped incision aka makuuchi incision
15
Q
Chevron / rooftop incision
A
the extension of the incision to the other side of the abdomen; used to access the oesophagus, the stomach, and the liver
16
Q
Chevron / rooftop incision
A
to access the oesophagus, the stomach, and the liver
17
Q
Fine tremor with Mercedes Benz scar?
A
Could be liver transplant with tacrolimus toxicity
18
Q
Face examination in abdo exam
A
• Parotid swelling
• Jaundice
• Angular cheilitis /stomatitis (usually fungal infection but can be deficiency in riboflavin (vitamin B2)
• Conjuctival pallor - anaemia (i.e. chronic GI blood loss, inflam bowel disease)
19
Q
inside mouth in abdo exam
A
Inside mouth
• aphthous ulcers - Crohn’s
• Denitition
• Tongue - candida? Atrophic glossitis? raw red tongue of B12 def
• central cynosis
20
Q
Atrophic glossitis
A
Partial or complete absence of filiform papillae on the dorsal surface of the tongue
Many causes, usually related to IDA, pernicious anemia, B vitamin complex deficiencies, unrecognized and untreated celiac disease
21
Q
Virchow’s node
A
L supraclavicular node
- called Troisier sign
signal node for the spread of gastric cancer
22
Q
fistula examination steps?
A
• Type - radiocephalic (most), brachiocephalic, upper arm transposed basilica fistula
• Signs of infection
• Feel for thrills (active or not) / listen for bruits
• Sign of recent needle punctures (regular dialysis)
Combine with other info, e.g. J shaped + needle punctures = not functional transplant
23
Q
fistula examination steps?
A
• location
• feel for thrills (active or not)
• sign of recent needle punctures (regular dialysis)
Combine with other info, e.g. J shaped + needle punctures = not functional transplant
24
Q
how do you imagine this man was diagnosed with PKD?
A
Usually asymp until 4th decade so most are found via screening service for family members who have PKD
This hasn’t always been the case, so it may that this gentleman was diagnosed via routine blood tests
25
benefits of screening for PKD
There's also now a treatment called tolvaptan, which can slow the growth of cysts and may be beneficial in some cases.
Reduce cardiovasc disease - Management of BP, Lipids etc
26
MoA of Tolvaptan
competitive antagonist at vasopressin V2 receptors...
...can slow the growth of cysts, reducing overall kidney growth and preserving kidney function for longer
27
poor prognostic features of PKD
• Declining eGFR
• Proteinuria
• Early onset
• Male gender
28
why is high fluid intake advised for PKD
Suppresses antidiuretic hormone (ADH) levels
ADH levels are correlated with cyst growth
hence use of Tolvaptan
29
signs that may indicate uraemia
• scratch marks - uraemic pruritis
• uremia flapping tremor
• chest pain - uraemic pericarditis
• crystallized urea deposits (now very rare)
30
isolated splenomegaly likely diagnosis
if no lymphad, travel, no evidence of anaemia / chronic liver disease... Top 3 CML, myelofibrosis, malaria
then Likely diagnosis - form of chronic haemolysis, like hereditary spherocytosis
31
Causes of MASSIVE splenomegaly
• Myeloproliferative disorders
- chronic or acute myeloid leukaemia
- myelofibrosis
• Malaria chronic
• Visceral leishmaniasis
• Gaucher disease (lipid build up - think re Ashkanazi Jew)
32
Mechanism of splenomegaly in chronic liver disease
cirrhosis, causing blockage of blood flow, portal vein back-up and portal hypertension, causing spleen to become engorged
33
causes of splenomegaly
1. INFILTRATION - malig or benign
- myelo/lymphproliferative disoders
- lymphoma
- amyloidosis
- sarcoidosis
- thyrotoxicosis
- gaucher disease (lipid build up, Ashkanazi Jew)
2. INCREASED function
• increased removal of defected RBC
- spherocytosis
- thalassaemia
- dietary anaemia
- sickle cell
• immune hyperplasia
- Malaria (recent travel to africa - also look for anaemia)
- visceral leishmaniasis
- subacute bact endocartiditis
- glandular fever (examine throat)
- Brucellosis (farmer)
• Disordered immunoregulation
- RA , with FElty's
- SLE
- Sarcoid
3. ABNORMAL flow
- Cirrhosis
- Vascular problem like Hepatic/portal vein obstruction
34
Large spleen - what investigation
FBC with blood film
If any suspicion of haem malig - CT TAP plus bone marrow aspirate, LN biopsy
If African deent, FBC plus Thin and Thick films - for sickle cell and malaria
35
Indications for liver transplants
• Cirrhosis
• Hepatocellular carcinoma
• Acute hepatic failure (hepatitis A and B, paracetamol overdose)
36
scoring system for liver transplant in chronic disease
United Kingdom Model for End-Stage Liver Disease (UKELD) = Na, Cr, Bili, INR,
predicts prognosis of patients with cirrhosis / CLD
Same as MELD but that includes if dialysis twice in last week
score of 49 = 9% one-year risk of mortality, and is the minimum score to be added to transplant waiting list in UK
37
hemochromatosis diagnosis investigation
routine bloods - ferritin, transferrin saturations
if raised then HFE gene testing
INR is a good marker of liver synthetic function
Remember HbA1c, Alpha fetoprotein, echo, XR of joints,
38
liver transplant scar?
Mercedes Benz
or J shaped incision aka Makuuchi incision
39
See a liver transplant scar, what is important?
1) What is the scar?
2) Is transplant functioning?
- signs of CLD
- Gynaecamastia and Dupytrens persist
- evidence of Portal hypertension (Caput medusa, splenomegaly)...but spleen can remain enlarged
- hepatic decompensation - asterixis, ascites, jaundice -but could be extrahepatic jaundice
3) SE from immunosuppression?
- signs of infection
- Skin - sebhorric warts, actinic keratosis, skin malig/scars
- Steroid SE -evidence of diabetes, Cushingoid
- Tremor - tacrolimus
- Gum hypertrophy - cyclosporin (but rare)
4) Underlying eitiology?
- venesection scar? - haemochromatosis
- tattooes - hepatitis?
- signif xanthelasma - primary biliary cholangitis
- scars for prev trachae, post op drain, or ascitic drains
40
what signs of CLD persist following liver transplant?
Gynaecamastia and Dupytrens
41
Signs of portal hypertension
caput medusa
splenomegaly
42
Liver transplant contraindications
• IVDU
• ongoing alcohol excess (abstinence is mandatory in ALD)
• Signif medical / psychiatric comorbs
• Hx of prior malig would be strongly considered...
Age alone is not a contra
43
criteria for liver transplant in acute hepatitis
If suspected survival without transplant, is less than that with
Estimated mortality: Maddrey score and Glasgow Alcoholic Hepatitis score (GAHS)
(chronic is UKELD)
44
what type of drug is tacrolimus?
calcineurin inhibitor
( same as cyclosporine and pimecrolimus)
45
immunosuppression post liver transplant
initially steroids, but these are weaned down
then calcineurin inhibitor (e.g. tacrolimus)
46
liver transplant survival stats
90% alive at one year
75% alive at three year
47
complications of liver transplant
1) Rejection (particularly early)
2) SE from immunsuppression
- infections
- increased risk of skin malig
- metabolic syndrome
3) Acute or chronic kidney disease
- from calcinuerin inhib
- diabetes
- hypertension
48
management of ascites + pyrexia
If ascites corrected neutrophil count >250
....treat as SBP
Gram stain and culture
49
causes of liver disease?
UK common
- alcoholic (most common in UK)
- non-alcoholic fatty LD
Globally most common
- viral hepatitis
Autoimmune
- autoimmune hepatitis
- primary biliary cholangitis
- primary sclerosing cholangitis
Inherited
- haemochromatosis
- wilson's disease
- alpha 1 anti trypsin
Drugs
- paracetamol OD
- methotrexate
- amiodarone
- HCC
50
Differential diagnoses of ascites
serum-ascites albumin gradient
SAAG = (serum albumin) – (ascites albumin)
≥11g/L - Portal hypertension (97%) accuracy
- cirrhosis (usually clear)
- CCF
- Budd Chiari
- Meig's
< 11 g/:
- Malig - peritoneal carcinoma (most common)
- Pancreatitis
- Nephrotic syndrome
- TB
51
causes of ascites by category
Need serum-ascites albumin gradient (SAAG) but categorised as:
1) Vascular
- Portal hypertension from cirrhosis (most common)
- Budd chiari
- CCF
- Constrictive pericarditis
2) Low Alb
- Nephrotic syndrome
3) Peritoneal disease
- Meig's - Pl Eff, ascites, benign ovarian tumour
- Infectious peritonitis (TB / fungal)
- Malig
3) Misc
- pancreatic leak
- PD related
- Advanced hypothy?
52
To complete my Abdo Exam i would like....
to examine
hernial orifices
external genitalia
rectal examination
urinalysis
53
tests for liver synthetic function
albumin and INR
most helpful blood indicators of cirrhosis in terms of hepatic function
54
USS of liver in pt ascites?
Echotexture of liver
Portal vein patency
55
What is medication: Pentasa?
aka Mesalazine
5-aminosalicylic acid
56
indications for surgery in inflammatory bowel disease
• Toxic dilatation /megacolon
• Perforation
• Haemorrhage
• Failure of medical therapy
• Abscess
(more common in Crohn's due to transmural inflammation, 80% at some point need surgery)
57
Management of Crohn's flare
• Weaning course of steroids
• Azathioprine (immunosuppressant)
• Reg FU, and nurse specialist
• Dietician
58
Risk of cancer in Ulcerative colitis and Crohn's
and screening
Increased risk, but more so in UC than Crohn's
IBD >10yr, then regular endoscopy
59
what is the most common Extra-intestinal feature of inflammatory bowel disease?
• Arthritis
Usually asymmetrical, pauciarticular (less than 4joints) is related to disease activity
60
management of Crohn's vs Ulcerative Colitis to induce remission?
Crohn's:
• glucocorticosteroids first line
+/- azathioprine
• aminosalicylate (ASA) if steroids not an option
• or infliximab (give aza or methotrexate so body doesn't make antibodies to inflix)
UC
• ASA first line, topical if possible
• Except in severe - IV steroids +/- ciclosporin or surgery
61
surgery in Crohn's vs Ulcerative colitis
Surgery is more common in Crohn's due to transmural inflammation... up to 80% require surgery at some point
Colectomy can be curative in UC
62
What antibodies tests would you request for chronic liver failure?
PRIMARY BILIARY CHOLANGITIS
• Anti-mitochondrial antibody (AMA)
AUTOIMMUNE HEPATITIS
• Antinuclear Antibodies (ANA)
• Smooth muscle antibody
• IgG
• Anti-Liver-Kidney Microsomal (LKM) antibody (type 2 AIH)
• AFP tumour markers - HCC
63
Antibodies in primary biliary cholangitis
Anti-mitochondrial antibody (AMA)
64
primary biliary cirrhosis treatment
Ursodeoxycholic acid
Can relieve symps and improve prog
Can do transplant
65
causes of jaundice
PRE- (haemolytic)
• Hereditary Spherocytosis
• Sickle cell
• Malaria
• Bacteraemia
• g6pd deficiency
INTRA- hepatocellular disease (cell failure) or intrahepatic obstruction
• Cirrhosis
• Hepatitis
• Alcohol
• Liver cancer
• Gilbert's
POST-
• Intrahep / extra hepatic bile duct stones
• Gall bladder stones
66
Commonest causes of end stage renal failure
Diabetes
Hypertension
PKD
67
What are the potential barriers to renal transplant?
• Donor matching
• Active or recent malig
• Ongoing deep-seated infection (especially in diabetic patients)
• Active vasculitis
• Severe obesity due to technical difficulty
68
SE from immunosuppression?
- signs of infection
- Skin - sebhorric warts, actinic keratosis, skin malig/scars
- Steroid SE -evidence of diabetes, Cushionoid, brusing
- Tremor - tacrolimus
- Gum hypertrophy - cyclosporin (but rare)
69
Renal transplant on Mycophenolate
What do you need to tell patient
• Neutropenia and thrombocytopenia so bloods
• CXR (pulmonary fibrosis risk)
• Stop 6 weeks before trying for baby, and not during breast feeding
70
what's the purpose of simultaneous pancreas kidney transplant
for ESRF in T1DM (and sometimes Insulin-dep T2DM)
intends to cure both the patient’s diabetes and end stage renal failure
----> reduces risk of the vascular complications of diabetes (exept unclear if helps diabetic retinopathy)
71
Live kidney donation vs Simultaneous cadaver-donor pancreas and living-donor kidney transplant
Live kidney donation has better results than deceased
----> the donor and recipient can be in the same hospital, reducing warm and cold ischaemic time for the donated kidney, so better graft function
However, cadaveric simulataneous can cure diabetes
----> so longer lasting graft, and increased 10yr survival, compared to kidney alone
SPK last longer than just pancreas because kidney rejection is more quickly identifiable, so can be resolved
72
outcomes of SPK transplant
1 in 3 have to go back to theatre, and about 1 in 10 have major problems (removed, bleeding, thrombosis etc)
only 1 in 5 will be back on insulin in 5 years (15-20%)
and 1 in 5 will be on dialysis in 10 years (20-25%)
73
DRAINAGE of the transplanted pancreas?
Traditionally drained into the BLADDER
----> Lipase in urine could be measured to assess for rejection
----> However, risk of UTIs and reflux pancreatitis
Now, attached and drained to the SMALL BOWEL (enteric drainage)
74
islet cell transplantation vs pancreatic transplantation
no RCTs comparing them
Higher insulin independence in panc, but also higher morbidity
Islet cell transplantation in pancreatitis get their own islet cells so dont need immunosup
75
Investigation for coeliac disease
SCREENING: serum IgA tissue transglutaminase antibody
(make sure 6weeks of gluten)
CONFIRM: Gastro referral for endoscopy and biopsy looking for duodenal villous atrophy
76
Gluten containing products
wheat rye, and barley
77
anaemia in coeliac
• Folate deficiency - raised MCV
• Vit B12 def
• Iron Def - low MCV
78
Causes of portal hypertension
PREHEPATIC
• Portal vein thrombosis
• Splenic vein thrombosis
• Extrinsic compression
INTRAHEPATIC
• cirrhosis
• Primary biliary cirrhosis
• Myeloproliferative disease
• Polycystic disease
• Hepatic Mets
• Sarcoid/tb etc
• Budd chiari
POST
• thrombosis of IVC
• R sided HF
• Constrictive pericarditis
• Severe TR
79
Stigmata of chronic liver disease
• jaundice
• encephalopathy
• clubbing
• Dupytren’s contractures
• palmar erythema
• asterixis
• spider naevi
• gynacomastia
• caput medusa
• ascites
• hepatomegaly
• would have examined for testicular atrophy
80
haemochromatosis on examination
could be slate grey or bronze
chronic liver disease, i.e. hepatomegaly, ascites etc
venesection scars
81
symptoms of haemochromatosis
• fatigue
• weight loss
• weakness
• joint pain
• erectile dys (Hypogonadotropic hypogonadism)
• irreg / absent periods
• ascites
• jaundice
• arrythmia
• testicular atrophy
82
causes of chronic liver disease
3 Cs 4 Is:
• Cirrhosis (alcoholic)
• Carcinoma
• Congestion (congestive cardiac failure, budd Chiari)
• Infectious (viral hepatitis - globally most common)
• Immune (PBC, PSC, AIH)
• Inherited (Iron: haemochromatosis, Wilson's disease, alpha 1 anti trypsin)
• Infiltrative (amyloid, myeloproliferative disorder)
83
What is Budd-Chiari Syndrome
occlusion of the hepatic veins
classical triad of abdominal pain, ascites, and hepatomegaly
75% are primary thrombosis of the hepatic vein
25% compression of the hepatic vein by an outside structure (e.g. a tumor)
84
ceruloplasmin / caeruloplasmin
Ceruloplasmin is a protein that is made in the liver that stores and transports copper
Test result below 10 mg/dL indicates Wilson's disease
85
ascitic tap indicating antibiotics are necessary
Corrected Neut ≥ 250/mm3
Culture +ve
86
Importance of Thiamine in alcoholics
Deficiency occurs due to
• poor diet
• poor absorption due to gastritis
• high demand as it is a coenzyme in alcohol metabolism
Severe thiamine def can lead to Wernicke's encephalopathy, (ocular motility disorders, ataxia, and confusion)
87
Three symptoms of Wernicke's encephalopathy
confusion, ataxia, and ocular motility disorders (nystagmus)
88
How to give advice for alcoholic patients who want to change
FRAMES for brief intervention
• Feedback — on the person's risk of having alcohol problems
• Responsibility — change is their responsibility
• Advice — what can be done
• Menu — and what are the options of how that can be achieved
• Empathy — an approach that is warm, reflective, and understanding
• Self-efficacy — optimism about the person's ability to change their own behaviour
89
inheritance of hereditary haemochromatosis
autosomal recessive
90
Spontaneous bacterial peritonitis
Common - occurs in 25% of patients w ascites
Mortality of up to 40%
91
How can you assess prognosis with cirrhosis?
Model for End-Stage Liver Disease (MELD) = Na, Cr, Bili, INR, and if had dialysis twice in last week
92
Koilonychia
• can be idiopathic
• iron deficiency anemia (Plummer Vinson syndrome)
• malnutrition
• hemochromatosis
• coronary disease
• thyroid disorders
spoon-shaped
93
Pros and Cons of haemo and peritoneal dialysis
• Peritoneal dialysis can be done from home
• fewer restrictions to diet and fluid intake
but
• done every day (rather than 3/week)
• peritonitis/hernias
• often avoided in PKD because of mechanical and infectious complications
94
risks of peritoneal dialysis
• peritonitis
• hernias
• weight gain (your body absorbs the dextrose)
• reduced energy
• loss of proteins (significantly greater in PD than in hemodialysis)
95
is a liver tranplant palpable?
It isn't necessarily
If it is, it may just indicate a missmatch in donor-size, rather than any issue
96
Variant syndromes for liver transplantation
• diuretic resistant ascites
• chronic hepatic encephalopathy
• intractable pruritus
• hepatopulmonary syndrome
• polycystic liver disease
• recurrent cholangitis.
97
Indications for super-urgent liver transplantation, e.g. in paracetamol OD
King's College Criteria:
• pH < 7.3, 24 hours after overdose and after fluid resuscitation
or all three of:
• INR > 6.5 (PT > 100 sec)
• Cr > 300
• grade 3–4 encephalopathy
lactate > 3.0 is strongly poor prognostic
98
This man has a diagnosis of cirrhosis. Is there anything else that should be arranged for him?
An endoscopy, looking for:
• varices
• portal hypertensive gastropathy
• gastric antral vascular ectasia (GAVE) syndrome (blood vessels in lining of stomach become fragile / prone to rupture / bleeding)
99
?cirrhosis. when do you need liver biopsy?
• if low albumin and derranged clotting... or if Hep C, or heavy drinkers /diagnosed ALD:
• Offer Transient elastography (FibroScan) , might give enough to diagnose cirrhosis
• Liver biopsy is gold standard, but expense, risk of complications, and restriction to secondary care. Only samples limited area so 15% false neg rate
• Needs to be transjugular if ascites
100
complications of haemochromatosis
Liver, pancreas, heart, ant pit, joints
• Liver cirrhosis
• diabetes (type 1, due to selective beta-cell damage due to iron overload)
• iron overload cardiomyopathy
• Hypogonadotropic hypogonadism (from ant pit iron accummulation)
• athropathy
• slate grey or bronzing skin
Normal life expectancy with venesection
101
Prograf
Aka new version of tacrilimus
102
Young person with liver transplant
? Wilson's
103
Scoring for Cirrhosis mortality
Child-Pugh Score
Bili, Alb, INR, Ascites, Hepatic enceph
or MELD
104
Causes of nephrotic syndrome
• Infection - HIV, hepatitis B + C, mycoplasma, syphilis, malaria
• Inflammatory - SLE, RA, polyarteritis nodosa, HSP, vasculitides
• Metabolic - DM, amyloidosis.
• Inherited - Sickle, Alport's
• Malignant - multiple myeloma, leukaemia, lymphoma, breast, lung, colon, stomach
• Drugs - NSAIDs, captopril, lithium, gold, diamorphine, interferon alfa, penicillamine, probenecid etc
105
Diagnosis of nephrotic syndrome
• Proteinuria > 3-3.5 g/24h
• or urine PCR of >300-350 mg/mmol
• Alb <25 g/l
• Peripheral oedema
total cholesterol often >10 is often present
106
Extra intestinal features of IBD
Conjunctivitis/Uveitis/Episcleritis
Apthous ulcer
Erythema nodosum
Pyoderma granulosum (purulent ulcers with blue-black edge)
PSC
Clubbing
107
Indications for splenectomy
• Rupture
• Haematological (ITP and hereditary spherocytosis)
108
management after splenectomy
• Vaccination (ideally 2/52 prior to protect against encapsulated bacteria):
⚬ Pneumococcus
⚬ Meningococcus
⚬ Haemophilus influenzae (Hib)
• Prophylactic penicillin: (lifelong)
• Medic alert bracelet
109
four signs of decompensated liver failure
• Bruising/bleeding
• Jaundice
• Ascites
• Hepatic encephalopathy
110
Long-term risks of Coeliac disease
• Malnutrition
• Malabsorption - anaemia, b12 , folate, osteoporosis
• Slightly increased risk of s. bowel cancer, s bowel lymphoma and H lymphoma
• Preg - low birth weights etc
If gluten-free for 3 - 5 years, risk is same as gen pop
111
Irritable Bowel Syndrome management
• identify any associated stress, anxiety, and/or depression
• Good hydration, reg meals with balanced diet
• exercise
• If diarrhoea: reduce intake of insoluble fibres /any exacerbating things like caffeine alcohol
• CAn consider loperamide
• If constipated: can add Bulk-forming laxatives (fibre supplements: ispaghula) and gradually add more in
For spasms:
• Can consider mebeverine or peppermint oil
• trial of a low-dose tricyclic antidepressant
112
Inherited bowel cancer
• Familial adenomatous polyposis (FAP) bowel cancer
• Heriditary Non-Polyposis Colorectal Cancer HNPCC (Lynch syndrome)
113
Causes of pancreatitis
Most common are
• Alcohol
• Gallstones
Others include
• Traumatic
• Post ERCP
• Hypercalcaemia
• Hypertriglyceridemia
• Drug-related , azathioprim like steroids
Genetic causes like
• Cystic fibrosis
• PRSS1
114
complications of pancreatitis
Acute
• Sepsis
• ARDS
• Death
Chronic
• chronic pancreatitis
• Type 3c diabetes from chronic
• portal vein thrombosis
• pseudocysts - can cause duodenal, billiary and pancreatic obstruction
-----> they can be drained by endoscopically place AXIOS stent in stomach
• Increased risk of cancer
115
Management of chronic pancreatitis
• Avoid triggers
• Quit smoking/alcohol
• Creon - If signs of malabsorption, vit d def, hypomag, steatorrhoea
• PPI
• Good diet
• Pseudocysts can be drained by endoscopically place AXIOS stent in stomach
116
Achalasia key points
• Failure of peristalsis of oesophagus
• and failure of the lower esophageal sphincter to relax
Management:
• nitrates and calcium channel blockers
• Balloon dilation
• Surgery - myotomy
• Botox injection
increased risk of developing esophageal cancer
117
H Pylori investigation
• urea breath test
• stool antigen test
Can't have had PPI for 2/52 or Abx for 4/52
118
What further investigations for haemochromatosis
Diagnosis
• fasting transferrin saturation & ferritin
• if raised - HFE genetic testing
+- Liver biopsy rarely necessary but can assess disease severity
Complications
• HbA1c
• Cirrhosis - USS liver
• Echo - cardiomyopathy
• AFP - Hepatocellular carcinoma
119
What is indomethacin?
NSAID
contraindicated in severe CKD
120
Consequences of untreated or inadequately treated coeliac disease
• symptoms of coeliac
Malabsorb
• IDA
• Folate/B12
• Osteoporosis
Malnutrition
Pregnancy
• Low birth weight/premature baby
Cancer
• Rarely, increased risk of cancer of gut (Enteropathy associated T-cell lymphoma)
• Also risk of other autoimmune
Can rarely get gluten ataxia, neuropathy and enephalopathy
121
Cancer associated with coeliac
rare, but
substantially increased risk of developing Enteropathy associated T-cell lymphoma
particularly if poorly controlled coeliac
122
Nephrotic vs nephritic syndrome
Nephrotic
• signif proteinuria
• hypoalbuminaemia - so signif oedema
• hyperlipidaemia
• hypercoagulability
Nephritic
• Haematuria
• red cell casts in the urine
• Some proteinuria and oedema
• Hypertension
