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Finals PACES > Abdo > Flashcards

Abdo Flashcards

1
Q

Dupuytren’s contractures causes

A

liver cirrhosis, diabetes, heavy labour, phenytoin, trauma, familial

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2
Q

Clubbing causes

A

IBD, cirrhosis, lymphoma, coeliac’s

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3
Q

McBurney’s point

A

distal 1/3 of umbilicus and ASIS

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4
Q

McBurney’s sign

A

pressuring on Mcburney’s area causes pain in that point acute appendicitis
Aaron sign is when it causes pain to epigastric when at that area

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5
Q

Hepatomegaly (IIBBCC) causes

A

Infection (viral hepatitis, EBV, malaria)
Infiltration (sarcoid, amyloid, fatty liver, haemochromatosis)
Blood related (lymphoma, leukaemia, myeloproliferative disorders, haemolytic anaemias*)
Biliary (PBC, PSC)
Cancer (primary HCC, metastatic deposit)
Congestion (RHF, tricuspid regurg, budd-chiari syndrome)
*causes of hepatosplenomegaly

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6
Q

Causes of hepatosplenomegaly

A

lymphoma, leukaemia, myeloproliferative disorders, haemolytic anaemias, sarcoid, amyloid, viral hepatitis, EBV, malaria

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7
Q

Massive splenomegaly (past umbilicus) causes

A

malaria
myelofibrosis
CML

splenomegaly - IE, RA (if low WCC = Felty’s syndrome)

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8
Q

Extra-intestinal manifestation of IBD

A 
finger clubbing
mouth ulcers (Crohn's)
eyes (episcleritis, conjunctivitis)
skin (erythema nodosum, pyoderma gangrenosum)
joints (seronegative arthropathy)
PSC (esp UC)
amyloidosis (Crohn's)
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9
Q

portal hypertension leads to…

A

causes splenomegaly, caput medusae, oesophageal varices, gastropathy and ascites

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10
Q

AV fistula types

A

radio-cephalic (Cimino)
branchio-cephalic fistula
never measure BP on fistula arm

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11
Q

LIF mass

A 
renal transplant
loaded colon
diverticular mass
colorectal carcinoma
ovarian mass / cysts
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12
Q

RIF mass

A 
renal transplant
appendix mass
crohn's disease
caecal carcinoma
ovarian mass / cysts
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13
Q

Bilateral enlarged kidneys

A

APKD (autosomal dominant PKD)
bilateral hydronephrosis
amyloidosis

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14
Q

Spleen (vs left kidney)

A 
Can get over a kidney
percussion note is resonant over a kidney
kidney is balottable
spleen has notch
spleen moves more on respiration
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15
Q

unilateral enlarged kidney

A

hydronephrosis
renal cancer
renal cyst

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16
Q

indications for dialysis in CRF

A

CKD stage 5 (GFR <15 ml/mins)
symptomatic uraemia despite conservative Rx
Renal bone disease
pericarditis
volume overload despite fluid restriction and diurectics
hyperkalaemia despite Rx

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17
Q

Complications of haemodialysis

A 
hypotension
hypovolaemia
hypokalaemia
cerebral oedema
dialysis related amyloidosis (beta-2)
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18
Q

Side effects of post transplant immunosuppression

A

high dose steroids

ciclosporin (gingival hypertrophy, warty skin lesions, hypertrichosis = werewolf syndrome)

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19
Q

Pseudomembranous colitis

A 
Severe disease if one of:
 WCC >15
 Cr >50% above baseline
 Temp >38.5
 Clinical / radiological evidence of severe colitis

Normal 1st line: metronidazole 400mg TDS

Severe 1st line: vancomycin

Urgent colectomy needed if: toxic megacolon; elevated LDH; deteriorating condition

Recurrence in up to 30% cases; first relapse can repeat metro, on further relapses give vanco

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20
Q

Constipation causes

A 
OPENED IT
Obstruction
Pain (anal fissure)
Endocrine/Electrolyte (hypothy; hypocalc -kae, uraemia)
Neuro: MS, cauda equina
Elderly
Diet/Dehydration
IBS
Toxins (opioids/anti-mAch)

Must exclude obstruction, cauda equina!

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21
Q

IBS diagnosis

A 
ROME Criteria:
Abdo discomfort / pain for ≥ 12wks which has 2 of:
 Relieved by defecation
 Change in stool frequency (D or C)
 Change in stool form: pellets, mucus
\+ 2 of:
 Urgency
 Incomplete evacuation
 Abdo bloating / distension
 Mucous PR
 Worsening symptoms after food
Exclusion criteria
 >40yrs
 Bloody stool
 Anorexia
 Wt. loss
 Diarrhoea at night

Perform colonoscopy if >60 years or features of organic disease

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22
Q

IBS Rx

A

 Exclusion diets can be tried
 Bulking agents for constipation and diarrhoea (e.g. fybogel or bran).
 Antispasmodics for colic/bloating (e.g. mebeverine)
 Amitriptyline may be helpful
 CBT

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23
Q

Plummer-Vinson syndrome

A

Benign oesophageal web causing dysphagia

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24
Q

Pharyngeal pouch: zenker’s diverticulum

A

Outpouching at Killian’s dehiscence with swelling usually to left side and posterior
 Pres: regurgitation, halitosis, gurgling sounds
 Rx: excision, endoscopic stapling

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25
Q

Diffuse oesophageal spasm

A

 Intermittent dysphagia ± chest pain

 Ba swallow shows corkscrew oesophagus

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26
Q

Gastric ulcer stress causes

A

 Cushing’s: intracranial disease

 Curling’s: burns, sepsis, trauma

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27
Q

Hiatus hernia classification

A
  1. Sliding (80%) - gastro-oesophageal junction slides into chest and associated with GORD
  2. Rolling (15%) - gastro-oesophageal junction remains in abdomen with bulge into chest and so no GORD as LOS intact; can strangulate. Should repair therefore
  3. Mixed (5%)

Typically treat reflux and advise to lose weight

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28
Q

Rockall score

A

Prediction of re-bleeding and mortality in upper GI bleed
 40% of re-bleeders die

Initial score pre-endoscopy:
 Age
 Shock: BP, pulse
 Comorbidities

Final score post-endoscopy:
 Final Dx + evidence of recent haemorrhage
 Active bleeding
 Visible vessel
 Adherent clot

Initial score ≥3 or final >6 are indications for surgery

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29
Q

AST:ALT

A

 > 2 = EtOH

 < 1 = Viral

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30
Q

LFT in liver failure

A

↓ albumin in chronic failure

↑ PT in acute failure

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31
Q

Hepatorenal syndrome

A

Renal failure in patients with advanced liver failure

 Type 1: rapidly progressive deterioration (survival <2wks)
 Type 2: steady deterioration (survival ~6mo)

Rx:
 IV albumin + splanchnic vasoconstrictors (terlipressin)
 Haemodialysis as supportive Rx
 Liver Tx is Rx of choice

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32
Q 
Complications of liver failure Mx
Bleeding
Sepsis
Ascites
Hypoglycaemia
Encephalopathy
Seizure
Cerebral oedema
A

 Bleeding: Vit K, platelets, FFP, blood
 Sepsis: tazocin (avoid gent: nephrotoxicity)
 Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
 Hypoglycaemia: regular BMs, IV glucose if <2mM
 Encephalopathy: avoid sedatives, lactulose ± enemas, rifaximin
 Seizures: lorazepam
 Cerebral oedema: mannitol

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33
Q

Prescribing in liver failure

A

 Avoid: opiates, oral hypoglycaemics, Na-containing IVI
 Warfarin effects ↑
 Hepatotoxic drugs: paracetamol, methotrexate, isoniazid, salicylates, tetracycline

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34
Q

Liver transplant decisions

A

Types
 Cadaveric: heart-beating or non-heart beating
 Live: right lobe

Can use the Kings College Hospital Criteria in Acute failure which has different criteria depending on whether paracetamol induced or not

Immunosuppression:
 Ciclosporin / Tacrolimus +
 Azathioprine / Mycophenolate Mofetil +
 Prednisolone

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35
Q

Child-Pugh grading of cirrhosis

A

Predicts risk of bleeding, mortality and need for Tx

Graded A-C using severity of 5 factors
 Albumin
 Bilirubin
 Clotting
 Distension: Ascites
 Encephalopathy

Score >8 = significant risk of variceal bleeding

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36
Q

Mx of Cirrhosis

A

General
 Good nutrition
 EtOH abstinence: baclofen helps ↓ cravings
 Colestyramine for pruritus
 Screening for HCC (US and AFP) & Oesophageal varices (endoscopy)

Specific
 HCV: Interferon-α
 PBC: Ursodeoxycholic acid
 Wilson’s: Penicillamine

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37
Q

Portosystemic anastomoses

A
  1. left and short gastric veins + infer. oesophageal veins = oesophageal varices
  2. peri-umbilical veins + superficial abdominal wall veins = caput medusae
  3. Super. rectal veins + inf. and mid. rectal veins = haemorrhoids
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38
Q

Abdominal veins seen

A

More common than caput medusa

 Blood flow down below the umbilicus: portal HTN
 Blood flow up below the umbilicus: IVC obstruction

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39
Q

Causes of portal HTN

A

 Pre-hepatic: portal vein thrombosis (e.g. pancreatitis)
 Hepatic: cirrhosis (80% in UK), schisto (commonest
worldwide), sarcoidosis.
 Post-hepatic: Budd-Chiari, RHF, constrictive
pericarditis, TR

Leads to SAVE
Splenomegaly
Ascites
Varices
Encephalopathy
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40
Q

Classification of liver encephalopathy

A

 1: Confused – irritable, mild confusion, sleep inversion
 2: Drowsy – ↑ disorientated, slurred speech, asterixis
 3: Stupor – rousable, incoherence
 4: Coma – unrousable, ± extensor plantars

Important to give lactulose (+/- phosphate enemas) to these patients with encephalopathy

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41
Q

Ascites

A

Caused calculated via serum ascites albumin gradient (serum albumin – ascites albumin)
If >1.1g/dL = portal HTN

If <1.1g/dL = NINI
Neoplasia
Inflammation (pancreatitis)
Nephrotic syndrome
Infection (TB)

Rx: reduce weight by 0.5kg/d via fluid restriction, spironolactone and frusemide and can drain via paracentesis with HAS infusion

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42
Q

Alcoholism Mx

A

 Group therapy or self-help (e.g. AA)
 Baclofen: ↓ cravings
 Acamprosate: ↓ cravings
 Disulfiram: aversion therapy

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43
Q

Alcoholic hepatitis prognosis

A

Maddrey score predicts mortality
 Mild: 0-5% 30d mortality
 Severe: 50% 30d mortality
 1yr after admission: 40% mortality

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44
Q

Hep B prognosis and Rx

A

 Carrier: 10%
 HBsAg +ve > 6mo
 Chronic hepatitis: 10%
 Cirrhosis: 5%

Rx: PEGinterferon

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45
Q

Hep C prognosis and Rx

A

 Carrier: 80%
 HCV RNA+ve >6mo
 Chronic hepatitis: 80%
 Cirrhosis: 20%

Rx: PEGinterferon + ribavarin

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46
Q

Budd-Chiari Syndrome presentation

A

Presentation
 RUQ pain: stretching of Glisson’s capsule
 Hepatomegaly
 Ascites: SAAG ≥1.1g/dL
 Jaundice (and other features of liver failure)
Can be from JAK2 mutation analysis; anticoagulate unless varices

47
Q

Hereditary Haemochromatosis Rx

A

Iron removal
 Venesection: aim for Hct <0.5
 Desferrioxamine is 2nd line

General
 Monitor DM
 Low Fe diet

Screening
 Se ferritin and genotype
 Screen 1st degree relatives

Transplant in cirrhosis
Venesection returns life expectancy to normal if non-cirrhotic and non-diabetic

48
Q

Wilson’s disease Rx

A

 Diet: avoid high Cu foods: liver, chocolate, nuts
 Penicillamine lifelong (Cu chelator). SE: nausea, rash, ↓WCC, ↓Hb, ↓plats, lupus,
haematuria
 Monitor FBC and urinary Cu excretion
 Liver Tx if severe liver disease
 Screen siblings

49
Q

Autoimmune hepatitis

A

Predominantly in early and middle aged women
Type 1 is anti-smooth muscle +ve
Ix: Raised IgG and LFTs
Mx: immunosuppression with pred and azathioprine (steroid sparing)
Prognosis: remission in 80% of patients

50
Q

Primary Biliary Cirrhosis

A

Intrahepatic bile duct destruction via granulomatous inflammation

Jaundice is late sign

Ix: antimitochondrial ab and raised IgM and LFTs (ALP), US

Liver biopsy shows non-caseating granuloma

Rx: ADEK vitamins, UDCA, symptomatic relief for pruritus (naltrexone), diarrhoea and osteoporosis
Ultimately need liver transplant with survival of 2 years if jaundice develops

51
Q

Primary sclerosing cholangitis

A

Inflammation and fibrosis of intra- and extra-hepatic ducts.
More likely to get abdo pain
Increased risk of ascending cholangitis, cholangiocarcinoma and associated with UC and autoimmune hepatitis

Ix: pANCA (80%), ANA and SMA; ALP raised
ERCP: “beaded” appearance of ducts and biopsy shows fibrous, obliterated cholangitis

Rx: ADEK vitamins, UDCA, symptomatic relief for pruritus (naltrexone), diarrhoea

Ultimately need liver transplant with 30% recurrence

52
Q

Dermatitis herpetiformis from Coeliac’s

A 
Symmetrical vesicles, extensor surfaces
 Esp. elbows
Very itchy
biopsy shows granular deposition of IgA
Rx: gluten free diet or dapsone
53
Q

Malabsorption causes

A

Common in UK: Coeliac, Chronic pancreatitis, Crohn’s

Rarer
 ↓Bile: PBC, ileal resection, colestyramine
 Pancreatic insufficiency: Ca, CF, chronic panc
 Small bowel: resection, tropical sprue, metformin
 Bacterial overgrowth: spontaneous, post-op
blind loops, DM, PPIs
 Infection: Giardia, Strongyloides, Crypto parvum
 Hurry: post-gastrectomy dumping

54
Q

Trousseau Sign

A

Thrombophlebitis migrans in cancer, e.g. pancreatic cancer

55
Q

Chronic pancreatitis Mx

A 
Drugs
 Analgesia: may need coeliac plexus block
 Creon
 ADEK vitamins
 DM Rx
Diet
 No EtOH
 ↓ fat, ↑ carb
Surgery - Pancreatectomy
 Ind: unremitting pain, wt. loss
56
Q

Carcinoid syndrome Ix

A

 ↑ urine 5-hydroxyindoleacetic acid
 ↑ plasma chromogranin A
 CT/MRI: find primary; can be appendix, ileum, colorectum, stomach

57
Q

Carcinoid Rx

A

Symptoms: octreotide or loperamide

Curative
 Resection: tumours are v. yellow
 Give octreotide to avoid carcinoid crisis

Carcinoid Crisis
 Tumour outgrows blood supply or is handled too
much → massive mediator release
 Vasodilatation, hypotension, bronchoconstriction,
hyperglycaemia
 Rx: high-dose octreotide

58
Q

Vit A deficiency (Xerophthalmia)

A

 Dry conjunctivae, develop spots (Bitots spots)
 Corneas become cloudy then ulcerate
 Night blindness → total blindness

59
Q

Thiamine B (Beri Beri) deficiency

A

 Wet: heart failure + oedema
 Dry: polyneuropathy
 Wernicke’s: ophthalmoplegia, ataxia, confusion

60
Q

Niacin B3 (Pellagra) deficiency

A

 Diarrhoea, Dermatitis, Dementia
 Also: neuropathy, depression, ataxia
 Causes: dietary, isoniazid, carcinoid syndrome

61
Q

Pyridoxine (B6) deficiency

A

 Peripheral sensory neuropathy

 Cause: PZA

62
Q

Cyanocobalamin (B12) deficiency

A

Glossitis → sore tongue

Peripheral neuropathy
 Paraesthesia
 Early loss of vibration and proprioception → ataxia

Subacute Combined Degeneration of spinal Cord
 Dorsal and corticospinal tracts
 Sensory loss and UMN weakness

Overall mixed UMN and LMN signs with sensory
disturbance
 Extensor plantars + absent knee and ankle
jerks

63
Q

Monitoring of NaCl in kidneys occurs

A

in macula densa

64
Q

Regulation of water reabsorption

A

At cortical Collecting ducts

controlled by aquaporin-2 channels

65
Q

Carbonic Anhydrase Inhibitors (acetazolamide)

A

 MOA: inhibit carbonic anhydrase in PCT (which reabsorbs carbonic anhydrase)
 Effect: ↓ HCO3 reabsorption → small ↑ Na loss
 Use: open angle glaucoma
 SE: drowsiness, renal stones, metabolic acidosis

66
Q

Loop Diuretics (fursemide, bumetanide)

A

 MOA: inhibit Na/K/2Cl symporter in thick ascending limb
 Effect: massive NaCl excretion, Ca and K excretion, creating a weaker gradient so water not reabsorbed
 Use: Rx of oedema – CCF, nephrotic syndrome,
hypercalcaemia
 SE: hypokalaemic met alkalosis, ototoxic, Hypovolaemia

67
Q

Thiazide Diuretics (bendroflumethazide)

A

 MOA: inhibit NaCl co-transporter in DCT
 Effect: moderate NaCl excretion, ↑ Ca reabsorption
 Use: HTN, ↓ renal stones, mild oedema
 SE: ↓K, hyperglycaemia, ↑ urate (C/I in gout)

68
Q

K-Sparing Diuretics (spironolactone, amiloride)

A

 MOA:
 Spiro: aldosterone antagonist
 Amiloride: blocks DCT/CD luminal Na channel
 Effect: ↑ Na excretion, ↓K and H excretion
 Use: used with loop or thiazide diuretics to control K loss,
spiro has long-term benefits in aldosteronsim (LF, HF)
 SE: ↑K, anti-androgenic (e.g. gynaecomastia)

69
Q

Osmotic Diuretics (mannitol)

A

 MOA: freely filtered and poorly reabsorbed
 Effect: ↓ brain volume and ↓ ICP
 Use: glaucoma, ↑ICP, rhabdomyolysis
 SE: ↓Na, pulmonary oedema, n/v

70
Q

False -ve for haematuria

A

myoglobin, porphyria

71
Q

False -ve for proteinuria

A

Bence-Jones proteins

72
Q

Post-renal causes

A 
SNIPPIN
Stone
Neoplasm
Inflammation: stricture
Prostatic hypertrophy
Posterior urethral valve
Infection: TB, shisto
Neuro: post-op, neuropathy
73
Q

Presentation of renal failure

A
  1. Protein loss and Na retention (HTN and overload)
  2. Acidosis (Kussmaul respiration)
  3. Hyperkalaemia
  4. Anaemia
  5. Uraemia (need GFR <15ml/min)
74
Q

Sterile Pyuria

A 
 TB
 Treated UTI
 Appendicitis
 Calculi
 TIN
 Papillary necrosis
 Polycystic Kidney
 Chemical cystitis (e.g. cyclophosphamide)
75
Q

UTI classification

A

 Uncomplicated: normal GU tract and function
 Complicated: abnormal GU tract, outflow obstruction, ↓ renal function, impaired host defence, virulent organism
 Recurrent: further infection with new organism
 Relapse: further infection with same organism

76
Q

Pyelonephritis Rx

A

1st line: Cefotaxime 1g IV BD for 10d

 No response: Augmentin 1.2g IV TDS + gentamicin

77
Q

GN causes

A 
 Idiopathic
 Immune: SLE, Goodpastures, vasculitis (e.g. Wegener's)
 Infection: HBV, HCV, Strep, HIV
 Drugs: penicillamine, gold
 Amyloid

Can present with:

  1. asymptomatic haematuria 2. nephrotic syndrome
  2. nephritic syndrome
78
Q

Asymptomatic haematuria causes

A
  1. IgA Nephropathy (Berger’s) - typically in young males few days post URTI with raised IgA. Rx = steroids or cyclophosphamide if renal function impaired. ESRF in 20% after 20 years
  2. Thin basement membrane disease - AD and commonest causes. Very small risk of ESRF
  3. Alport’s syndrome - X-linked. Progressive renal failure, deafness and cataracts; in female haematuria only
79
Q

Nephritic syndrome

A

Triad of:
Haematuria; proteinuria (oedema); HTN

Causes:

  1. Proliferative/post-strep
  2. Crescentic / RPGN
80
Q

Proliferative/post-strep

A 
Features
 Young child develops malaise and nephritic syndrome with smoky urine 1-2wks after sore throat or skin infection.
 ↑ ASOT
 ↓C3
Biopsy: IgG and C3 deposition
Rx: Supportive

Prognosis
 95% of children recover fully

81
Q

Cresentic / RPGN

A

Type 1: Anti-GBM (Goodpasture’s) – 5%
 Haematuria and haemoptysis
 CXR shows infiltrates
 Rx: Plasmapheresis and immunosuppression

Type 2: Immune Complex Deposition – 45%
 Complication of any immune complex deposition e.g. Berger’s, post-strep, endocarditis, SLE

Type 3: Pauci Immune (ANCA) – 50%; i.e. no features of systemic vasculitis
 cANCA: Wegener’s
 pANCA: microscopic polyangiitis, Churg-Strauss
 Even if ANCA+ve, may still be idiopathic

82
Q

Nephrotic syndrome causes

A

Primary:

  1. Minimal change - associated with URTI in children, biopsy shows normal light micro and fusion of podocytes on EM. Rx = steroids
  2. Membranous nephropathy - biopsy shows subepithelial immune complex deposits. Rx = immunosuppression if RF declines, but 40% have spontaneous remission
  3. Focal Segmental Glomerulosclerosis - common in Afro-Cari; biopsy shows focal scarring and IgM depositions. Rx = steroids or cyclophosphamide/ciclosporin
  4. Membranoproliferative - rare and associated with HBV, HCV and endocarditis; 50% develop ESRF

Secondary:
 DM: glomerulosclerosis
 SLE: membranous
 Amyloidosis

In general, if symptomatic / complications give frusemide and salt + fluid restrict, give ACEi for proteinuria

83
Q

Indications for Acute Dialysis

A

AEIOU

  1. acidosis <7.2
  2. Electrolytes - refractory hyperkalaemia >6.5
  3. Intoxication (SLIME toxins) - salicyclates, lithium, isopropanol, methanol, ethyl glycerol
  4. oedema (pulmonary)
  5. uraemia - leading to encephalopathy or pericarditis
84
Q

Hyperkalaemia Mx

A

 10ml 10% calcium gluconate
 50ml 50% glucose + 10u insulin (Actrapid)
 Salbutamol 5mg nebulizer
 Calcium resonium 15g PO or 30g PR
 Haemofiltration (usually needed if anuric)

85
Q

Pulmonary oedema Mx

A

 Sit up and give high-flow O2
 Morphine 2.5mg IV (± metoclopramide 10mg IV)
 Frusemide 120-250mg IV over 1h
 GTN spray ± ISMN IVI (unless SBP <90)
 If no response consider: CPAP +/- Haemofiltration / haemodialysis ± venesection

86
Q

Surgical complications for colectomy

A

Abdominal:
 SBO
 Anastomotic stricture
 Pelvic abscess

Stoma:
 retraction
 stenosis
 prolapse
 dermatitis

Pouch
 Pouchitis (50%): metronidazole + cipro
 ↓ female fertility
 Faecal leakage

87
Q

Tubulointerstitial nephritis causes

A 
Drug hypersensitivity in 70%:
 NSAIDs
 Abx: Cephs, penicillins, rifampicin, sulphonamide
 Diuretics: frusemide, thiazides
 Allopurinol
 Cimetidine

Infections in 15%:
 Staphs, streps

Immune disorders:
 SLE, Sjogren’s

88
Q

Tubulointerstitial nephritis presentation and Rx

A

Presentation:
[] AKI, uveitis, fever, arthralgia, rashes
[] elevated IgE and eosinophilia
[] dip: haematuria, proteinuria, sterile pyuria

Rx:
[] stop offending drug
[] prednisolone

Prognosis - most recover GFR

89
Q

Chronic tubulointerstitial nephritis

A 
Fibrosis and tubular loss
Commonly caused by:
 Reflux and chronic pyelonephritis
 DM
 SCD or trait
90
Q

Analgesic Nephropathy

A

Prolonged heavy ingestion of compound analgesics

Features
 Sterile pyuria ± mild proteinuria
 Slowly progressive CRF
 Sloughed papilla can → obstruction and renal colic

Ix: CT w/o contrast (papillary calcifications)

Rx: stop analgesics

91
Q

Nephrotoxic drugs

A 
NSAIDs
Antimicrobials: AVASTA
 Aminoglycosides
 Vancomycin
 Aciclovir
 Sulphonamides
 Tetracycline
 Amphotericin
ACEi
Immunosuppressants:
 Ciclosporin
 Tacrolimus
Contrast media
Anaesthetics: enflurane
Myoglobin
Urate
92
Q

CKD causes

A

Common
 DM
 HTN

Other
 RAS
 GN
 Polycystic disease
 Drugs: e.g. analgesic nephropathy
 Pyelonephritis: usually 2O to VUR
 SLE
 Myeloma and amyloidosis
93
Q

Complications of CKD

A 
CRF HEALS
 Cardiovascular disease
 Renal osteodystrophy - sevelamer is phosphate binder; give calcium supplements
 Fluid (oedema)
 HTN
 Electrolyte disturbances: K, H
 Anaemia - EPO raised to 11 (any higher is thrombosis risk)
 Leg restlessness - clonazepam
 Sensory neuropathy
94
Q

Kidney transplant C/I and immunosuppression

A

 Active infection
 Cancer
 Severe HD or other co-morbidity

 Pre-op: alemtuzumab (anti-CD52)
 Post-op: prednisolone short-term and tacro/ciclo long term

95
Q

Kidney transplant complications

A 
Post-op
 Bleeding
 Graft thrombosis
 Infection
 Urinary leaks

Hyperacute rejection (minutes)
 ABO incompatibility
 Thrombosis and SIRS

Acute Rejection (<6mo)
 ↑ing Cr (± fever and graft pain)
 Cell-mediated response
 Responsive to immunosuppression

Chronic Rejection (>6mo)
 Interstitial fibrosis + tubular atrophy
 Gradual ↑ in Cr and proteinuria
 Not responsive to immunosuppression

Ciclosporin / tacrolimus nephrotoxicity
 Acute: reversible afferent arteriole constriction → ↓GFR
 Chronic: tubular atrophy and fibrosis

↓ Immune Function
 ↑ risk of infection: opportunists, fungi, warts
 ↑ risk of malignancy: BCC, SCC, lymphoma (EBV)

Cardiovascular Disease
 Hypertension and atherosclerosis

96
Q

Myeloma renal complications

A

Can cause ARF / CRF; amyloidosis

Rx - ensure fluid intake of 3L/d to prevent further impairment
Dialysis may be required in ARF

97
Q

RA renal complications

A

 NSAIDs → ATN
 Penicillamine and gold → membranous GN
 AA amyloidosis occurs in 15%

98
Q

SLE renal complications

A

 Involves glomerulus in 40-60% → ARF/CRF
 Proteinuria and ↑BP common

Rx
 Proteinuria: ACEi
 Aggressive GN: immunosuppression

99
Q

Diffuse Systemic Sclerosis renal complciations

A

Renal crisis: malignant HTN + ARF. Commonest cause of death

 Rx: ACEi if ↑BP or renal crisis

100
Q

Renal Tubular Acidosis

A

Features = hyperchloraemic met acidosis; hypokal

Type 1 (Distal)
Inability to excrete H+, even when acidotic.
Causes
 Hereditary: Marfan’s, Ehler’s Danlos
 AI: Sjogren’s, SLE, thyroiditis
 Drugs
Features
 Rickets / osteomalacia (bone buffering)
 Renal stones and UTIs
 Nephrocalcinosis → ESRF
Dx - Failure to acidify urine (pH >5.5) despite acid load

Type 2 (Proximal)
Defect in HCO3 reabsorption in PCT usually assoc. Fanconi syndrome
Dx - Urine will acidify with acid load (pH <5.5)

101
Q

Fanconi Syndrome

A

Disturbance of PCT function → generalised impaired
reabsorption
 amino acids, K+, HCO3, phosphate, glucose

Features:
 Polyuria (osmotic diuresis)
 Hypophosphataemic rickets (Vit D resistant)
 Acidosis, ↓K

102
Q

Bartter’s syndrome

A

Blockage of NaCl reabsorption in loop of Henle (like frusemide)
Hypokalaemia and met alkalosis with normal BP with salt wasting

103
Q

Gitelman Syndrome

A

Blockage of NaCl reabsorption in DCT (like thiazides)

hypokalaemia and metabolic alkalosis + hypocalciuria with normal BP

104
Q

Polycystic Kidney disease presentation

A 
MISSHAPES
 Mass: abdo mass and flank pain
 Infected cyst
 Stones
 SBP ↑
 Haematuria or haemorrhage into cyst
 Aneurysms: berry → SAH
 Polyuria + nocturia
 Extra-renal cysts: liver
 Systolic murmur: mitral valve prolapse

PKD1 is Chr16, polycystin 1
PKD2 is Chr4, polycystin 2

Recessive PKD you get congenital hepatic fibrosis as well

105
Q

Polycystic Kidney disease Rx

A 
General
 ↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation)
 Monitor U+E and BP
 Genetic counselling
 MRA screen for Berry aneurysms

Medical
 Rx HTN aggressively: <130/80 (ACEi best)
 Rx infections

Surgical
 Pain may be helped by laparoscopic cyst removal or
nephrectomy.

ESRF in 70% by 70yrs
 Dialysis or transplant

106
Q

Medullary Sponge Kidney

A

Multiple cystic dilatations of the CDs in the medulla, in young females. Renal function usually normal but can predispose to stones

107
Q

Tuberous sclerosis

A

 AD condition with hamartomas in skin, brain, eye, kidney
 Skin: nasolabial adenoma sebaceum, ash-leaf
macules, peri-ungual fibromas
 Neuro: ↓IQ, epilepsy
 Renal: cysts, angiomyolipomas

108
Q

Renal Enlargement Differential

A 
PHONOS
 Polycystic kidneys: ADPKD, ARPKD, TS
 Hypertrophy 2O to contralateral renal agenesis
 Obstruction (hydronephrosis)
 Neoplasia: RCC, myeloma, amyloidosis
 Occlusion (renal vein thrombosis)
 Systemic: early DM, amyloid
109
Q

Ecchymosis

A

A discoloration of the skin resulting from bleeding underneath, leading to bruising

110
Q

Left varicocele can be sign of

A

renal malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric vein - known as the nutcracker angle

111
Q

Cowden syndrome

A

PTEN mutation and intestinal hamartomas

112
Q

Investigations to differentiate IBS from IBD

A 
FBC
U&amp;E
ESR and CRP
Coeliac screen
Faecal calprotectin
113
Q

Causes of large bowel obstruction

A

Luminal:
[] Impacted faeces
[] Foreign body

Intramural:
[] Colorectal carcinoma*
[] Diverticular stricture*
[] Crohn’s stricture

Extramural:
[] Sigmoid volvulus*
[] Caecal volvulus
[] Adhesions and hernias (rare in LBO)

114
Q

Causes of small bowel obstruction

A

Luminal:
[] foreign body
[] gallstones

Intramural:
[] Crohn's strictures
[] Small bowel tumour
[] Congenital atresia
[] Malignancy (rare in SMO)
Extramural:
[] Adhesion*
[] Hernia*
[] Intussusception
[] Small bowel volvulus

*Common causes

Finals PACES (12 decks)

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