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Leila PACES > Abdo (liver/spleen) > Flashcards

Abdo (liver/spleen) Flashcards

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1
Q

Abdominal causes of clubbing

A

IBD
Gastric malignancy
CLD/Cirrhosis
Coeliac

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2
Q

RIF vs LIF stoma

A

RIF - Ileostomy
LIF - Colostomy

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3
Q

Causes of spider naevi

A

CLD
Pregnancy
OCP
Thyrotoxicosis
Normal in childhood

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4
Q

Causes of acanthosis nigricans

A

T2DM
Hyperthyroidism
Acromegaly
Cushing’s
Obesity

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5
Q

Causes of gynaecomastia

A

CLD
Drugs - spiro/digoxin
Idiopathic
Malignancies (hCG secreting, testicular tumours)

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6
Q

Examination features in the face in CLD

A

Parotid enlargement
Scleral icterus
Xanthelasma
Pallor - ACD
Kayser-Fleischer rings

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7
Q

CLD features on inspection of abdomen

A

Ascites
Umbilical hernia (make sure to demonstrate reducability)
Scars from taps/drains
Caput medusae
Scars from tx
Reduced body hair

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8
Q

Significant negatives in CLD patient

A

Signs of decompensation:
Ascites
Jaundice
Encephalopathy

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9
Q

Slate-grey appearance in cLD

A

Haemachromatosis

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10
Q

Midline sternotomy scar and CLD

A

CCF

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11
Q

Causes of CLD

A

Common:
- Alcoholic liver disease
- NAFLD
- Viral hepatitis (common worldwide)

Rarer:
- Metabolic: Haemachromatosis, wilson’s, A1AT
- Autoimmune: AIH, PBC, PSC
- Drugs: Amiodarone, MTX
- Malignancy (HCC)
- Vascular: Budd-Chiari, constrictive pericarditis
- Congestive: CHF

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12
Q

Complications of cirrhosis

A

Coagulopathy
Variceal haemorrhage secondary to portal HTN
Hepatic encephalopathy
SBP
Hepatorenal/hepatopulmonary syndrome

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13
Q

Autoantibodies in liver disease

A

PBC: AMA (M2), IgM increased
PSC: ANA, pANCA
AIH: Anti-Sm, Anti-LKM1, ANA

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14
Q

Investigations in CLD

A

Obs
Urine dip +/- MCS
Bloods:
- FBC, UE, LFT, Coagulation, B12/folate, Hba1c, lipids, CRP
Liver screen:
- EtOH: MCV, B12/folate, AST:ALT >2
- Viral: hep B and C serology
- NAFLD: Lipids, Hba1c
- Autoantibodies: ANA, AMA, pANCA, anti-Sm, Anti-LKM1
- Immunoglobulins: IgM (PBC), IgG (AIH)
- Metabolic: caeruloplasmin, ferritin, a1at
- Ca: AFP, ca 19-9

Other:
- Ascitic tap

Imaging
- Liver USS + duplex
- MRCP
- Biopsy
- CT Triple phase liver if ?vascular issue
- CTCAP if malignancy

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15
Q

What would you send the ascitic tap for?

A

Biochemistry
MC&S
Cytology
Cell count - Neutrophils >250mm3 = SBP
SAAG

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16
Q

General principles of ascites mx

A

Abstinence from alcohol
Salt restriction
Diuretics (aim 1kg loss/day) (spiro, furosemide)
Ascitic tap
Transjugular intrahepatic portosystemic shunt (TIPS)
Liver transplantation

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17
Q

Markers of hepatic synthetic function

A

INR (Acute) and albumin (chronic)

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18
Q

CLD general management

A

MDT: GP, hepatologist, dietitian, palliative care

Conservative
EtOH abstinence
Salt restriction if ascites + good nutrition

Medical
Treat underlying cause
Cholestyramine for pruritis

Screening
AFP for HCC
Varices: OGD

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19
Q

PBC treatment

A

ursodeoxycholic acid

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20
Q

Wilson’s treatment

A

Penicillamine

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21
Q

HH treatment

A

Venesection and desferrioxamine

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22
Q

General management of varices

A

Beta blockers
Banding

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23
Q

Child Pugh Grading of cirrhosis

A

Evaluates prognosis in cirrhosis
Graded A-C

Based on:
Albumin
Bilirubin
Clotting (INR)
Distension (Ascites)
Encephalopathy

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24
Q

Serum caeruloplasmin and urinary copper in Wilson’s

A

Serum caeruloplasmin: low
Urinary copper: high

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25
How do you grade severity of encephalopathy?
Graded from 0-4 using the West Haven criteria
26
What are some causes of decompensation in liver disease?
Alcohol use Constipation (most common) Dehydration Infection (UTI, pneumonia) Bleeding (variceal haemorrhage)
27
Presentation of an encephalopathic patient
Asterixis Ataxia Constructional Apraxia Confusion Dysarthria
28
Decompensated liver disease management
Use the BSG/BASL decompensated liver disease care bundle <24h admission Bloods + septic screen Ascitic tap: MCS, cell count and differential, protein, albumin Liver USS + doppler of hepatic and portal vein Alcohol: IV pabrinex/thiamine + CIWA scoring SBP: Abx as per trust guidelines + HAS, prophylactic abx in some ie cipro GI bleeding and varices: Terlipressin and Abx Encephalopathy: Lactulose QDS and ensure > 2 loose stools/day, rifaximin AKI: Suspend diuretics and nephrotoxics, fluid resuscitate, consider iTU/HDU for RRT Referral to liver/gastro for specialist review
29
UKELD and UKMELD score difference
UKELD - For transplant eligibility (sodium, creatinine, INR, bilirubin) UKMELD - Organ allocation prioritisation for those already listed
30
Haemachromatosis genetics
AR on chr 6 HFE gene mutation
31
Presentation of a haemochromatosis patient
CLD Arthralgia Diabetes Bronzed discoloration of skin Sexual dysfunction Fatigue Palpitations (Cardiomyopathy) HCC
32
Cardiac complication of HH
Dilated cardiomyopathy and arrhythmias
33
Causes of skin pigmentation in HH
Skin deposition of iron Amiodarone therapy for cardiac complications
34
Investigations for HH
Bloods: Ferritin (increased), transferrin saturation (increased) Liver biopsy Genetic testing Complications - Urine dip - CBG - Hba1c - Anterior pituitary function - ECG - Echo - Joint XR - Liver USS and AFP
35
Treatment of HH
Regular venesection Iron chelators ie desferrioxamine Surveillance for HCC
36
Prognosis in HH
If cirrhotic, 200x increased risk of HCC Normal life expectancy without cirrhosis and with treatment
37
General presentation of a pt with PBC
Middle aged female Pruritis Fatigue Jaundice RUQ fullness/pain Xanthelasma Stigmata of CLD
38
DDx for PBC
AIH PSC
39
ANtibodies in PBC
AMA M2 variant
40
Mx PBC
Ursodeoxycholic Cholestyramine
41
Vitiligo, scar from previous thyroidectomy + CLD
Think Autoimmune hepatitis
42
Commonest organism causing SBP
E.coli
43
Causes of ascites
Cirrhosis CCF Cancer Less common: Hypoalbuminaemia: nephrotic sx, protein losing enteropathy Malignancy (ovarian, liver, peritoneal) Budd chiari, portal vein thrombosis, constrictive pericarditis TB Hypothyroidism Pancreatitis
44
To complete examination in ascites
Cardiovascular examination Resp examination Urine dip for proetinuria in nephrotic syndrome
45
Refractory ascites mx
TIPSS Transplant
46
General principles of management of ascites
Treat underlying cause EtOH abstinence Salt restriction Fluid restrict Diuretics (initially spiro then add furosemide if needed) Aim 1kg weight loss/day Therapeutic paracentesis +/- HAS cover If fails TIPSS Transplants
47
interpreting the SAAG
SAAG > 1.1 = Transudative (portal HTN) SAAG < 1.1 = Exudative
48
Transudative causes of ascites
Portal HTN ie CLD CCF
49
Exudative causes of ascites
Peritonitis Pancreatitis TB Cancer
50
Investigations in ascites
Obs Urine dip + ACR Bloods: fbc, ue, lft (albumin), coag, tft, CRP, liver disease bloods, malignancy markers, amylase Ascitic tap: MCS, cell count and differential, biochemistry, protein, LDH, glucose, AFB Liver USS +/- echo Echocardiogram
51
Main causes for a liver tx
Cirrhosis Acute liver failure (hepatitis, paracetamol OD) Cirrhosis
52
DDx Mercedes benz scar
Liver tx Segmental resection Whipple's - pancreatoduodenectomy
53
Important negatives when presenting a liver tx case
Cause of tx Complications of immunosuppression Is the graft functioning? Signs of previous CLD?
54
55
Non invasive liver screen
(FBC UE LFT COAG) Virology: HbSAg HCV Ab Hep E HIV Autoimmune profile: ANA, ANCA, Anti-sm, Anti LKM1, Immunoglobulins (IgG raised in aIH and IgM in PBC) Coeliac serology, A1AT Ferritin/iron studies (raised ferritin and Tsat in HH) Copper/caeruloplasmin
56
Important negatives to mention in liver tx case
Evidence of CLD or cause for tx Evidence Of immunosuppression Any signs of liver failure to suggest tx not working
57
Causes of liver tx
Cirrhosis HCC Acute liver failure (Hep A/B, Paracetamol oD)
58
DDx for mercedes benz scar
Liver tx Segmental resection Whipple's (pancreaticoduodenectomy)
59
CLD signs that persist post transplant
dupytrens gynecomastia
60
signs of liver tx graft dysfunction
signs of CLD Signs of decompensation (ascites jaundice encephalopathy) Signs of portal HTN (caput medusae, splenomegaly, ascites)
61
What features in an individual with chronic liver disease would warrant consideration of transplantation?
Progressive jaundice Diuretic resistant ascites HCC
62
What criteria are used to decide on liver transplantation in the emergency setting?
King's College Criteria
63
What conditions can recur post-liver transplant?
Hep B/C, budd-chiari, HCC, PBC
64
If there is a scar of both liver and renal transplant – what diseases would you think of?
ADPKD Liver tx, CNI toxicity -> renal failure and tx Liver and kidney failure following paracetamol OD Hep C with concurrent cryoglobulinaemia
65
Investigations in a liver tx patient
Bedside Obs (temp ?infection) CBG Urine dip for hyperglycaemia Bloods FBC UE (CNI toxicity) LFT Coag Lipids Hba1c CRP (if infection concerns) drug levels (ciclosporin tacrolimus)
66
Mx of liver tx patients:
Conservative Smoking cessation, alcohol cessation Weight loss/ dietary changes Attendance at cancer screening Skin checks and sun avoidance Avoidance of live vaccines Medical Always check medicine interactions before prescribing Cardiovascular risk factor optimisation: BP, BMs, lipids Bone protection Immunosuppression tac/ciclosporin + aza + pred (temp) Surgical Liver biopsy if concerns re graft function
67
SOme atypical infections secondary to immunosuppression
PCP CMV VZV Herpes zoster
68
What are some surgical complications in the early post op period following liver tx
Hepatic vein/portal vein thrombosis Biliary leak
69
Causes of hepatomegaly
3C 3Is Cirrhosis CCF Cancer Infection (HBV HCV Hydatid cyst, amoebic abscess CMV toxo) Infiltration (Amyloid sarcoid Gaucher's myeloproliferative) Immune PBC PSC AIH
70
Other causes of hepatomegaly
Vascular: budd-chiari, portal vein thrombosis Extramedullary haematopoiesis Polycystic liver disesae
71
Signs of hepatomegaly on examination
Palpation and percussion Mass in RUQ Moves with respiration Cannot get above Dull to percussion Smooth or craggy/nodular ?Pulsatile (TR in CCF) Auscultation ?bruit over liver to suggest HCC
72
Hepatomegaly + cachexia/lymphadenopathy
malignancy
73
hepatomegaly + slate-grey skin
HH
74
Hepatomegaly + midline sternotomy
CCF
75
Hepatomegaly + jaundice (infective cause)
Malaria
76
Clinical features o/e that may point to a diagnosis of amyloidosis
Heliotrope rash Ank spond RA signs multiple myeloma
77
hepatomegaly + lupus pernio
sarcoidosis
78
Why may CML present with jaundice?
AIHA (pre-hepatic jaundice)
79
Scoring system to evaluate a patient presenting with acute alcoholic hepatitis
Maddrey's discriminant function Prognosticates and also informs whether treatment with steroids is recommended
80
Mx of patient with acute alcoholic hepatitis
Mainstay is supportive with abstinence from alcohol, psychological support, managing any alcohol withdrawal, adequate nutrition Some cases, steroids are indicated
81
Causes of congestive hepatomegaly
CCF Constrictive pericarditis Restrictive cardiomyopathy
82
What symptoms may a patient with hepatomegaly present with
Asymptomatic Abdominal pain / distension Jaundice Features of malignancy: B symptoms
83
Ix in hepatomegaly
Hsitory: travel, sexual, drug B symptoms Obs (temp) Urine dip for proteinuria (amyloid), urobilinogen Bloods FBC UE LFT Coag CRP Viral screen (Hep B/C/E/HIV CMV), screen for fungal infection and parasites, iron studies, copper/caeruloplasmin, B12/Folate, immunoglobulins, autoimmune screen Imaging Abdo USS +/- PV duplex CT AP MRCP Ascitic tap if ascites present
84
what things ot look out for o/e of patient with hepatomegaly
is there presence of splenomegaly, ascites, lymphadenopathy, CLD,M fluid od
85
DDx hard and nobbly liver enlargement
Malignancy (primary or secondary) Polycystic liver disease Hydatid cyst
86
When may you get isolated enlargement of the left lobe of the liver?
Alcoholic hepatitis Budd-chiari
87
What is Felty's syndrome?
Triad of Splenonegaly, neutropenia and RA
88
How would you differentiate between a splenic and renal mass?
Spleen: - Cannot get above - Moves with inspiration - Dull to percussion - Has a notch - Not ballotable
89
Why may platelet count be reduced in alcoholic liver disease?
Splenomegaly associated with portal HTN results in platelet sequestration and thrombocytopenia Alcohol also has a directly toxic effect on production
90
Causes of left sided portal HTN
portal or splenic vein thrombosis ie pancreatic malignancy or pancreatitis
91
Splenomegaly + lymphadenopathy
Infection + haematological cause
92
Splinter haemorrhages, murmur + splenomegaly
Bacterial endocarditis
93
Causes of massive splenomegaly
Myeloproliferative disorders: CML, Myelofibrosis Tropical infections: chronic malaria, visceral leishmaniasis
94
Splenectomy work up
Vaccination against encapsulated bacteria ideally 2 weeks prior Prophylactic penicillin lifelong Medic alert bracelet
95
Which bacteria should splenectomy patients be vaccinates against
Encapsulated i.e. Pneumonoccus, meningococcus, haemophilus influenza
96
significant negatives in a patient with splenomegaly
presence of hepatomegaly presence of lymphadenopathy signs of IE Signs of CLD Haem: bruising, pallor, cachexia RA hands: Felty's
97
genetic analysis in CML
Phildaelphia chromosome due to t9;22 translocation -> BCR-ABL gene
98
Myelofibrosis genetic mutation
JAK2 IN 50%
99
Indications for splenectomy
Rupture Haematological: ITP, hereditary spherocytosis
99
Investigations in a patient presenting with splenomegaly
Bedside - Obs - Urine dip (?proteinuria ?haematuria in IE) Bloods - FBC, LFT, UE, coag - Blood film - haemolysis screen - autoimmune screen (RA and SLE): ESR, ANA, Rf, anti-cCP, anti-dsDNA, ACE - Viral serology (HIV, hepatitis etc) - Cultures if ?IE Imaging - US abdomen - CT CAP if ?malignancy - PET scan - CXR for LN enlargement - Echo if ?IE Special tests - Thick and thin films (malaria) - Antigen test, malaria - BM aspirate and trephine - Lymph node biopsy - Genetic analysis: JAK2, Philadelphia chromosome
100
what is included in a haemolysis screen?
Blood film (Schistocytes and reticulocytosis) FBC LDH (high) Haptoglobin (low) Bilirubin DAT (positive if autoimmune haemolysis)
101
complications of splenectomy
infection with encapsulated organisms Thrombocytosis post operatively
102
what is considered mild, mod and severe splenomegaly?
mild: palpable 1-3cm below costal margin mod: 4-8cm from costal margin towards iumbilicus massive >8cm, crosses midline and umbilicus
103
how to differentiate between myelo or lymphoproliferative causes of splenomegaly o/e?
Lymphoproliferative -> lymphadenopathy
104
Mx of splenomegaly
depends on underlying cause haematological -> haem referral RA/Felty's -> rheumatology IE -> Cardio discussion and micro
105
stigmata of portal HTN
Ascites Distended abdominal veins
106
Where may you find a bone marrow biopsy scar?
PSIS
107
Some differentials for isolated splenomegaly
Myeloproliferative Lymphoproliferative Portal or splenic vein thrombosis Chronic malaria
108
Causes of splenomegaly
Massive: CML, MF, Chronic malaria, visceral leishmaniasis, Gaucher's Infective: Viral: EBV, CMV, HIV, hepatitis Bacterial: endocaditis, brucellosis Parasitic: malaria, schistosomiasis, leishmaniasis Haematological: Lymphoproliferative: ALL, CLL, HL/NHL Myeloproliferative: CML, MF, PRV, ET Destructive: HS ITP AIHA Thalassaemia Congestive: Cirrhosis Portal HTN (Left-sided ie portal vein or splenic vein thrombosis from pancreatic malignancy or pancreatitis) Immune: Felty's/RA, SLE Infiltrative: amyloidosis, sarcoidosis, gaucher's
109
Blood film in Myelofibrosis and FBC in MF
poikilocytes (teardrop) Pancytopenia
110
Myelofibrosis on BM aspirate
dry tap so need to do trephine biopsy
111
blood film in CLL
Smear cells
112
Treatment of CML
Imatinib (tyrosine kinase inhibitor) Stem cell transplant
113
causes of hyposplenism
splenectomy coeliac IBD SCD
114
hepatosplenomegaly causes
Cirrhosis with portal HTN - ALD, MASLD, Viral hepatitis, PBC/PSC/AIH, Wilson's, HH, A1AT etc Haematological - Myeloproliferative and lymphoproliferative - HS - AIHA - Thalassaemia Infective Malaria, visceral leishmaniasis, schisto, viral hepatitis/ EBV/ CMV Neoplastic Primary or malignant Primary HCC iwth portal HTN and cirrhosis Infiltrative Amyloidosis Sarcoidosis Gaucher's
115
dx test for thalassaemias
hb electrophoresis

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