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Abdominal Flashcards

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1
Q

Complications of fistula

A
  • Clotting
  • Ulceration/poor healing
  • Failure (up to 40% before ever used)
  • Steal syndrome in 10% (blood stolen from artery = cold/numb hand)
  • High output cardiac failure (is L to R shunt. May have up to 2L flow/min)
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2
Q

RIF mass differential

A
  • Renal transplant
  • Caecal carcinoma
  • Ovarian tumour
  • Ileocaecal mass (amoebic, TB, appendicular mass, ileal carcinoid or lymphoma)
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3
Q

LIF mass differential

A
  • Carinoma of sigmoid
  • Diverticular mass/abscess
  • Faeces
  • Ovarian tumour
  • Renal transplant
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4
Q

Epigastric mass differential

A
  • Left (caudate) lobe of liver (HCC, alcoholic hepatitis)
  • Carcinoma of stomach or pancreas
  • Lymphoma
  • AAA
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5
Q

Nail signs for CKD

A
  • Leukonychia
  • Half-and-half nails
  • Absent lunulae
  • Mees’ and Beau’s lines (transverse lines)
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6
Q

Causes of leukonychia

A
  • Hypoalbumin (malabsorption, nephrotic syndrome)
  • Familial
  • Sulphonamides
  • Heavy metal poisoning
  • Idiopathic
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7
Q

Causes of koilonychia

A
  • IDA
  • Poor peripheral circulation
  • Exposure to solvents
  • Altitude
  • Familial
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8
Q

Causes of clubbing

A
  • IBD
  • Cirrhosis
  • Coeliac
  • Hyperthyroidism (thyroid acropachy)
  • Idiopathic/familial (autosomal dominant) are most common!
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9
Q

Cause of unilateral clubbing

A
  • Arteriovenous fistula
  • Other vascular malformations
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10
Q

GI cause of Virchow’s node

A
  • Stomach adenocarcinoma
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11
Q

Causes of acanthosis nigricans

A
  • Paraneoplastic (stomach cancer)
  • Insulin-resistant T2DM
  • Hypo/hyperthyroid
  • Cushing’s
  • Obesity
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12
Q

Drug causes of gynaecomastia

A

DISCO
- Digoxin
- Isoniazid
- Spironolactone
- Cimetidine
- Oesotrogens

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13
Q

Causes of gynaecomastia

A
  • Drugs (DISCO)
  • Liver disease
  • CKD
  • Thyrotoxicosis
  • Secretory malignancies (hCG)
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14
Q

Causes of abdominal distension

A

5 F’s
- Fat
- Fluid
- Flatus,
- Faeces
- Fetus

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15
Q

How much fluid needed to diagnosed ascites clinically

A
  • 1500ml (USS can detect 500ml)
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16
Q

Signs of portal hypertension

A
  • Splenomegaly
  • Caput medusae (dilated superior epigastric veins)
  • Oesophageal varices
  • Ascites
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17
Q

Sites of portosystemic anastomoses

A

(In brackets = which portal vein joins which systemic vein)
- Oesophageal (left gastric vein –> azygos vein)
- Rectal (superior rectal vein –> middle/inferior rectal veins)
- Umbilical (paraumbilical vein –> superior epigastric vein)

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18
Q

3 most common causes of chronic liver disease

A
  • Alcohol
  • Hep B (abroad), Hep C (IVDU)
  • Non-alcoholic hepatic steatosis (overweight)
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19
Q

Types of hepatorenal syndrome

A

Due to liver not breaking down vasoactive substances (e.g. prostaglandins)–> excess renal vasoconstriction

  • Type 1: doubling in Cr/halve in Cr clearance in 2 weeks –> 50% mortality after 1month. Should improve with vasoconstrictors and volume expanders
  • Type 2: slower progression - starts with ascites and then diuretic-resistant ascites (kidneys can’t secrete enough sodium)
  • May need combined liver-renal transplant if pre-morbid eGFR <30 (as immunosuppression post-transplant will reduce eGFR…)
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20
Q

What is hepatopulmonary syndrome (with diagnosis and treatment)

A
  1. Liver failure
  2. Unexplained hypoxaemia
  3. Intrapulmonary vascular dilation (liver does not excrete NO)
  • Diagnosis: contrast echo (microbubbles pass through dilated pulmonary vessels into left atrium)
  • Treatment: liver transplant
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21
Q

Features of decompensated liver disease

A
  • Ascites
  • Encephalopathy
  • Hepatorenal/hepatopulmonary syndrome

(won’t come up in exam!)

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22
Q

Grades for hepatic encephalopathy

A
  • Grade 0: normal (mild changes on psychometric tests)
  • Grade 1: mild confusion; short attention span; disordered sleep
  • Grade 2: disorientated to time/place occasionally; lethargy; personality change
  • Grade 3: very disorientated; somnolent but rousable to speech; amnesia
  • Grade 4: comatose (no response to pain)

Test for it with constructional apraxia (ask pt to draw a 5-pointed star)

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23
Q

How to grade severity of cirrhosis

A

Modified Child-Pugh Score- based on ABCDE
- Albumin
- Bilirubin
- Clotting (INR)
- Distension (ascites)
- Encephalopathy

(Modify bilirubin scores in PSC/PBC as expect high bilirubin)

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24
Q

Management of ascites due to Chronic Liver Disease

A

Aim weight loss 1kg/day
1. No-added salt diet (5.2g a day/90mmol)
2. Spironolactone 100-400mg OD (if not getting hyperkalaemia)
3. Add furosemide 40-160mg OD
4. Ascitic drain (PleurX drain for malignant ascites)
5. Transjugular intrahepatic portosystemic shunt (TIPSS) = shunt from portal vein to hepatic vein, giving another route for portal blood to go to systemic circulation- increases encephalopathy risk as nitrogenous waste bypasses liver

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25
Causes of ascites
Transudative - Cirrhosis with portal HTN = commonest cause in PACES - CCF - Nephrotic syndrome (reduced oncotic pressure) - Portal vein thrombosis - Budd-Chiari Syndrome (occlusion of hepatic vein which drains liver to IVC) Exudative - Malignancy (metastatic GI, liver, ovarian, peritoneal mesothelioma) - TB peritonitis - Pancreatitis
26
Budd-Chiari Syndrome is triad of
- Abdo pain - Ascites - Hepatomegaly
27
Types of Budd-Chiari Syndrome
Primary (75%) = thrombosis of hepatic vein - Polycythaemia - Pregnancy - COCP Secondary (25%) = occlusion of hepatic vein - Tumour
28
Cause of ascites in Chronic Liver Disease
1. - Renal hypoperfusion --> renin from juxtaglomerular apparatus --> aldosterone - Liver failure means aldosterone not broken down--> salt/water retention 2. - Hypoalbumin reduces oncotic pressure--> increased portal pressure 1+2 = ultrafiltration of fluid into abdominal cavity
29
How differentiate between exudative and transudative cirrhosis
- Exudate: low serum:ascites albumin gradient (SAAG) <11g/L = loss of protein from serum into ascites - Transudate: high serum:ascites albumin gradient (SAAG) >11g/L
30
Causes of hepatomegaly
DINMCO Drug-induced -Alcohol/drugs Infective - Hepatitis - Tropical (malaria, leishmaniasis) - Infectious mononucleosis Neoplastic - Hepatocellular carcinoma - Lymphoma Metabolic - NAFLD - Haemochromatosis Cardiac - CCF Other - Sarcoidosis
31
Scoring systems to assess severity of acute alcoholic hepatitis
- Modified Maddrey’s discriminant function test - Mayo End Stage Liver Disease (MELD) score - Glasgow Alcoholic Hepatitis score - do on Day 1
32
Treatment for acute alcoholic hepatitis
- Adequate nutrition - Maddrey's discriminant function test >32 = pred 40mg for 4/52 and then taper - IV NAC if severe
33
Histological stages of alcoholic liver disease
- Hepatic steatosis (fat in liver cells)- reversible - Alcoholic hepatitis (inflammation liver cells--> necrosis) - reversible - Hepatic cirrhosis
34
Hepatic amyloidosis affects which clotting factors
- Factor IX and X
35
Differentiate been palpable spleen and palpable left kidney
- Spleen cannot be balloted, is dull to percussion, has a notch and you should not be able to ‘get above’ it
36
Causes of isolated splenomegaly
Massive (>8cm) - Myeloproliferative (CML, myelofibrosis) - Tropical (chronic malaria = p. vivax/ovale, visceral leishmaniasis a.k.a kal-azar) Moderate (4-8cm) - Infiltrative (amyloid) Tip (<4cm) - Portal hypertension - Acute infection (EBV, CMV, endocarditis) - Felty's Syndrome (rheumatoid arthritis) - Haemolytic anaemia
37
Features of Felty's Syndrome
SANTA - Splenomegaly - Anaemia - Neutropenia - Thrombocytopaenia - Arthritis (rheumatoid) Unknown cause
38
Presenting symptoms for hepatosplenomegaly
- Anaemia: fatigue/SOB - Thrombocytopaenia: easy bruising - Abdo pain referred to left shoulder - Constitutional symptoms - Febrile illness
39
Causes of hepatosplenomegaly
- Cirrhosis with portal HTN - Infection (chronic malaria, visceral leishmaniasis, schistosomiasis) - Myeloproliferative (CML, polycythaemia, myelofibrosis) - Lymphoproliferative (CLL, lymphoma) - Metabolic (Wilson's, haemochromatosis)
40
Important differential for hepatosplenomegaly
- Bilateral large kidneys (PCKD)!
41
Cause of Wilson's Disease (inc chromosome)
- Autosomal recessive - Mutation of the adenosine triphosphatase 7B ( ATP7B) gene on chromosome 13 - Copper accumuates in liver --> blood --> urine
42
Tests for Wilson's Disease
- Low serum caeruloplasmin (acute phase protein so may be raised abnormally!) = protein which binds to copper in serum - High 24hr urine copper
43
Features of Wilson's Disease
Present in 2nd decade of life - Gastro: chronic liver disease and cirrhosis - Neuro: Parkinsons, tremor, dysdiadochokinesia - Renal: Fanconi Syndrome - Cardiac: cardiomyopathy - Psych: emotion labile, psychotic
44
Signs of Primary Biliary Cirrhosis
- Middle aged female with CLD --> always include PBC in differential! - Scratch marks - Orbital xanthelasma - Hepatosplenomegaly - Jaundice - Most asymptomatic and diagnosed incidentally at cholecystectomy!
45
Antibody in Primary Biliary Cirrhosis
- Anti-mitochondrial antibodies
46
Antibodies in autoimmune hepatitis
- ANA - Anti-smooth muscle - Anti-dsDNA
47
Differential for Primary Biliary Cirrhosis
- Autoimmune hepatitis - Primary Sclerosis Cholangitis - Cholestatic sarcoidosis (-ve anti-mitochondrial antibody)
48
Management of Primary Biliary Cirrhosis
- No alcohol - Fat-soluble vitamins (ADEK) - Ursodeoxycholic acid: reduced cholestasis/liver function decline - Cholestyramine: less itchy
49
Prevalence of haemochromatosis
- 1 in 200
50
Symptom triad for haemochromatosis
- Fatigue - Arthralgia - Sexual/gonadal dysfunction
51
Complications of haemochromatosis
GI - Increased liver cancer risk Endo - T1DM (pancreatic failure)- 2/3 of patients - Anterior pituitary dysfunction--> hypothyroid (TSH, ACTH) Cardio - Dilated cardiomyopathy (+/- arrhythmia) Skin - Bronze skin
52
Cause of haemochromatosis (inc mode of inheritance)
- Autosomal recessive - Mutation in genes regulating iron metabolism (HFE gene on chromosome 6)
53
What speeds up iron overload in haemochromatosis
- Excess alcohol consumption
54
Management of haemochromatosis
- Weekly venesection (1unit a week until iron deficient, then 4x a year) - Desferrioxamine (binds to free iron--> excreted in urine)
55
Complications of liver transplantation
- Infection: typical (LRTI) and atypical (PCP, CMV, varicella) - Malignancy: solid organ (bowel), lymphoproliferative (post-transplant lymphoproliferative disease), skin (SCC or BCC) - Metabolic: post-transplant diabetes and hyperlipidaemia - Cardiovascular: IHD
56
Palpable mass in left loin for liver transplant patient
- Simultaneous liver-kidney transplant (paracetamol overdose)
57
Survival following liver transplant
- Over 60% over 15yrs
58
King's College criteria for liver transplant in paracetamol overdose
- pH <7.3 after 12hrs resuscitation - Or all 3 of: INR > 6.5, creatinine > 300, encephalopathy (grade III or IV)
59
King's College criteria for liver transplant in non-paracetamol overdose
- Arterial lactate >3.5 4h after resuscitation - Or INR > 6.5 - Or any 3 of: INR > 3.5, age<10 or > 40 years, bilirubin >300, jaundice > 7 days, caused by drug reaction
60
Types of liver support system
- Bio-artificial: Extracorporeal Liver Assist Device (ELAD) = remove blood--> pass through ultrafiltration generator which separates blood from plasma--> pass through semi-permeable membrane to remove toxins - Artificial: Molecular Absorbents Recirculation System (MARS) = in 1st circuit, blood exposed to albumin, which binds to toxins --> in 2nd circuit, remove bound toxins from albumin
61
Prevalence of IBD
- 250 per 100,000 in West
62
Extra-abdominal signs of IBD
- Clubbing = extensive small bowel Crohn's - Uveitis - Sacroiliitis - Skin: pyoderma gangrenosum, erythema nodosum
63
Palpable mass in RIF in IBD
- Could be acute exacerbation
64
Differences between Crohn's and UC
Crohn's - Non-bloody diarrhoea - Mouth-to-anus skip lesions - Full thickness wall inflamed - Granulomas - Fat malabsorption (affecting ADEK vitamins) - because affects small bowel - Peri-anal disease (ulceration, fistulas) UC - PR bleeding + tenesmus (feeling incomplete defecation) - Colon continuous inflammation - Partial thickness wall inflamed - Crypt abscesses - Dilated terminal ileum ("backwash ileitis")
65
Truelove and Witt's criteria for IBD exacerbation
- Mild: <4 poos a day, normal ESR, no systemic symptoms - Moderate: >4 poos a day, mild systemic symptoms - Severe: >6 bloody poos a day, ESR >30 or fever/tachy/anaemic
66
Management of Crohn's
- Ileocaecal: budesonide if mild and pred is more severe --> move on to immunosuppressants (azathioprine) or biologics (infliximab or adalimumab = anti-TNF) - Colonic disease but non-fistulating: prednisolone if mild and pred + azathioprine if more severe --> consider biologics - Perianal fistulae: surgery and infliximab
67
Management of UC
Acute = induce remission - Mild: topical mesalazine if proctitis --> oral mesalazine if more extensive colitis - Moderate/severe: oral prednisolone (or can do azathioprine + infliximab) - Severe: IV hydrocortisone 100mg QDS --> add on infliximab if no response within 3 days Maintain remission - Proctitis: topical mesalazine - More extensive: azathioprine +/- infliximab
68
Indications for surgery in acute IBD
- Toxic megacolon (colon >6cm or caecum >9cm) - Stools >8/day or CRP >45 after 3 days of IV hydrocortisone - Fistula/perforation/obstruction
69
Which IBD is more commonly associated with Primary Sclerosis Cholangitis
- UC
70
Management of Primary Sclerosis Cholangitis
- ADEK vitamins - Stent fibrotic bile duct - Liver transplant
71
Presenting features of Adult Polycystic Kidney Disease
- Asymptomatic (proteinuria, blood tests) - Recurrent UTIs - Abdo pain - Subarachnoid haemorrhage
72
Signs of Adult Polycystic Kidney Disease
- Large kidneys with bruit over them (increased perfusion or vascular tumour e.g. angiomyolipoma) - Hepatomegaly- irregular (cysts) - Anaemia/HTN/CKD/dialysis signs
73
Causes of unilateral kidney enlargement
- Polycystic Kidney (other not palpable because had nephrectomy - look for scar!) - Tumour - Hydronephrosis - Horseshoe kidney
74
Types of Adult Polycystic Kidney Disease
- Type 1 and Type 2 (milder)
75
Mechanism of Adult Polycystic Kidney Disease (including mode of inheritance and chromosomes affected)
- Autosomal dominant mutation --> abnormal cilia function --> cysts form and replace kidney tissue - Type 1 = PKD1 gene on Chromosome 16 (85%) - Type 2 = PKD2 gene on Chromosome 4 (15%) - Type 2 is less severe/later onset
76
Ultrasound diagnostic criteria for Adult Polycystic Kidney Disease
- 15–39yrs: 3+ cysts in the kidneys (unilaterally or bilaterally). - 40–59yrs: 2+ cysts in each kidney. - >60yrs: 4+cysts in each kidney.
77
Complications of Adult Polycystic Kidney Disease
- Mitral valve prolapse (also MR, TR, AR) - Cysts elsewhere (liver, pancreas, arachnoid) - Intracranial berry (saccular) aneurysm - HTN (excess renin) - Polycythaemia (excess EPO)
78
Causes of new abdominal pain in Adult Polycystic Kidney Disease
- Infected cyst - Haemorrhage into cyst (also diverticulitis, kidney stones, AAA rupture)
79
Complications of chronic immunosuppression (e.g. transplant)
- Infection (PCP, CMV, EBV, BK virus) - Malignancy (solid organ, lymphoproliferative, skin)-- look for surgical/radiotherapy scars - Metabolic (diabetes, anaemia, HTN) - CVD - CKD (ciclosporin/tacrolimus)
80
Cause of end-stage renal failure if no signs
- Glomerulonephritis
81
Patient wearing hearing aids in Abdominal station
- Alport's disease (glomerulonephritis, hearing loss, vision changes) - Aminoglycoside (gentamicin) induced nephrotoxicity and ototoxicity
82
Things to check when assessing functional status of renal transplant
- HTN - Fluid overload - Ongoing dialysis
83
Complications of CKD
- Anaemia (EPO) - Renal osteodystrophy (secondary hyperparathyroidism) - CVD - Hyperkalaemia - Pulmonary oedema
84
Causes of end-stage renal failure
- Diabetes - Adult Polycystic Kidney Disease - Chronic glomerulonephritis - HTN in blacks only! (association in other races less established)
85
Issue with renal transplant in Alport's Syndrome
- Defect in type IV collagen --> transplant exposes to new antigens --> develop anti-GBM antibodies (Goodpasture's!)
86
Complications of specific immunosuppressants
- Seborrheic wart (azathioprine) - Fine tremor (tacrolimus) - CKD (tacrolimus, ciclosporin)
87
Presenting features of Hereditary Haemorrhagic Telangiectasia
- Epistaxis - Anaemia (not melaena/UGI bleeding) - Telangiectasia on fingers, face, lips, tongue, buccal mucosa, conjunctiva and nose - High-output cardiac failure due to large AVM - Stroke (cerebral AVM) and lung haemorrhage (lung AVM)
88
Difference between Hereditary Haemorrhagic Telangiectasia and Peutz-Jeghers syndrome
- HHT = telangiectasia - Peutz-Jeghers = macules
89
Difference between Hereditary Haemorrhagic Telangiectasia and Systemic Sclerosis
- Systemic Sclerosis has thickened skin
90
Common sites for AVM in Hereditary Haemorrhagic Telangiectasia
- Brain, lung, liver, bowel, spine
91
Cause of Hereditary Haemorrhagic Telangiectasia
- Autosomal dominant mutation (chromosome 9-- relates to TGFb signalling)
92
Features of Peutz-Jeghers Syndrome
- Mucucutaneous pigmented macules (lips, hands, feet) - Benign hamartomas in GI tract - Increased risk of malignancy (not related to hamartoma)
93
Surface marking of abdominal aorta
- Just left to midline - Bifurcates at L4/5 (umbilicus)- less reliable if fat
94
Surface marking of gallbladder
- Right costal margin in mid-clavicular line
95
Surface markings of kidneys
- Lowest point of left and right costal margins (L1)
96
Surface anatomy of liver
- Left upper border = just medial to left nipple - Right upper border = 5th rib at mid-clavicular line - Lowest point of liver = 0.5inch below right costal margin in mid-axillary line
97
Gold-standard investigation for Primary Sclerosis Cholangitis
- MRCP (Magnetic Resonance Cholangiopancreatography)
98
Causes of palmar erythema
- Cirrhosis - Hyperthyroidism - Pregnancy - Polycythaemia - Rheumatoid arthritis
99
Indications for splenectomy
- Trauma (including intraoperative damage) - Rupture - ITP (platelets destroyed in spleen) - So massive that destroys RBCs/platelets
100
Post-splenectomy management
- Vaccination against encapsulated bacteria 2 weeks BEFORE: pneumococcal, meningococcal, Hib - Lifelong penicillin - Medic alert bracelet
101
Patient with large kidneys and long-term catheter
- Hydronephrosis
102
3 commonest causes for liver transplant
- Cirrhosis - Acute liver failure (paracetamol, Hepatitis A/B) - Cancer
103
Differentiate caput medusae between portal HTN and IVC obstruction
Press vein below umbilicus - Drains away from umbilicus = portal HTN - Drains towards umbilicus = IVC obstruction
104
Areas to cover when presenting renal patient
- Cause for CKD - Current RRT - Previous RRT - Immunosuppression evidence - Volume status
105
Causes of dysphagia
Inflammatory - Tonsillitis - Oesophagitis - Candidasis Mechanical - Luminal: foreign body, food - Mural: cancer, benign stricture (Plummer Vinson) - Extramural: goitre, mediastinal Lymph nodes, lung cancer Motility: - Achalasia - Stroke - MND - Myasthenia gravis
106
Eradication therapy for H. Pylori
- Omeprazole 20mg BD - Amoxicillin 1g BD - Clarithromycin 500mg BD
107
Causes of jaundice
Pre-hepatic = excess bilirubin - Haemolytic anaemia - Ineffective erythropoiesis Hepatic- Unconjugated - Reduced bilirubin uptake: drugs (rifampicin), CCF - Reduced bilirubin conjugation: Gilbert's (autosomal dominant), Crigler-Najjar (autosomal recessive Hepatic - Conjugated - Liver failure (congenital e.g. Wilson's, infectious, toxins, autoimmune) Post-hepatic - Gallstones - Cancer head of pancreas - PSC/PBC
108
Medication causes of liver injury/jaundice
Haemolytic - Methyldopa - Penicillin - Anti-malarials Hepatitis - TB meds RIP - Valproate - Statins Cholestatic - Co-amoxiclav - Flucloxacillin - COCP - Chlorpromazine
109
Deficiency in Gilbert's Syndrome
- UDP-glucuronyl transferase
110
Investigations for pre-hepatic jaundice
- Blood film - Coomb's test (direct = antibodies attached to RBCs- shows haemolytic anaemia is immune-related; indirect = antibodies against foreign RBCs- do before transfusion) - Hb electrophoresis (thalassaemia)
111
Diagnosis of spontaneous bacterial peritonitis
- Ascitic fluid polymorphonuclear cells >250mm3
112
Hepatitis B antibodies
- Surface antigen = acute infection - Anti-HBc IgM = acute infection - e Antigen = high infectivity - Core antibody = previous infection - Surface antibody = immunity
113
Features of carcinoid syndrome
FIVE HT - Flushing - Intestinal diarrhoea - Valve fibrosis (TR, PS) - whEEze - Hepatic involvement - Tryptophan deficiency = niacin precursor --> pellagra (diarrhoea, dermatitis, dementia)
114
Definition of pathological dilation on AXR
3-6-9 - 3cm small bowel - 6cm large bowel - 9cm caecum
115
Cancer screening in IBD
- Active disease for 10 years --> regular endoscopy to identify pre-malignant changes
116
Features of dermatitis herpetiformis rash
- Itchy - Symmetrical - Extensor surfaces - Vesicular --> can erupt, leaving crusted lesions
117
Treatment for dermatitis herpetiformis if first-line management (gluten-free) does not work
- Dapsone (sulphonamide antibiotic which has anti-inflammatory properties)
118
Investigations for dermatitis herpetiformis
- Anti-TTG (also FBC, haematinics, LFTs etc) - Skin biopsy: dermal papillae infiltrated with micro-abscesses containing eosinophils, neutrophils, fibrin
119
Investigations for coeliac disease
- Anti-TTG (also FBC, haematinics, LFTs etc) - Duodenal biopsy: villous atrophy and high lymphocytes (should be on a gluten diet!)
120
Causes of renal transplant failure
SCARI - Structural (transplant artery stenosis) - Calcineurin toxicity - Antibody - Recurrence (focal segmental glomerulosclerosis) - Infection
121
General management of chronic liver disease
MDT approach! - Alcohol abstinence - Nutrition (thiamine) - Laxatives (3 soft poos a day) - Avoid hepatotoxic meds - Propranolol if varices
122
How does peritoneal dialysis work
- Dialysate fluid is infused via peritoneal catheter into abdo cavity - Toxins diffuse across the peritoneum and into the dialysate fluid - Dialysate fluid removed while patient sleeps (automatic peritoneal dialysis) or up to 6 times throughout the day (continuous ambulatory peritoneal dialysis)
123
Advantages for AV fistula over tunnelled line
- Faster flow rates = shorter dialysis sessions - Less infection - Longer lifespan
124
Complications of haemodialysis
- Dialysis washout (remove too much fluid --> hypotension) - Infection - Bleeding (heparin used in dialysis)
125
Complications of peritoneal dialysis
- Infection (peritonitis) - Hernias - Hyperglycaemia (sugar in dialysate fluid)
126
4 things must ask yourself if see a transplant
- Which organ - Why done - Is it working - Complications
127
Important blood test in organ transplant rejection
- Immunosuppressant levels!
128
See ileostomy which has been reversed- what 2 surgeries has patient had
1. Pan-proctocolectomy with end-ileostomy 2. Reversal of ileostomy with J pouch formation (part of jejunum attaches to rectal stump)
129
Important panel of investigations in liver failure
- Non-invasive liver screen! - Also AFP
130
Hepatomegaly with fluid overload
- Congestive hepatopathy! (right-sided heart failure --> hepatomegaly)
131
Management of Wilson's Disease
1. Copper-chelation (penicillamine or trientine hydrochloride) 2. Zinc once copper levels stable (stimulates protein in gut which binds to copper and prevents its reabsorption) Also: - Less copper in diet - Liver transplant (nuts, shellfish, organ meats)
132
Alcohol effects on other systems
Cardio - Alcoholic cardiomyopathy - Arrythmias Haem - Macrocytic anaemia - Coagulopathy CNS - Peripheral neuropathy - Cerebellar
133
When to do SBP prophylaxis and which drug to use
- Ascitic protein content <15g/L or previous SBP - Ciprofloxacin
134
Commonest cause of SBP
- E.coli (then staph and strep)
135
CKD stages in terms of eGFR
- 1: >90 - 2: 60-89 - 3: 30-59 - 4: 15-29 - 5: <15
136
Referral criteria for dialysis in CKD
- eGFR <30 (CKD stage 4 or 5) - eGFR 30-60 but rapidly progressing (reducing by 15 in 1yr) - Nephrotic syndrome and rapidly reducing eGFR <60
137
Risk of breast/ovarian cancer with BRCA1 and BRCA2
- BRCA1: 80% breast cancer, 40% ovarian cancer - BRCA2: 40% breast cancer
138
1-year survival based on Child-Pugh grades
- A: 100% - B: 80% - C: 45%
139
Which IBD patients are eligible for screening colonoscopies (checking for cancer)?
- UC (not proctitis alone) - Crohn's involving >1 segments of colon
140
Frequency of screening colonoscopies (checking for cancer) in IBD
- Low risk: 5 years. - Intermediate risk: 3 years. - High risk (severe inflammation, PSC, colonic stricture): 1 year.
141
Management of ascitic drain after insertion
- 100ml 20% HAS for every 2L drained - Max 6hrs or 10L drained, whichever comes first
142
Management of Polycystic Kidney Disease
- Low salt, high fluid diet (suppresses vasopressin levels) - HTN control - Tolvaptan (vasopressor receptor antagonists) for rapidly progressive disease - RRT
143
Indications for nephrectomy in Polycystic Kidney Disease
- To make room for transplanted kidney - Renal cell carcinoma - Chronic pain/haematuria - Recurrent UTIs
144
Indications for liver transplant
- Acute (King's criteria) - Cirrhosis with high UK End-Stage Liver Disease score >49 - Hepatocellular carcinoma (e.g. tumour <5cm) - "Variant syndromes": PBC with intractable pruritus, hepatopulmonary syndrome
145
Absolute contraindications for liver transplant
- Ongoing alcohol/drug use - Untreated HIV - Previous/active extra-hepatic cancer - Severe irreversible lung disease
146
When to refer for renal transplantation
- CKD stage 4+ (eGFR <30) who may need dialysis within next 6 months
147
Definition of end-stage renal failure
- eGFR <15ml/min
148
Absolute contraindications for renal transplantation
- Untreated malignancy - Untreated HIV - Deep-seated infection
149
Investigations in haemochromatosis
- Raised ferritin and transferrin saturations - HFE gene mutation testing (but variable penetrance so not everyone with mutation will have the condition)
150
Meig's Syndrome components
- Ascites (transudative) - Pleural effusion - Benign ovarian tumour
151
Tests to send for ascitic fluid
- Albumin (calculate Serum: Ascites Albumin Gradient) - Polymorphonuclear leukocyte count >250/mm3 - Amylase (raised in pancreatitis) - MC&S inc Gram Stain - Cytology (?malignant)
152
Indications for haemachromatosis screening
- 1st-degree relatives (check ferritin and transferrin saturations)
153
Mechanism of Hereditary Spherocytosis (inc mode of inheritance)
- Autosomal dominant on Chromosome 8 (can be recessive!) - RBCs are spherical = more prone to rupture = haemolytic anaemia
154
Presenting symptoms of Hereditary Spherocytosis
- Splenomegaly - Jaundice - Lethargy
155
Complications of Hereditary Spherocytosis
- Aplastic crisis (triggered by infection) - Gallstones
156
Investigations for Hereditary Spherocytosis
- Blood smear (check for haemolysis) - Reticulocytes - EMA-binding test = reduced fluorescence as reduced binding of eosin to the RBCs (do Osmotic Fragility Test if this is not available) - Haemolysis screen (LDH, split bilirubin, Coomb's, haptoglobin)
157
Management of Hereditary Spherocytosis
- Folic acid - Regular transfusions for anaemia - Severe: splenectomy as stops haemolysis of RBCs in the spleen - Cholecystectomy for gallstones
158
Foods which contain gluten
- Wheat - Rye (flour, bread, beer) - Barley (cereal, porridge)
159
Types of renal transplant
- Live - Cadaveric (circulatory death or neurological death)
160
Types of renal transplant rejection and treatment for each
Hyperacute = within minutes/hours (pre-existing antibodies in recipient attack the transplant e.g. ABO) - Plasmapheresis and IVIG - May need to remove the transplanted kidney! Acute = antibody or T-cell mediated - Antibody: Plasma exchange --> IVIG. Rituximab (anti-CD20) - T-cell: IV methylprednisolone Chronic = usually antibody (may be non-compliance to immunosuppression) = irreversible usually - Immunosuppressants
161
Complications of pancreatitis
Acute pancreatitis - SIRS --> ARDS Chronic pancreatitis - Pseudocysts --> can obstruct pancreas/duodenum - Portal vein thrombosis
162
Symptoms of chronic pancreatitis
- Chronic grumbling pain (usually epigastric, radiates to back, better sitting up)-- some patient experience attacks - Steatorrhoea (fat malabsorption) - Weight loss
163
Management of chronic pancreatitis
- Stop triggers (stop alcohol/smoking) - Creon with PPI to improve absorption - Endoscopic drainage of pseudocysts - ERCP stenting of calcified ducts
164
Genetic causes of chronic pancreatitis
- CF! - SPINK1 mutation - PRSS1 mutation
165
Investigations for chronic pancreatitis
- Magnesium (low) - Faecal elastase (low) - IGG4 in autoimmune pancreatitis - CT abdo-pelvis - EUS with fine needle biopsy if suspect cancer (as may be difficult to differentiate cancer from pancreatitis on CT)
166
Mechanism of sickle cell disease (inc mode of inheritance)
- Autosomal recessive: sickle cell trait = 1 gene, disease = both genes - Valine replaces glutamic acid at the sixth amino acid of the beta globin chain--> have sickled HbS instead of normal HbA
167
Complications of sickle cell disease
- Painful vaso-occlusive crises (bone, chest, priapism) - Splenic sequestration (sickled RBCs build up --> splenomegaly and splenic failure = drop in RBCs) - Aplastic crisis (triggered by parvovirus B19) - Hyposplenism --> encapsulated infections - Stroke/MI - Gallstones - Avascular necrosis
168
Investigations in sickle cell disease
- Blood film (Howell-Joly bodies = hyposplenism) - Reticulocytes (high) - Hb electrophoresis
169
Management of sickle cell disease
- Hydroxycarbamide reduces crises by increasing fetal Hb (HbF) - Crizanlizumab (monoclonal against P-selectin) reduces vaso-occlusive crises - Splenectomy (sequestration crises)
170
Types of glomerulonephritis
Non-proliferative - Minimal change disease: nephrotic syndrome wibtoit changes on light microscopy. Steroid responsive - Focal segmental glomerulosclerosis: steroids but half end in CKD - Membranous glomerulonephritis: 1/3 stable, 1/3 remit, 1/3 end stage renal failure Proliferative = increased cells in glomerulus - IgA nephropathy: includes HSP - Post-infectious: esp strep pyogenes (1 week after) - Rapidly progressive
171
Nephritic syndrome symptoms
Triad of - Haematuria - Oligouria - HTN
172
Definition of oligouria
<0.5ml/kg/hr
173
Definition of anuria
<100ml/day

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