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Abdominal Flashcards

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1
Q

ADPKD presentation

A

Renal:
- Hypertension
- Abdo pain (rupture, stones, infection)
- Haematuria
- ESRF
Extrarenal
- SAH
- Mitral valve prolapse
- Liver/pancreas cysts

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2
Q

PKD inheritance/chromosomes

A

AD - Chromosome 16 or 4
10% de novo
(AR also exists)
4 slower course

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3
Q

ADPKD management

A

Lifestyle
- High fluid, low salt
Medical
- BP control (RAAS blockade)
- Vasopressin analogues (tolvaptan) reduces cyst formation
- Later - RRT/transplant
- Avoid nephrectomy if possible

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4
Q

ADPKD nephrectomy indications

A
  • Frequent/chronic infection
  • Mass effect
  • Space for transplant
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5
Q

Causes of bilateral kidney enlargement

A

PKD
Bilateral renal carcinoma
Bilateral hydronephrosis (e.g. HPCR)
Tuberous sclerosis

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6
Q

Extrarenal ADPKD

A
  • HTN
  • Liver/pancreas/seminal vesical cyst
  • Cerebral aneurysm - ICH/SAH
  • MR/AR
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7
Q

Clinical signs of portal hypertension

A

Caput medusae
Splenomegaly
JVP, oedema less so

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8
Q

Clinical signs hepatic decomensation

A

Ascites/oedema
Asterixis
Altered consciousness (encephalopathy)
Coagulopathy

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9
Q

Causes of hepatomegaly

A

3Cs, 4Is
- Cirrhosis (alcoholic)
- Carcinoma
- Congestive (CCF, Budd Chiari)
- Infection (HBV/HCV)
- Immune (PBC, PSC, AIH)
- Infiltrative (myeloproliferation, amyloid)
- Iron (haemochromatosis)

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10
Q

Liver screen bloods

A
  • Autoantibodies (PBC (antimitochondrial), PSC, AIH (ANA, anti-smooth muscle, ALKM1))
  • HBV, HCV serology
  • Ferritin (haemochromatosis)
  • Caeruloplasmin (Wilson’s)
  • Alpha-1 antitrypsin
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11
Q

Causes of palmar erythema

A

Cirrhosis
Hyperthyroidism
RA
Pregnancy
Polycythaemia

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12
Q

Conjugated vs unconjugated bilirubin

A

Prehepatic - unconjugated
Intrahepatic - conjugated ->therefore pale stools/dark urine

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13
Q

Urine dip to distinguish site of jaundice

A

Prehepatic - no urinary bilirubin
Post-hepatic - no urobilinogen

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14
Q

Prehepatic jaundice causes

A

Haemolysis
Hereditary:
- Membrane defects (spherocytosis etc)
- Enzyme deficiencies (G6PD, pyruvate kinase)
- Abnormal Hb (SCC, thalassaemia)

Acquired:
- Autoimmune haemolytic anaemia (SLE, RA, scleroderma)
- Alloimune e.g. ABO incompat
- Infection (CMV, EBV, toxo, leishmania)
- MAHA (DIC, TTP, HUS)

Non-haemolytic
- Conjugation - Gilbert’s

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15
Q

Intrahepatic jaundice causes

A

NAFLD - now called MASH (metabolic associated steatohepatosis)

Infectious
- HAV, HBV (ac/ch), HCV (ch), HDV+BV, HEV (ac)
- HIV
- Parasites (e.g. ascaris, entamoeba)
- Leptospirosis
Toxic
- Alcohol
- DILI (paracetamol, antibiotics, anti-inflammatories)

Neoplasia
- HCC
- Lymphoma - mass or infiltration
- Metastases (CRC, breast, lung, etc)

Autoimmune
- AIH
- PBC
- PSC (initially cholestatic)

Genetic
- Haemochromatosis
- Wilson’s
- Alpha-1 antitrypsin

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16
Q

Post-hepatic jaundice causes

A

Benign
- Gallstones
- Cholangitis
- Strongyloides

Malignant
- Pancreatic cancer
- Cholangiocarcinoma
- Metastases
- Lymphoma

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17
Q

Courvoisier’s law

A

Palpable gallbladder with jaundice is cancer, not stone - in impacted stone, chronic infection leads to GB atrophy

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18
Q

Autoimmune hepatitis antibodies

A

ANA, anti-smooth muscle, ALKM1

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19
Q

PBC antibodies

A

Anti-mitochondrial

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20
Q

Haemolysis blood tests

A

Haptoglobin
LDH
Reticulocytes
Smear
Direct/indirect antiglobulin test

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21
Q

Cirrhosis complications

A
  • Portal hypertension -> varices
  • Hepatic encephalopathy
  • SBP
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22
Q

Conditions most likely to recur in renal transplant

A

Glomerular sclerosis
Amyloidosis
IgA nephropathy
HUS

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23
Q

Renal transplant rejection presentation

A

Hyperacute - within minutes. Swelling, discolouration of graft
Acute - 2/52-6/12. Cell or Ab mediated. Pain, dysfunction
Chronic - Proteinuria and HTN most common

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24
Q

Most common causes ESRF

A

Hypertension
Diabetes
Glomerulonephritis
(PKD, reflux/obstructive)

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25
Renal transplant workup tests
ABO, HLA Viral screen - CMV (don & rec), Hep B, C Urinalysis & culture Optimise comorbidities Cardio ax - ECG, echo, ?stress test Psychological
26
Calcineurin inhibitors
Tacrolimus, cyclosporin
27
Antiproliferative angents
Mycophenolate Cyclophosphamide
28
Liver function best tests
PT/INR (+ coag) Albumin
29
Alcoholic liver disease LFTs
AST:ALT >2:1 (>50 if ischaemic)
30
sBP ascites WCC
>250/mm3
31
Ascitic fluid tests
- Cell count - Albumin / SAAG - Amylase/lipase - MC&S - Cytology - Glucose
32
Utility of ascites glucose measurement
Low - increases likelihood of infection or malignancy Low sens/spec
33
Grading of liver disease
MELD score -Labs only: Bili, PT, Na, Cr, Dialysis Child-Pugh - Bili, Alb, PT + Ascites, Encephalopathy
34
SAAG
Serum ascites albumin gradient - SAAG >1.1 g/dL = Transudate = Hydrostatic/Oncotic pressure problem = CCF/Renal failure/Liver failure/Budd Chiari etc - SAAG <1.1g/dL = Exudate = Capillary permeability = Malignant, Infection (inc. TB), Inflammatory (e.g. RA)
35
Extra-intestinal IBD signs
Mouth: Aphthous ulcers Skin: Erythema nodosum, pyoderma gangrenosum Joints: Clubbing, seronegative arthritis (e.g. AS) Eye: Uveitis, episcleritis, iritis Liver: PSC with UC Amyloidosis
36
IBD severity
Truelove & Witt - Frequency >6/day - Stool blood vol - Temp >37.8 - Pulse >90 - Hb <105 - ESR >30 ECCO (European Crohn's & Colitis Org)
37
UC vs CD endoscopy
UC: - rectal/colon only - Continuous - Mucosa/submucosa CD: - Whole bowel - Skip lesions - Full depth, may include granulomas - Structures, fistulae - Cobblestoning
38
IBD investigations
Bedside: - T, HR Labs: - Stool culture - Faecal calpro - FBC, U&E, CRP, LFT, extended electrolytes, B12/fol, iron studies - Consider TPMT level if considering thiopurines Imaging: - AXR - dilatation - CT - fistulae etc - Sigmoidoscopy in acute /colonoscopy
39
Management acute severe UC
- Admit, resus (IVF) - LMWH - IV corticosteroid - Ciclosporin (calcineurin inhib)/Infliximab (anti TNF) if failure to respond in 72h - Surgery if failure to respond
40
Mild acute UC management
Topical 5-ASA or steroid (e.g. rectal mesalazine or budesonide) 5-ASAs better
41
Maintenance of remission UC & monitoring
Depends on what induced remission. Options include: - Topical/oral 5-ASAs (mesalazine/sulfasalazine) If 2 flares/year - immunomodulation: - Thiopurines (azathioprine) - Infliximab (anti TNF) - Tofacitinib (JAK2 inhibitor) Vaccinations (flu, pneumococcal, HBV, VZV) Scope 10 years post Dx + ongoing depending on findings/Hx Vit D/Ca supplements Dietician input
42
IBD and smoking
CD - increased risk 3x UC - lower risk
43
Mild crohns flare treatment
Oral steroid (budesonide/pred) OD, reduce over 7/52
44
TPMT level relevance
Prior to starting thiopurines (azathioprine/mercaptopurine) measure thiopurine S-methyltransferase.
45
Aminosalicilates in IBD
Good evidence in UC Poor evidence in CD e.g. Mesalazine, sulfasalazine
46
Maintenance of remission CD
- Thiopurines (e.g. azathioprine) - Can use MTX if failure - Or consider infliximab - Anti-integrin mabs also - reduce lymphocyte trafficking in bowel - Aim to avoid surgery, and if using minimise
47
IBD surgery indications
- Obstruction - Fistulation - Toxic megacolon/severe colitis - Intractable symptoms Relapse rate high in CD
48
Ileum absorption
B12 Bile salts (which absorb fat soluble vitamins ADEK)
49
Coeliac endoscopy findings
Villous atrophy Crypt hypertrophy Lymphocytes in epithelium and lamina propria
50
Coeliac most common deficiencies
B12, Folate, D (Iron)
51
Coeliac complications
Malabsorptive: - Anaemia - Osteopenia/porosis - Neuropathy / SACDC Other: - Dermatitis herpetiformis - Hyposplenism - T cell lymphoma
52
Causes splenomegaly
Infiltrative: - Myeloproliferation - Lymphoproliferation - Lymphoma - Amyloid/sarcoid - Thyrotoxicosis - Gauchers (lipid breakdown disorder) Increased function: - Red cell sequestration: spherocytosis, thalassaemia, early sickle cell disease - Infection - malaria, leishmaniasis, glandular fever (EBV), brucella - Disordered immunoregulation: Felty's (in rheumatoid), SLE, Sarcoid Abnormal flow: - Cirrhosis - Hepatic/portal vein obstruction
53
Causes massive splenomegaly
- CML - Myelofibrosis - Gaucher's disease - Chronic malaria - Kala-azar (leishmaniasis)
54
Splenomegaly investigations
- FBC & film - Thin/thick films for sickle & malaria - CTCAP for ?malignancy - Bone marrow aspirate/trephine - Lymph node biopsy if present
55
Complications of splenomegaly
Pancytopenia -> anaemia, infection, bleeding
56
Indications for splenectomy
- Trauma usually - Hypersplenism - Autoimmune haemolysis Leads to Howell-Jolly and Pappenheimer bodies, and target cells
57
Splenectomy follow up
Risk of encapsulated organism infections: S. pneumoniae, N meningitides, H influenzae. - Immunisations: pneumococcal, meningitis, Hib - Penicillin V lifelong - Alert cards - Broad spectrum Abx if infected - Meticulous malaria prophylaxis if travelling
58
Indications for liver transplant
Chronic liver failure: - Cirrhosis - alcoholic, MASH, autoimmune, haemochromatosis, Wilson's, a1 antitrypsin etc. - HCC Acute liver failure (within 8/52 of onset): - Paracetamol most common - Hep A, B Variant: - Diuretic-resistant ascites - Intractable pruritis - Intractable encephalopathy - Hepatopulmonary syndrome
59
Liver transplant contraindications
IVDU Ongoing alcohol excess Significant med/psych comorbidities Extrahepatic spread of HCC
60
Liver transplant complications
- Operative risk - Immunosuppression - infection, cancers - Post transplant lymphoproliferation - Metabolic syndrome - Rejection - Recurrence of indicative disease
61
Haemochromatosis gene
HFE chromosome 6. Autosomal recessive Variable penetrance Leads to defective hepcidin, which would normally control negative feedback in duodenal iron absorption (Other genes exist including transferrin receptor, juvenile
62
Haemochromatosis presentation
- 1st degree relative screening commonly - Incidental with raised ferritin OR - Lethargy - Loss of libido & sexual dysfunction - Arthralgia (often 2-3 CP, PIPs - pseudogout) LATER - Hepatomegaly, cirrhosis - Diabetes - Cardiomyopathy - Bronze/"slate-grey" skin Tends to present earlier in males due to menstruation Examination: - Bronze diabetes - Venesection scars - CCF - Arthropathy
63
Haemochromatosis investigations
- Transferrin sats and ferritin both high - HFE gene - LFTs - though haemochromatosis does not often cause transaminitis - Glucose/HbA1c regularly - Consider AFP Imaging: - Liver US - 6/12ly if cirrhosis - Echocardiogram - Consider DEXA - association with osteoporosis - Joint XRs - chondrocalcinosis Liver biopsy can be considered for severity assessment
64
Haemochromatosis screening
1st degree relatives of patients Ferritin - 200 in F, 300 in M + T sats >45% F, >50% M Then HFE gene
65
Haemochromatosis management
- Avoid dietary iron - Avoid alcohol - Avoid vitamin C - Phlebotomy until iron deficient, then reduce frequency - Iron chelation only when above not feasible - HCC surveillance - 6 monthly if cirrhosis - Family screening
66
Liver transplant eligibility score
Chronic: United Kingdom Model for End-Stage Liver Disease (UKELD). INR, Creatinine, Bilirubin, Sodium Acute - various, inc Kings criteria for paracetamol
67
PBC antibodies
Antimitochondrial
68
PSC antibodies
ANA, Anti-smooth muscle sometimes
69
Autoimmune hepatitis antibodies
Anti smooth muscle Anti liver/kidney microsomal (LKM1)
71
Massive splenomegaly
Haem - Myelofibrosis - CML INFECTION - malaria - leishmaniasis

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