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Consequences of cirrhosis

Portal hypertension – oesophageal varices, ascites hypersplenism
Liver dysfunction - coagulopathy encephalopathy, jaundice, hypoalbuminaemia
HCC

1

Causes of liver cirrhosis

Alcohol
Viral - hep B and C
Autoimmune - PBC, PSC, auto hep
Metabolic - NAFLD, haemochromatosis, alpha-1 antitrypsin deficiency, Wilsons disease, cystic fibrosis
Drugs - metronidazole isoniazid amiodarone, phenytoin

2

Causes of hepatomegaly

Malignancy (1 + 2)
Cirrhosis - NAFLD, ALD, PBC
Hepatic congestion - R heart failure, constrictive pericarditis, restrictive cardiomyopathy
Alcoholic hepatitis
Infected - viral, toxoplasmosis, hydatid dz, amoebic/pyrogenic abscess
Infiltration - amyloid, sarcoidosis, glycogen storage disorders
Vascular - budd-chiari, sickle cell
Polycystic liver disease

3

Causes of decompensation in cirrhosis

Infection
SBP (>500 neutrophils/microlitre)
Hypokalemia (decreases renal ammonia clearance)
GI bleeding
Sedatives
HCC

4

Cancers which commonly metastasise to liver

Colorectal
Breast
Oesophageal
Lung
Gastric
Renal
Endometrial
Sarcoma
Bone

5

Name some benign liver tumours

Cavernous haemangioma - most common benign
Hepatic adenoma
Focal nodular hyperplasia

6

Infective causes of acute hepatitis

Hep A B C E
EBV
CMV
Toxoplasmosis
HSV

7

Causes of massive splenomegaly

CML
myelofibrosis
Malaria
AIDS with mycobacterium avium complex
visceral leishmaniasis

8

Causes of moderate splenomegaly

Portal hypertension
lymphoma
leukaemia (Acute or chronic)
Thalassaemia
Glycogen and lipid storage diseases

9

What are the cytogenetics of CML?

The Philadelphia chromosome is present in 90 to 95% of patients with CML. This is a translocation of chromosome 9 and 22 leading to increased oncogene activity through tyrosine kinase

10

What are the causes of hyposplenism?

Splenic infarction (sickle-cell anaemia, vasculitis)
Splenic artery thrombosis
Infiltrative conditions (amyloid, sarcoid)
Coeliac disease
Autoimmune disease

11

What is Felty's syndrome?

Rheumatoid Arthritis with splenomegaly and neutropenia

12

How do you diagnose haemochromatosis?

Transferrin sats >60% in males, >50% in females
Liver biopsy to confirm Dx

13

Complications of haemochromatosis

HCC - needs 6monthly surveillance (USS and alpha fetoprotein)
Diabetes (decreased insulin sensitivity)
Arthropathy
Restrictive or dilated cardiomyopathy

14

Major causes of chronic renal disease in developed world

Hypertension
Diabetes
Glomerulonephritis
Polycystic kidneys
Reflux nephropathy

15

What are the complications of CKD?

Fluid overload
Hyperkalaemia
Hyperphosphataemia
Metabolic acidosis
Renal osteodystrophy (low Ca and vit D, high phos and PTH)
Anaemia

16

What is renal osteodystrophy?

In End stage CKD, you get reduced phos excretion and decreased conversion of vit D3 to calcitriol (active form)
-> low Ca -> 2ndary high PTH -> altered bone mineralisation
Osteitis fibrosa - increased bone turnover, bone cysts
Osteomalacia - decreased mineralisation,
Adynamic bone disease - MOST COMMON. Bone turnover markedly reduced, no mineralisation defect

17

Indications for renal replacement therapy

Uraemic pericarditis/pleuritis/encephalopathy
Volume overload refractory to diuretics
Hypertension refractory to antihypertensives
Refractory hyperkalaemia/acidosis

18

Define nephrotic syndrome

Hypoalbuminaemia 3g/24hours
Oedema

19

Causes of nephrotic syndrome

Systemic - DM, SLE, amyloidosis
Renal:
Minimal change disease - idiopathic, secondary to DM, NSAIDS, HIV, paraneoplastic Hodgkin's lymphoma, IgA nephropathy
Focal segmental glomerulosclerosis
Membranous GN
Mesangiocapillary GN

20

What is the inheritance of haemochromatosis?
which chromosome?

auto recessive chrom 6

21

What is the inheritance of haemochromatosis?
which chromosome?

auto recessive chrom 6

22

Causes of unilateral kidney enlargement

polycystic kidney disease
renal cell carcinoma
simple cyst
obstructive hydronephrosis

23

Causes of bilateral kidney enlargement

renal cell carcinoma
bilateral hydronephrosis
polycystic kidney disease
tuberous sclerosis
amyloidosis

24

genetics of polycystic kidney disease?

85% ADPKD1 chrom 16
15% ADPKD2 chrom 4

25

other organ involvement with PKD

hepatic cysts and hepatomegaly
intracranial Berry aneurysms
mitral valve prolapse

26

Causes for renal transplant

glomerulonephritis
diabetic nephropathy
ADPKD

27

Causes for renal transplant

glomerulonephritis
diabetic nephropathy
ADPKD

28

Differential diagnosis for Crohn's disease

UC
Yersinia
TB
lymphoma

29

Differential Diagnosis for UC

Crohns
infection (campylobacter)
ischaemic bowel
drugs
radiation

30

Treatment of Crohns disease

mild-mod - oral steroids, mesalazine
severe - IV steroids, IV infliximab
maintenance - steroids, azathioprine, methotrexate, infliximab

31

Treatment of UC

mild - mod: rectal steroids, mesalazine
severe: IV steroids, IV ciclosporin
maintenance: oral steroids, 5-ASA, azathioprine

32

Treatment of UC

mild - mod: rectal steroids, mesalazine
severe: IV steroids, IV ciclosporin
maintenance: oral steroids, 5-ASA, azathioprine

33

complications of Crohns

malabsorption
anaemia
fistula
abscess
SBO from strictures

34

Complications of UC

anaemia
toxic megacolon
perforation
colonic carcinoma (high risk with pancolitis)

35

extra-intestinal manifestations of IBD

mouth: apthous mouth ulcers
skin: clubbing, pyoderma gangrenosum, erythema nodosum
eyes: uveitis, episcleritis, iritis