``` Ascitis and peritonitis abdomen Complicated by HRS in 30% E. Coli, Klebsiella, Strep Ascitic tap = PMN >250mm3 + MC&S Possible for ciprofloxacin to be given as prophylaxis against SBP ```

AS PACES Abdo Flashcards by Maciej Adler

Child Pugh grading cirrhosis

A, B, C
ABCDE = albumin, bilirubin, clotting, distension (ascites), encephalopathy
Correlates with mortality: A (score 5-6); C (score 10-15) 1 yr mort 50%

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Decompensated LD - precipitants

HEPATICS
Haemorrhage, electrolytes, poisons (diuretics, sedatives), alcohol, tumour, infection (SBP, pneumonia, UTI), Constipation (commonest), Hypoglycaemia (malnutrition)

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Hepatic encephalopathy - presentation

Asterixes, ataxia
Confusion
Dysarthria
Constitutional apraxia
Seizures

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Hepatic encephalopathy - Mx

Nurse in well lit, calm environment
Correct precipitants
Avoid sedatives
Lactulose - decrease nitrogen forming bowel bacteria

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Hepatorenal syndrome

Cirrhosis = splanchnic vasodilation = reduction in ECV = RAS activation = renal arterial vasoconstriction = failure
Type 1 (rapidly progressing) - survival 2wks
Type 2 (steady decline) - survival 6mo
IV albumin + terlipressin ± haemodyalisis ± liver transplant

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SBP

Ascitis and peritonitis abdomen
Complicated by HRS in 30%
E. Coli, Klebsiella, Strep
Ascitic tap = PMN >250mm3 + MC&amp;S
Possible for ciprofloxacin to be given as prophylaxis against SBP

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Causes of ascites

80% cirrhosis with portal HTN
CCF
Carcinomatosis
SAAG = Se albumin - Ascites albumin; >1.1g/dL = portal HTN (if <1.1 Ca, pancreatitis, nephrotic syndrome

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Diagnosing Portal HTN

Serum Ascites Albumin Gradient >1.1g/dL
TE
Portal presure >10mmHg (norm 5-10)

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Causes of Portal HTN

Pre hepatic - Portal vein thrombosis
Hepatis - Cirrhosis
Post hepatic - Bubb-Chiari syndrome, RHF, TR

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Ascites Tx

Conservative - no ETOH, fluid monitoring (aim 0.5kg/d reduction), fluid restrict <1.5L/d, low Na diet
Spironolactone
Therapeutic paracentesis
Refractory - TIPSS or transplant

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DDx jaundice

Pre hepatic - Unconjugated. AIHA, HS, SCD, PNH, MAHA, malaria, G6PDD
Hepatic - CLD, paracetamol, statins, Ca
Post hepatic - conjugated, GA, Ca Panc, PBC, PSC, cholangiocarcinoma, OCP, augmentin

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Immunosupression signs on peripheral examination

Cushingoid
Skin tumours - SCC, BCC, MM, AKs
Gingival hypertrophy

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Ddx Rooftop scar

Liver transplant
Segmental resection
Whipples pancreatoduodenectomy

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Liver transplant - causes, success rates, immunosupression regimen

Cirrhosis, acute liver failure, malignancy
80% 1 yr survival; 70% 5 yr survival
Tacrolimus / ciclosporin, azathioprine ± prednisolone

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Causes of hepatomegaly

Hepatitis - ETOH, viral, NAFLD
Congestion - RHF, TR, budd chiari
Malignancy
Anatomical - Riedel’s lobe, hyperexpanded chest
Haem - leukaemia, lymphoma, myeloproliferative, SCD
Sarcoid, Amyloid, ADPKD

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Splenomegaly DDx

Massive –> Myeloproliferative (CML, MF); Lymphoproliferative (CLL, lymphoma); Infiltrative (amyloid); Infectious (malaria, visceral leishmaniasis)
Small –> Haem proliferative, portal HTN, EBV, IE, malaria, RA, SLE, Sjorgen’s

Blood film: Myelofibrosis, CLL, Haemolysis

MF –> leukoerythroblastic, teartrop poikilocytes (Jak2 mutation in 50%)
CLL –> Smudge cells (Ph chr t9;22)
Haemolysis –> spherocytes, reticulocytosis

CML

Clonal proliferation of myeloid cells, 15% leukaemia
B symptoms, massive HSM, platelet dysfunction, gout, hyperviscosity
Ph Chr t(9;22) in >80% –> resulting BCR-ABL gene = tyrosine kinase activity
Imatinib or allogenic SCT (if blast crisis or TKi refractory)

Primary myelofibrosis

Clonal expansion of megakaryocytes, ++ PDGF
B symptoms, massive HSM, BM failure
Leukoerythroblastic teardrop poikilocytes on film
Cytopenias, BM often dry tap
50% Jak2 + ve
Splenectomy ± allogenic BMT, other than that treatment supportive with blood products

Hypersplenism

Pancytopenia due to pooling and destruction in large spleen (anaemia, bruising, infections)

Hyposplenism

Ddx splenectomy, coeliac disease, IBD, SCD
Howell Jolly bodies, pappenheimer bodies, target cells
Mx –> immunisation (HiB, pneumovax, Men C, flu)
Abx –> Pen V or erythromycin
Warning alert card / bracelet

Splenectomy - indications and complications

Trauma, rupture, AIHA, ITP, HS
Early VTE - need post op aspirin
Transient ileus - post op NG tube
Atelectasis
Pancreatitis
Susceptibility to infections by encapsulated bacteria (haemophilus, pneumo, meningo)

Mx APDKD

1:1000, PKD1 chr 16 85%; PKD2 chr 4 15%
Conservative - ensure good hydration, less caffeine, genetic counselling
Monitor U&E & BP, MRI for Berri aneurysms
Medical –> HTN (aggressively, target <130/80)
Surgical –> nephrectomy if recurrent bleeds / infections / abdo discomfort
Prognosis –> ESRF 70% by 70 yrs

ARPDK

1:400000, perinatal presentation with oligohydramnios

ESRF 20 yrs, need Tx

Tuberous sclerosis

AD, hamartomas in skin brain eye kidney Skin --> nasolabial adenoma sebaceum, ash-leaf macules, peri ungal fibromas Neuro --> Low IQ, epilepsy, astrocytoma Renal --> cysts, angiomyolipomas

RCC

90% renal Ca, median 55yrs, m:f 2:1 RF: smoking, obesity, HTN, dialysis (15% pts), 4% heritable (VHL) AC from proximal renal tubular epithelium Clear cell (glycogen) subtype: 70-80% 50% incidental finding, haematuria, loin pain, loin mass Cannonball mets --> SOB Paraneoplastic --> EPO, PTHrP, renin, ACTH Spread: renal vein, lymph, haematogenous bone liver lung

VHL syndrome

``` AD, renal and pancreatic cysts B/L RCC Haemangioblastomas (often cerebellum) Phaeochromocytoma Islet cell tumours ```

RCC Mx

Medical - for poor prognosis, temsirolimus (mTOR) Surgical - radical nephrectomy 45% 5yr survival

Commonest indications for renal Tx

DM GN PKD HTN

Assessment for renal Tx

``` Virology: CMV, HIV, VZV, HBV, HCV Co-morbidities ABO anti-HLA Abs Haplotype: HLA DR, A, B XM CI --> infection, Ca, co-morbidityies, failed pre implantation XM ```

Immunosupression for renal Tx

Pre-op --> campath (anti CD52) | Post-op --> Steroids short term; tacrolimus/ciclosporin long term

Transplant rejection

Hyperacute --> ABO incompatibility, thrombosis and SIRS Acute --> <6mo; fever and graft pain, reduce UO, high Cr, immunosupression Chronic --> >6mo; gradual increase in Cr, interstitial fibrosis, Rx supportive

Immunospuression drug toxicity

Ciclosporin --> Calcineurin inhibitor (IL2 blocker). Nephrotoxic, hingival hypertrophy Tacrolimus --> calcineurin inhibitor. DM, crdiomyopathy, neurotoxicity Steroids

Steel syndrome

Distal tissue ischaemia due to fistula

Classifying CRF

``` >90 60-89 30-59 16-29 <15 ```

Renal osteodystrophy: features

OP, OM, 2*/3* HPT (subperiosteal bone resorption, acral osteolysis, pepperpot skull) Osteosclerosis of the spine (Rugger Jersey spine) Extraskeletal calcification

Renal bone disease - Mx

Phosphate binders - calichew Vit D analogues - alfacalciferol Ca supplements

UC Mx

MDT Conservative: ADEK, high fibre, dietician review Induction: 5ASA, pred (oral and PR), infliximab Maintenance: 5ASA azathioprine, biologics Surgical: Obstruction, megacolon, perforation, failure to respond to medical therapy

CD Mx

Conservative: ADEK, high fibre, dietician review Induction: budesonide/sulfasalazine; pred; methotrexate, biologics Maintenance: azathioprine, methotrexate, biologics Surgical: Obstruction, perforation, failure to respond to medical therapy