Ch 10. Renal, Liver, GU, GI Flashcards Preview

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Flashcards in Ch 10. Renal, Liver, GU, GI Deck (55):
1

List the 3 categories of acute kidney injury, and five causes of each? (3)


**Think anatomically: pre-renal (vasculature), then glomerular, then interstitial nephritis, then ATN**
1. Prerenal (70%): “Pre-renal failure equals shock”. dehydration, hemorrhage, vomiting, diarrhea, sepsis, pancreatitis, burns, hepatic failure, heart failure, drugs (diuretics/antihypertensives),
2. Renal (Intrinsic) (20%) – Vascular (aortic dissection, thrombosis, infarction), Glomerular (autoimmune Goodpasture’s syndrome, Wegener’s granulomatisis), rhabdomyolysis, glomerulonephritis, AIN, DRUGS
3. Postrenal (10%) – prostate, nephrolithiasis, cancer, trauma, blood clot in bladder/urethra, phimosis or stricture, anticholinergic toxicity, neurogenic bladder,

2

Causes of acute interstitial nephritis (AIN)? (3)

1. Immune mediated
2. Drugs (PCN, sulfa, diuretics, NSAIDs)
3. Infections
*This can be an allergic type phenomenon – allergy to PCN, sulfa etc, eosinophils. Symptoms are fever, rash, renal failure, enlarged kidneys, NV malaise.
**30% have high eosinophils in blood , and most have urine eosinophils

3

What causes ATN? (2)

1. Ischemic (trauma, sepsis)
2. Toxic: contrast dye, myoglobin (rhabdo), multiple myeloma

4

What is the FENa and urine Na+ in pre-renal failure and renal (ATN)? (2)

1. FENa in pre-renal <1%, in renal >1% (the kidney doesn’t work and loses Na+)
2. Urine Na+ in pre-renal is low <20, high in renal >40

5

DDx hematuria (5)

1. Kidney stone
2. Bladder Ca
3. Nephritic syndrome
4. Menses
5. Renal contusion

6

Hemolysis DDx (6)

1. DIC
2. MAHA
3. ABO incompatability (transfusion)
4. Sickle cell, thalassemia (chronically low grade)
5. Aortic valve replacement / AS (chronic low grade)
6. TTP
7. HUS
8. Drug induced
*HIGH LDH, HIGH bilirubin, LOW haptoglobin, present reticulocytosis
**Do a COOMB’s/DAT to see if auto-immune or not
***Peripheral blood smear for schistocytes

7

Which drugs cause AKI (5)?


**ACEi, NSAIDs, diuretics (90%)
1. Cox-1 and Cox-2 inhibitors (NSAIDS)
2. ACE inhibitors, ARBs
3. Diuretics
4. Statins
5. Antiretroviral therapy
6. Gabapentin/pregabalin
7. Levetiracetam (Keppra)
8. Topiramate
9. Immunosuppressives
10. PPI’s
11. Metformin
12. Antibiotics: aminoglycosides, vancomycin, floroquinolones, cephalosporins.
13. Cocaine
14. Ethanol

8

What are the causes of renal artery and small-vessel disease associated prerenal failure? (5)

1. Embolism: thrombotic, septic, cholesterol
2. Dissection
3. Drugs: NSAIDS, ACEi, ARBs, Cyclosporine and tacrolimus
4. Microvascular thrombosis: pre-eclampsia, HUS, DIC, vasculitis, sickle cell disease
5. Hypercalcemia

9

What are the indications of emergent Dialysis? (5)


AEIOU
1. Severe metabolic acidosis
2. Electrolytes (Serum sodium <115 or >165 mEq/L, hyperkalemia (K>6.5 mmol/L or rising)) *Refractory to medical management
3. Ingestion (LAME: Lithium, aspirin, methane, ethylene glycol or theophylline)
4. Overload: intractable fluid overload, i.e. hypoxia
5. Uremia (pericarditis, bleeding, encephalopathy, seizures)

10

What are dialyzable drug overdoses? (4)


LAME 

1. Lithium

2. ASA

3. Methanol

4. Ethylene glycol

5. THEOPHYLLINE

11

How do you avoid contrast-induced nephropathy? (1)

1. IV fluid hydration

12

Liver Disease: how is acute liver failure defined? (2) List 6 causes of ALF (6)

Fulminant Liver failure/ALF:
1. Acute hepatic encephalopathy 
2. Synthetic function decline: INR up (decr.1972 clotting factors), Albumin down, Bili up, Transaminitis)
Causes: DAVIM
1. Drugs (tylenol, herbals) 
2. AIH
3. Viral (Hep ABC, CMV, EBV, HSV)
4. Ischemic
5. Metabolic (Pregnancy (AFLP, HELLP), WD)
- Prevalence: Tylenol >> Indeterminant > Idiosyncratic drug rxns > Hep B > Hep A 

13

Treatment of rhabdomyolysis (1)
Life threatening complications of rhabdomyolysis (2)

1. IV fluid. Aim for UO of 200-300mL/hour
*The value of CK does not correlate with getting renal failure very well.
1. Hyperkalemia
2. Hypocalcemia (only treat if symptomatic)

14

What is the diagnosis:
1. Urinalysis dips for blood but no RBC (1)
2. Urinalysis has RBC casts (1)
3. WBC casts (1)
4. Granular gasts or Renal Tubular Epithelial cells (1)
5. Hyaline casts (1)
6. Urine eosinophils (1)
7. Oxalic acid crystals (1)
8. Oval fat bodies or fatty casts (1)
9. Proteinuria (>3g/day or 3+ proteinuria) (1)

1. Urinalysis dips for blood but no RBC = rhabdomyolysis (myoglobin) or hemolysis – MAHA, valve
2. Urinalysis has RBC casts = glomerulonephritis (nephritic or nephrotic syndrome, usually with nephritic syndrome).
3. WBC casts = pyelo or acute interstitial nephritis (eosinophils) *PCN, NSAIDs, Diuretics
4. Granular gasts or Renal Tubular Epithelial cells = ATN
5. Hyaline casts = AKA Tamm-Horsfall, most common. From dehydration, exercise, pre or post renal ARF
6. Urine eosinophils = Acute Interstitial Nephritis *PCN, NSAIDs, Diuretics
7. Oxalic acid crystals (1) = ethylene glycol
8. Oval fat bodies or fatty casts = nephrotic syndrome
9. Proteinuria (>3g/day or 3+ proteinuria) = nephrotic syndrome

15

Three things that cause a bicarb less than 1 (3)


1. Severe sepsis
2. Toxic alcohol ingestion

3. Metformin induced acidosis

4. DKA

16

General categories of solid organ transplant complications (4)


1. Anatomy – vascular stenosis or thrombosis, anastomosis leak

2. Rejection (fevers, chills, grumbles, pain to the site, rising Cr or LFT’s)

3. Infection – viral, bacterial, any

4. Drug toxicity – to a cyclosporine or tacrolimus level

17

Nephrolithiasis kidney stone composition (4)

1. Calcium oxalate (most common)
2. Struvite
3. Uric acid
4. Cystine


18

What is the passage rate of kidney stones 1-4mm, 6mm, 8mm (3)?


1. 1-4mm = 90%

2. 5-7mm = 60%

3. 8mm and larger = 40%
*5-15% of patients will have NO hematuria

19

Patients with nephrolithiasis to admit (5)

1. Stone >8mm (call and discuss)
2. Stone with renal failure
3. Stone with solitary kidney
4. Infected stone
5. Intractable pain/vomiting

20

Kidney stone mimics (6)

1. AAA AAA AAA AAA
2. Pyelonephritis
3. Appendicitis
4. Renal infarction
5. Urinary retention
6. Diverticulitis
7. Tumor
8. MSK back pain
9. Ovarian/testicular torsion


21

Treatment of priapism (4)


*Low-flow (painful) or high-flow (painless) – often traumatic

The corpus cavernosa ABG shows low pH, high CO2

1. Consult urology (often not helpful…)

2. IV opioids

3. Dorsal penile nerve block

4. Terbutaline ORAL 

5. Aspirate 30mL from each side

6. Phenylephrine injection 0.5mg to each side in 1mL

7. Corporal injection then aspiration from each side 


22

The acute scrotum: 3 do-not-miss diagnoses (3)


1. Testicular torsion

2. Fournier’s gangrene

3. Incarcerated inguinal hernia


23

Testicular torsion findings (4)


1. Sudden onset pain

2. Nausea
 / V
3. Transverse lie

4. Absence of cremasteric reflex (don’t use)
*Recovery best within 6 hours, you can go up to 72hours. Get a STAT US or call urology

24

Contraindications to placing a Foley catheter (3)


1. Pelvic fracture

2. Blood at meatus

3. High-riding prostate

25

Treatment of urinary retention (4)

1. Check medications
2. Foley catheter for THREE days – then remove
3. Suprapubic catheter
4. Alpha blockers (tamsulosin)
*There are handouts and homecare follow-up for these patients. Outpatient referral to urology.

26

Triad of nephrotic syndrome (3)

1. Proteinuria
2. Hypoalbuminemia + Hyperlipidemia
3. Peripheral edema
*Causes= FSGS, membranous GN, MCD, diabetes, lupus, HIV, medications
**Increase risk of clotting

27

Acute Interstitial Nephritis triad (3)

Acute Interstitial nephritis = FUR
1. Fever
2. Urine eosinophils
3. Rash
Drugs that cause AIN = penicillins, diuretics, NSAIDs
Treatment of acute interstitial nephritis = stop the drug

28

Liver enzymes in alcoholic hepatitis (1)


1. AST > ALT 2:1 


29

Wernicke’s encephalopathy symptoms (3), and treatment (1)


Wernicke’s = WACO

1. Ataxia

2. Confusion

3. Opthalmoplegia
1. Wernicke’s treatment = thiamine 500mg IV q8H


30

DDx Hepatitis 1000-club (5)


1. Viral (Hep ABCDE, EBV, CMV)

2. Ischemic (shock liver/trauma),

3. Toxicology: acetaminophen, mushrooms, serotonin syndrome/NMS

4. Drugs: acetaminophen

5. Metabolic: Budd Chiari, Wilson disease


31

Diagnosis of acute liver failure (3)


1. Acutely elevated liver enzymes

2. Encephalopathy

3. Coagulopathy

32

Complications of hepatic cirrhosis (5)


1. Hepatic encephalopathy
2. Ascites (SBP!!!)

3. Variceal bleeding
4. Hepatorenal syndrome
5. Portal HTN

33

Active bleeding in cirrhosis targets for HGB, Plt, Fibrinogen (2)


1. HGB > 70

2. Plt > 50
3. Fibrinogen >0.5 (FFP)

34

Treatment of the bleeding liver failure/cirrhosis patient (3)


* Consider massive transfusion protocol (and they get FFP)

1. Blood/massive transfusion protocol (they get FFP)

2. TXA

3. PCC (Octaplex)

4. Vitamin K


35

INR guidelines for paracentesis (1)


1. INR does not accurately reflect bleeding risk in liver failure patients. Don’t need to give FFP/PCC. Consider Vitamin K.

36

DDx WAGMA (8)

MUDPILES
1. M — Methanol
2. U — Uremia (chronic kidney failure)
3. D — Diabetic ketoacidosis
4. Propylene glycol (used as an inactive stabilizer in many medications)
5. I — Iron, Isoniazid, Inborn errors of metabolism
6. L — Lactic acidosis
7. E — Ethylene glycol
8. S — Salicylates

37

DDx NAGMA (6)

HARD-UP
1. Hyperchloremia (too much NS?)
2. Acetazolamide, Addison’s disease
3. RTA
4. Diarrhea, ileostomy, fistula
5. Uretero-ostomy
6. Pancreato-ostomy

38

Triad of hemolytic uremic syndrome (3)

1. Hemolytic anemia,
2. Thrombocytopenia
3. Renal failure
*Often preceded by diarrhea (bloody diarrhea 75%). Leading cause of acute renal failure in peds. E.coli O157:H7 is leading cause.

39

Testicular mass DDx (4)

1. Testicular cancer
2. Epididymitis / orchitis
3. Abscess
4. Hernia
5. Hydrocele
*Testicular cancer will metastasize to lungs and liver
*Differentiate epididymitis and torsion by torsion is SUDDEN ONSET, high horizontal lie, absent cremasteric, and the cremasteric reflex is absent.

40

DDx asymptomatic pyuria (WBC in urine, no bacteria) (3)

1. Chlamydia
2. TB
3. Inflammation (interstitial cystitis)

41

Polycystic kidney disease signs/Sx, and deadly association (3+1)

1. Flank pain
2. Hematuria
3. Renal failure
1. PKD is associated with cerebral aneurysms (SAH!!!)
*Painless hematuria, or microscopic hematuria needs FU. High incidence of renal and bladder carcinoma

42

Signs/Sx of prostatitis (5)

1. Pelvic pain
2. Pain with voiding
3. Pain with BM
4. Fevers
5. Hematuria
6. On exam SICK, big tender boggy prostate
*Needs IV antibiotics for 4-6 weeks!

43

Treatment of thrombosed external hemorrhoid (1), rectal prolapse (1)

1. Excise if within 72 hours of onset (elliptical incision)
- Also stool softeners, high fibre diet
1. Rectal prolapse: apply sugar. Reduce.

44

WASH regimen for perianal abscess, anal fissure (4)

1. Warm water (Sitz bath 15mins TID)
2. Anaesthesia (topical lidocaine)
3. Stool softener
4. High fiber diet
*Consider topical hydrocortisone, nitro for anal fissure

45

Difference between biliary colic, cholecystitis, cholangitis, choledocolithiasis (4)

1. Biliary colic – RUQ/epigastric pain. Normal liver enzymes. Rx no fatty foods, refer to surgery
2. Cholecystitis – RUQ pain +/- fever, LFTs, WBC. Murphy’s sign 90%Sp. Dx. US
3. Choledocolithiasis – gallstone in CBD. RUQ, vomiting, jaundice, elevated LFTs. US shows dilated CBD (normal CBD <5mm, add 1mm per decade over 50). CT can be better for choledoco.
4. Cholangitis: Charcot’s triad is fever, RUQ pain, jaundice. Rx ERCP. IV ceftriax and flagyl.

46

US findings in cholecystitis (3)

1. Gall stones
2. Gall bladder wall thickening >3mm
3. Pericholecystic fluid
4. Sonographic Murphy’s sign

47

Extra-intestinal manifestations of IBD (4)

1. Ocular – iritis, episcleritis
2. Derm – erythema nodosum, pyoderma gangrenosum
3. Arthritis – Ank Spond, RA
4. Renal stones, PSC

48

Causes of high output heart failure (5)

*Normal systolic function but symptoms of heart failure (SOB, peripheral edema, pulmonary edema, PND, orthopnea)
1. Thyrotoxicosis
2. Beriberi (thiamine deficiency)
3. Dialysis fistula complication
4. Large AVM
5. Burns
6. Red man syndrome (from vancomycin)
7. Chronic anemia

49

Treatment of acute urethral syndrome (1)

1. Treat empirically in young males for C+G
*Same as PID in females. Treat empirically

50

Which drugs cause AIN (3)?

1. NSAIDs
2. PCN
3. Diuretics

51

Mechanisms of diarrhea (4)

1. 2 fast – hypermotility (component of every diarrhea)
2. 2 strong – osmotic diarrhea (laxitives, steatorrhea, sorbitol)
3. 2 broken – inflammatory diarrhea damages the cells so they can’t absorb. Continues despite fasting (infections, chemo, radiation)
4. 2 confused – cytotoxic chemicals cause cell secretion not absorption (cholera)

52

What are diarrhea red flags? (6)

1. Dehydration
2. Bloody diarrhea
3. Travel history
4. Recent antibiotics
5. Camping/well-water
6. Outbreak (O157:H7 / HUS)
7. Immunocompromised / HIV
8. MSM – giardia, entamoeba

53

Indications for empiric antibiotic treatment in diarrhea (3)

1. Severe diarrhea (significant dehydration)
2. Systemic symptoms (fever)
3. Severe abdominal pain
4. Toxic appearance
*Rx Cipro 500mg BID 3-5days
**These are the indications to do cultures (2% positivity rate!!)

54

When is loperamide indicated? (1)

1. Non fever, non-bloody diarrhea. Probably safe if combined with antibiotics in the fever/bloody diarrhea cases
*Avoid in peds. Leads to HUS, toxic megacolon. Use probiotics instead

55

Causes of bloody diarrhea (6)

1. Salmonella
2. Shigella
3. EHEC
4. Yerssenia
5. Campylobacter
6. C Diff
7. Vibrio