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CPC 8 acute abdo Flashcards

1
Q

What stimulates the acute phase response?

A

Cytokines IL-1, IL-6 and TNF

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2
Q

What does the acute phase response increase (blood results)

A

CRP and fibrinogen, increased ESR, fever, increased leukocytes and negative nitrogen balance.

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3
Q

What does a CRP of 100-200 suggest

A

Marked inflammation, bacterial infection

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4
Q

What does a CRP of more than 200 suggest?

A

Severe bacterial infection or extensive trauma.

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5
Q

What is pyelonephritis?

A

Suppurative inflammation of the kidney, with neutrophils within the tuules and interstitioum, although glomeruli are only involved in severe disease. Generally there are yellow-white cortical abscesses and surrounding hyperaemia.

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6
Q

What are some complications of pyelonephritis

A

Pyonephritis
Peri-nephric abscess
Papillary necrosis,

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7
Q

Causes of papillary necrosis - acronym

A

POST CARDS

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8
Q

Causes of papillary necrosis, POST CARDS

A 
Pyelonephritis
Obstruction of the urogenital tract
Sickle cell disease
Tuberculosis
Chronic liver disease
Analgesia/alcohol abuse
Rejection of renal transplant
Diabetes mellitus
Systemic vasculitis.
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9
Q

First line investigations for suspected pyelonephritis

A

MSU and blood cultures.

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10
Q

Treatment for uncomplicated pyelonephritis

A

Ciprofloxacin for 7 days.

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11
Q

How do you treat an infection which is resistant to several antibiotics i.e. has extended spectrum beta lactamase?

A

With meropenem.

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12
Q

What are the components of human bile?

A

bile salts (primary and secondary), phospholipids, cholesterol, protein, bilirubin and electrolytes.

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13
Q

Discuss the pathogenesis of gall stones

A

Cholesterol supersaturation in bile (with mucin hypersecretion
gall bladder hypomotility
and increased intetinal conversion to deoxycholate also involved.)
Crystal nucleation
Stone growth

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14
Q

What are the types of gall stones?

A

Cholesterol and pigment. Cholesterol is most common in western populations, while pigment stones are predominantly in others.

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15
Q

What populations are susceptible to cholesterol stones?

A

Western populations. Forty, fat, female, fertile, also those who have just had rapid weight loss and or have inborn errors of bile acid metabolism.

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16
Q

What populations are risk factors for pigment stones?

A

Chronic hemolytic syndromes, biliary infection, ileal disease (crohn’s, resection or bypass), cystic fibrosis with pancreatic insufficiency.

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17
Q

Where does gallstone pain radiate?

A

Epigastric pain radiating to the back (in waves if in CBD), vomiting. If gall stone ileus, also pain and distension. If in bile duct, jaundice.

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18
Q

What investigation do you do for a suspected bile duct stone?

A

EUS is best, but MRCP if this is not available. US not really good for duct stones.

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19
Q

Complications of gallstones?

A

Biliary sepsis
Gall bladder empyema
Gall stone ileus
Acute cholecystitis.

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20
Q

What organisms cause biliary sepsis (mostly)

A

E. coli and bacteroides fragilis.

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21
Q

What immune cells are mostly involved in gall bladder empyema?

A

Neutrophils.

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22
Q

What is the treatment for biliary sepsis which is mild and community acquired?

A

Co-amoxiclav

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23
Q

What is the treatment for biliary sepsis which is mild and community acquired with penicillin allergy?

A

ciprofloxacin and metronidazole

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24
Q

What is the treatment for biliary sepsis which is hospital acquired MRSA positive?

A

Vancomycin (for MRSA) and Piperacillin-Tazobactam (for anaerobes)

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25
What is the treatment for biliary sepsis which is hospital acquired MRSA positive in penicillin allergic patient?
vancomycin, ciprofloxacin and metronidazole.
26
What causes acute cholecystitis?
Diabetes mellitus, gallstones, sepsis, immunosuppression and trauma.
27
What is the appearance of a gallbladder with cholecystitis?
Fibrinous exudate on external surface Subserosal haemorrhage Gallbladder wall is thickened, oedematous and hyperaemic Neutrophilic inflammation
28
What is the most common cause of chronic cholecystitis?
Gallstones (90%)
29
General chronic cholecystitis info
Supersaturation of bile leads to chronic inflammation and stone formation. ⅓ have E. coli or enterococcus in bile.
30
Appearance of gallbladder in chronic cholecystitis
Thickened wall, variable chronic inflammation, sub-epithelial and sub-serosal fibrosis, outpouchings of epithelium through the wall.
31
Imaging of choice for right iliac fossa pain, fever and diarrhoea
CT the best, but US has less radiation.
32
Differential diagnoses for right iliac fossa pain, fever and diarrhoea
``` Appendicitis Carcinoid tumour Endometriosis Enterobius vermicularis Idiopathic inflammatory bowel disease. Ectopic pregnancy ```
33
Pathophysiology of appendicitis
Obstruction of lumen → stasis and loss of venous outflow → bacterial proliferation, inflam.response and ischaemia → neutrophilic inflammation and necrosis.
34
Appearance of appendix in appendicitis
Hyperaemic dilated vessels and/or fibrinious exudate on surface and/or perforation. Neutrophilic infiltrate at least as far as muscularis propria. Serosal involvement suggests peritonitis.
35
Complications of appendicitis
``` Perforation and peritonitis Appendix mass Pyelophlebitis Portal vein thrombosis Liver abscess Bacteraemia ```
36
Basic info on carcinoid tumours
Well differentiated neuro-endocrine tumour. | 40% jejunum/ileum,
37
Carcinoid syndrome symptoms
Flushing Diarrhoea Secondary restrictive cardiomyopathy.
38
What would be your imaging method of choice in the 74 year old with central abdominal pain radiating to the back and down into the legs?
CT
39
What would be your imaging of choice for suspected acute diverticulitis?
CT, unless young patient in which case expert US can be ok.
40
Causes of acute pancreatitis acronym
I GET SMASHED
41
Causes of acute pancreatitis I GET SMASHED
``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps Autoimmune Scorpion venom Hyperlipidaemia. ERCP and emboli Drugs (azathioprine) ```
42
Biochemistry of acute pancreatitis.
Increased serum amylase levels within first 24 hr Rising serum lipases 10% have glycosuria Hypocalcaemia secondary to deposition of calcium salts.
43
Histology of pancreatitis
``` Microvascular leak and oedema Fat necrosis Acute inflammation Destruction of parenchyma Destruction of blood vessels and interstitial haemorrhage. ```
44
Complications of acute pancreatitis
ARDS Renal failure Pseudocyst formation Sterile abscess.
45
Hereditary pancreatitis - what genes cause it?
Gain of function in trypsinogen gene (PRSS1) CFTR mutation Loss of function of SPINK1, a trypsin inhibitor
46
What are the complications of hereditary pancreatitis
Pancreatitic carcinoma - 40% lifetime risk.
47
Chronic pancreatitis - general
Prolonged inflammation with irreversible injury and fibrosis | Exocrine injury occurs first, endocrine later.
48
Causes of chronic pancreatitis
alcohol, long-standing obstruction, autoimmune pancreatitis, hereditary pancreatitis.
49
What is diverticular disease?
Multiple outpouchings through the muscularis mucosae at taeniae coli where the vasa recta penetrate.
50
What is the pathology of diverticular disease
Inflammation, perforation, abscess formation, fistula.
51
What are the risk factors for colorectal carcinoma?
Diet high in refined carbs NSAIDS are protective FAP or HNPCC
52
How does the position affect the shape of a colorectal carcinoma?
Exophytic in proximal, annular if distal
53
Colorectal carcinoma prognosis depends on...
Prognosis depends on depth of invasion (vascular?) lymph node mets, differentiation and whether or not it is mucinous.
54
Histology of colorectal carcinoma
Dysplastic glands | Stromal changes
55
Pathophysiology of ischaemic colitis.
Acute compromise vs chronic hypoperfusion Mucosal infarction may follow either Transmural infaction typically follows acute vascular obstruction.
56
Causes of acute obstructive ischaemic colitis.
``` Severe atherosclerosis at the origin of the mesenteric vessels Abdominal aortic aneurysm Oral contraceptive pill use Embolisation of cardiac vegetations. Hypercoagulable states ```
57
Causes of intestinal hypoperfusion.
Cardiac failure Shock Dehydration Vasocconstrictive drugs.
58
Macro appearance of ischaemic colitis
Congested and dusky Bloodstained contents Perforation Serositis with fibrin.
59
Histopathology of ischaemic colitis.
``` Mucosa haemorrhagic and ulcerated Atrophy and sloughing of surface epithelium Crypts regenerative Neutrophils after reperfusion Fibrosis if chronic. ```
60
Ectopic pregnancy general
2% of confirmed pregnancies | Risk factors: appendicitis, endometriosis, previous surgery, IUCD.
61
Likely causes of peritonism with epigastric pain with nausea.
Peptic ulceration Acute pancreatitis Acute cholecystitis (be aware appendicitis, lower lobe pneumonia, MI)
62
If someone has peritonism and pain, with cool peripheries, what does this mean?
He may have a degree of hypovolaemia - give him fluids.
63
Treatment for acute pancreatitis.
80%-90% resolve with conservative treatment - IV fluids, nil by mouth, possible Abx.
64
What is Wilson's disease?
Autosomal recessive condition characterized by toxic accumulation of copper in the liver and brain. Neurological problems may manifest as dementia, tremor or dyskinesias. Onset between 10-25 years
65
Features of Wilson's disease
liver: hepatitis, cirrhosis neurological: basal ganglia degeneration, speech and behavioural problems are often the first manifestations. Also: asterixis, chorea, dementia Kayser-Fleischer rings renal tubular acidosis (esp. Fanconi syndrome) haemolysis blue nails
66
Diagnosis of Wilson's disease
reduced serum caeruloplasmin | increased 24hr urinary copper excretion
67
Treatment of Wilson's disease
penicillamine (chelates copper) has been the traditional first-line treatment trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future tetrathiomolybdate is a newer agent that is currently under investigation Next question
68
Probable cause of painless enlarged gallbladder with mild jaundice on background of alcoholism
Pancreatic cancer
69
Likely cause of diarrhoea 1-6 hr after exposure
Staphylococcus aureus, Bacillus cereus
70
Likely cause of diarrhoea 12-48 h after exposure
Salmonella, Escherichia coli
71
Likely cause of diarrhoea 48-72 h after exposure
Shigella, Campylobacter
72
Likely cause of diarrhoea more than 7 days after exposure.
Giardiasis, Amoebiasis
73
What is Budd-Chiari syndrome?
Budd–Chiari syndrome is a condition caused by occlusion of the hepatic veins that drain the liver.
74
What is primary sclerosing cholangitis?
a biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra-hepatic bile ducts
75
What is primary sclerosing cholangitis associated with?
ulcerative colitis: 4% of patients with UC have PSC, 80% of patients with PSC have UC Crohn's (much less common association than UC) HIV
76
How to manage post-operative ileus
Nil by mouth and NG tube for stomach decompression
77
Charcot's triad for ascending cholangitis
Right upper quadrant pain, fever and jaundice
78
Medication for renal colic
Diclofenac for pain relief | Alpha-adrenergic blockers to help stone pass.
79
What medication can help prevent calcium renal stones?
Thiazide diuretics, which increase Ca++ reabsorption.
80
Common features of viral hepatitis
nausea and vomiting, anorexia myalgia lethargy right upper quadrant (RUQ) pain

► Med Misc 46 (31 decks)

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