Medical Abdomen

Question 1

Causes of splenomegaly

Answer 1

Infections 
Haemolysis 
Portal hypertension
Malignancy
Felty's syndrome
Infective endocarditis

Question 2

Signs of decompensated liver disease

Answer 2

 Jaundice
 Encephalopathy: asterixis, confusion
 Foetor hepaticus: ammonia and ketones 
 Hypoalbuminaemia: oedema and ascites 
 Coagulopathy: bruising

Question 3

Causes of CLD

Answer 3

Common
 EtOH
 Viral
 NASH

Rare
 Genetic: HH
 AI: AH
 Drugs: methotrexate

Question 4

Drug for pruritus

Answer 4

Cholestyramine

Question 5

Mx of Hepatitis C

Answer 5

interferon-α + ribavarin

Question 6

Mx of encephalopathy

Answer 6

Nurse in well lit, calm environment
Correct any precipitants
Avoid sedatives
Give Lactulose + rifaximin

Question 7

How to treat hepatorenal syndrome?

Answer 7

IV albumin + terlipressin

Question 8

Mx ascites?

Answer 8

Conservative: fluid and salt restrict, daily weight
Medical: Spironolactone/ Furosemide
Surgical: Ascitic Tap, TIPS

Question 9

Complications of chronic liver disease

Answer 9

1. Liver failure/decompensation
2. SBP
3. Portal HTN: SAVE
4. HCC

Question 10

How is Cirrhosis graded?

Answer 10

Child Pugh Score

Graded A-C using severity of 5 factors (ABCDE)

 Albumin
 Bilirubin
 Clotting
 Distension: ascites 
 Encephalopathy

Question 11

Precipitants of Encephalopathy

Answer 11

DIGS

Diuretics
Infection
GI bleed
Sepsis/ stroke

Question 12

How would you manage decompensated liver disease?

Answer 12

General Mx
 HDU or ITU
 Rx any precipitant
 Good nutrition: e.g. via NGT with high carbs
 Thiamine supplements
 Prophylactic PPIs vs. stress ulcers

Monitoring
 Fluids: urinary and central venous catheters
 Bloods: daily FBC, U+E, LFT, INR
 Glucose: 1-4hrly + 10% dextrose IV 1L/12h

Mx Complications
 Ascites: daily wt, fluid and Na restrict, diuretics, tap
 Coagulopathy: Vit K, FFP, platelets
 Encephalopathy: avoid sedatives, lactulose, rifaximin
 Sepsis / SBP: tazocin or cefotaxime
 Hypoglycaemia: dextrose
 Hepatorenal syndrome: IV albumin + terlipressin

Question 13

Pathophysiology of encephalopathy

Answer 13

 ↓ hepatic metabolic function
 Diversion of toxins from liver directly into systemic
system.
 Ammonia accumulates and passes to brain where
astrocytes clear it causing glutamate → glutamine
 ↑ glutamine → osmotic imbalance → cerebral oedema.

Question 14

Presentation of encephalopathy

Answer 14

 Asterixis, Ataxia
 Confusion
 Constructional apraxia 
 Dysarthria
 Seizures

Question 15

What is Hepatorenal syndrome?

Answer 15

Cirrhosis → splanchnic arterial vasodilatation → effective circulatory volume → RAS activation → renal arterial vasoconstriction.

Persistent underfilling of renal circulation → failure

Question 16

What makes up the portal triad?

Answer 16

Hepatic artery
Portal vein
Bile duct

Question 17

Mx of SBP

Answer 17

Tazocin or cefotaxime until sensitivities known

Question 18

Causes of ascites

Answer 18

 Cirrhosis
 CCF
 Carcinomatosis
 Budd Chiari
 TB
 Pancreatitis

Question 19

SAAG interpretation

Answer 19

Serum Ascites Albumin Gradient
SAAG = Se albumin – Ascites Albumin

SAAG ≥1.1g/dL = Portal HTN (97% accuracy)
 Cirrhosis in 80%

SAAG <1.1g/dL
 Neoplasia: e.g. peritoneal mets or ovarian Ca
 Inflammation: pancreatitis
 Nephrotic syndrome
 Infection: TB peritonitis

Question 20

Causes of portal HT

Answer 20

Pre-hepatic:
 Portal vein thrombosis 
 PV, ET
 PNH
 Nephrotic syndrome

Hepatic:
 Cirrhosis

Post-hepatic
 Cardiac: RHF, TR, constrictive pericarditis
 Budd-Chiari (hepatic vein thrombosis)

Question 21

Symptoms of SBP

Answer 21

Fever, abdo pain and ascites

Question 22

Management of refractory ascites

Answer 22

TIPSS

Transplant

Question 23

Causes of Jaundice

Answer 23

Pre-hepatic (haemolysis - unconjugated)

• AIHA
• HS
• SCD

Hepatic (conjugated/ unconjugated)

• CLD
• Hepatitis
• Drugs

Post Hepatic (conjugated)

• Gallstones
• Ca Head Panc
• LN enlargement

Question 24

Mercedes Benz scar ddx

Answer 24

 Liver transplant
 Segmental resection
 Whipples’: pancreaticoduodenectomy

Question 25

Causes of Hepatomegaly

Answer 25

``` Malignancy Cirrhosis (ALD, NASH, PBC) Congestion Infections (Viral, Toxo, Abscess) Infiltration (amyloid, sarcoid) Vasc (Budd-chiari, Sickle Cell) ```

Question 26

Imaging you would consider for hepatomegaly

Answer 26

Abdo US PV + Hepatic duplex CT MRI (enhanced with gadolinium)

Question 27

How do you treat HH?

Answer 27

Venesection + desferrioxamine

Question 28

How do you treat Wilson's?

Answer 28

Penicillamine

Question 29

How can you tell you are palpating the spleen?

Answer 29

```  Can’t get above it  Moves inferiorly toward RIF on respiration  Notch  Dull PN  Not ballotable ```

Question 30

Function of the spleen

Answer 30

```  Phagocytosis of old RBCs, WBCs  Phagocytosis of opsonised bugs: esp. encapsulates  Antibody production  Sequestration of formed blood elements  Platelets, lymphocytes and monocytes  Haematopoiesis ```

Question 31

Causes of hyposplenism

Answer 31

 Splenectomy  Coeliac disease  IBD  SCD

Question 32

Indications of a splenectomy

Answer 32

```  Trauma - uncontrollable splenic bleeding, hilar vascular injuries, devascularised spleen  Rupture: e.g. secondary to EBV  AIHA  ITP  HS  Hypersplenism ```

Question 33

Complications of splenectomy

Answer 33

 Redistributive thrombocytosis → early VTE  Temporary post-op aspirin prophylaxis  Gastric dilatation: transient ileus  May disturb gastro-omental vessel ligatures  Prophylactic NGT post-op  Left lower lobe atelectasis  Pancreatitis: tail shares blood supply ̄c spleen  ↑ susceptibility to infections  Encapsulates: haemophilus, pneumo, meningo

Question 34

Causes of enlarged kidneys

Answer 34

``` Bilateral  ADPKD  Diabetes  HIV  Bilateral RCC (5%)  Bilateral cysts: e.g. in VHL  Amyloidosis ``` ``` Unilateral  Simple renal cyst  RCC  Compensatory hypertrophy  + contralateral nephrectomy: ADPKD ```

Question 35

Mx of ADPKD

Answer 35

General  ↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation) Monitor U+E and BP Genetic counselling  50% chance of transmission  10% are de novo mutations  MRA screen for berry aneurysms Medical  Rx HTN aggressively: <130/80 (ACEi best)  Rx infections Surgical: Nephrectomy  Recurrent bleeds or infections  Abdominal discomfort

Question 36

Risk factors for RCC

Answer 36

```  Smoking  Obesity  HTN  Dialysis: 15% of pts. develop RCC  4% heritable: e.g. VHL syndrome ```

Question 37

Presentation of RCC

Answer 37

Haematuria Loin pain Loin mass Invasion of L renal vein → varicocele

Question 38

Mx of RCC

Answer 38

Medical  Reserved for pts. ̄c poor prognosis  Temsirolimus (mTOR inhibitor) Surgical  Radical nephrectomy  Consider partial if small tumour or 1 kidney  Prognosis: 45% 5ys

Question 39

Differentials for gum hypertrophy

Answer 39

```  Drugs: ciclosporin, phenytoin, nifedipine  Familial  AML  Scurvy  Pregnancy ```

Question 40

Commonest indications for a renal transplant

Answer 40

 Diabetic nephropathy  GN  Polycystic Kidney Disease  Hypertensive nephropathy

Question 41

Contraindications for a renal transplant

Answer 41

 Active infection  Cancer  Severe co-morbidity  Failed pre-implantation x-match

Question 42

Symptoms of renal transplant rejection

Answer 42

Hyperacute rejection: minutes  Path: ABO incompatibility  Presentation: thrombosis and SIRS ``` Acute Rejection: <6mo  Path: Cell-mediated response  Presentation  Fever and graft pain  ↓ urine output  ↑ Cr  Rx: Responsive to immunosuppression ``` Chronic Rejection: >6mo  Presentation: Gradual ↑ in Cr and proteinuria  Path: Interstitial fibrosis + tubular atrophy  Rx: supportive, not responsive to immunosuppression

Question 43

Complications of dialysis

Answer 43

```  Cardiovascular disease  Malnutrition  Infection  Amyloidosis  β2-microglobulin accumulation  Renal cysts → RCC ```

Question 44

Complications of AV access

Answer 44

```  Bleeding  Aneurysm  Thrombosis and stenosis  Infection  Steal syndrome ```

Question 45

General complications of dialysis

Answer 45

```  Malnutrition  Infection  Cardiovascular disease  Amyloidosis  Renal cysts → RCC ```

Question 46

Complications of haemodialysis

Answer 46

Disequilibration syndrome (leads to cerebral oedema) Fluid balance: BP↓, pulmonary oedema Electrolyte imbalance Aluminium toxicity (in dialysate) → dementia Psychological factors

Question 47

Methods of renal replacement therapy

Answer 47

Haemodialysis Peritoneal dialysis Renal transplant Haemofiltration

Question 48

Catheter used with peritoneal dialysis

Answer 48

Tenchkhoff catheter

Question 49

Types of AV fistula

Answer 49

 Radio-cephalic @ wrist = Cimino-Brescia |  Brachio-cephalic @ the elbow

Question 50

Complications of a tunnelled cuffed catheter

Answer 50

Adverse events @ insertion: e.g. pneumothorax Line or tunnel infection Blockage Retraction

Question 51

The commonest cause of CKD

Answer 51

HT DM RAS GN

Question 52

Complications of CKD

Answer 52

CRF HEALS  Cardiovascular disease  Renal osteodystrophy  Fluid (oedema) ```  HTN  Electrolyte disturbances: K, H  Anaemia  Leg restlessness  Sensory neuropathy ```

Question 53

Signs of IBD

Answer 53

``` General  Often young female pt.  Laparotomy scars  Malnutrition or wt. loss  Cushingoid  Pallor ``` Hands  Clubbing  Leukonychia  Beau’s lines Eyes  Pale conjunctivae  Iritis, episcleritis Mouth  Aphthous ulcers  Gingival hypertrophy (cyclosporin) Legs  Erythema nodosum  Pyoderma gangrenosum

Question 54

Acute Severe Exacerbation or IBD Criteria

Answer 54

True-Love and Witts Criteria Symptoms  BMs>6x/d  Large PR bleed Systemic Signs  ↑HR>90  Pyrexia >37.8 Laboratory Values  ↓ Hb <10.5g/dL  ESR >30mm/Hr

Question 55

Drugs for UC induction

Answer 55

Oral 1: 5-ASAs 2: prednisolone 3: ciclosporin / infliximab Topical: Enemas / foams - 5-ASA - Pred

Question 56

Drugs for CD induction

Answer 56

Oral 1: Ileocaecal: budesonide 1: Colitis: sulfasalazine 2: prednisolone (tapering) 3: methotrexate 4: infliximab / adalimumab

Question 57

Drugs for UC maintenance

Answer 57

1: 5-ASA 2: azathioprine 3: infliximab / adalimumab

Question 58

Drugs for Crohn's maintenance

Answer 58

1: azathioprine/mercaptopurine 2: methotrexate 3: infliximab / adalimumab