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MD2 Core Conditions > Vascular > Flashcards

Vascular Flashcards

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1
Q

Aneurysm

A

Artery with dilatation >50% of original diameter

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2
Q

True vs false aneurysms

A

True: involve all layers of the arterial wall

False (pseudoaneurysms): collection of blood in adventitia which communicates with the lumen

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3
Q

Common aneurysm sites

A

Aorta (infrarenal most common)
Iliac
Femoral
Popliteal

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4
Q

Complications of aneurysm

A 
Rupture
Thrombosis
Embolism
Fistulae
Pressure on other structures
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5
Q

Symptoms and signs of ruptured AAA

A

Intermittent or continuous abdominal pain, radiating through to back, iliac fossae or groin
Syncope
Expansile abdominal mass
Haemodynamic instability and shock

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6
Q

Symptoms and signs of unruptured AAA

A

Often no symptoms but may cause abdominal/back pain

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7
Q

RFs for AAA rupture

A

HTN
Smoking
Female
Strong FHx

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8
Q

Mx of ruptured AAA

A

Contact vascular surgeon and experienced anaesthetist, advice theatre
IV access with 2 large-bore cannulae
ECG, bloods (lipase, Hb, crossmatch)
Keep SBP

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9
Q

Features of polymyalgia rheumatica (PMR)

A

Age >50 years
Subacute onset (less than 2 weeks) of bilateral aching, tenderness and morning stiffness in shoulders and proximal limb muscles +/- mild polyarthritis, tenosynovitis and CTS
May be associated with fatigue, fever, LOW, anorexia, depression
NOT associated with true weakness

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10
Q

Ix in PMR

A

CRP
ESR >40 but may be normal
CK normal (cf myositis, myopathy)

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11
Q

Mx of PMR

A

Prednisolone 15mg/day (wean over months, according to symptoms and ESR; most need steroids for >2 years so give gastric and bone protection)
Expect a dramatic response within 1 week

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12
Q

Steroid SEs

A

GIT: pancreatitis, candidiasis, ulceration
MSK: myopathy, OP, #, growth suppression
Endocrine: adrenal suppression, Cushing’s syndrome (HTN, hyperglycaemia)
CNS: aggravated epilepsy, depression, psychosis
Eye: cataracts, glaucoma, papilloedema
Immune: increased susceptibility to and severity of infections
Fever, increased WCC (rarely cause leucopenia)

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13
Q

DDx for PMR

A 
Recent onset RA
Polymyositis
Hypothyroidism
Primary muscle disease
Occult malignancy or infection
OA (esp cervical spondylosis, shoulder OA)
Neck lesions
Bilateral subacromial impingement
Spinal stenosis
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14
Q

What is vasculitis?

A

Inflammatory disorder of blood vessel walls resulting in destruction (aneurysm/rupture) or stenosis
May be primary or secondary
Classified according to main size of blood vessel affected

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15
Q

Causes of secondary vasculitis

A

SLE
RA
Hepatitis B and C
HIV

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16
Q

Large vessel vasculitis

A

GCA

Takayasu’s arteritis

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17
Q

Medium vessel vasculitis

A

Polyarteritis nodosa

Kawasaki disease

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18
Q

ANCA+ small vessel vasculitis

A

p-ANCA associated microscopic polyangiitis
Churg-Strauss syndrome
c-ANCA associated with Wegener’s granulomatosis

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19
Q

ANCA- small vessel vasculitis

A

Henoch-Schonlein purpura
Goodpasture’s syndrome
Cryoglobulinaemia

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20
Q

Other causes of vasculitis

A

Malignancy-associated vasculitis

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21
Q

Sx of vasculitis

A

Differs depending on affected organs; should be considered in any unidentified multisystem disorder
May presents just as overwhelming fatigue with increased ESR or CRP

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22
Q

Is a severe vasculitis flare a medical emergency? Why/why not?

A

Yes

Organ damage may occur rapidly (e.g. critical renal failure within 24 hrs)

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23
Q

Epidemiology of GCA

A

Elderly (if under 55 consider Takayasu’s)

Associated with PMR in 50%

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24
Q

Sx of GCA

A

Headache
Temporal artery and scalp tenderness (e.g. when combing hair)
Jaw claudication
Amaurosis fugax or sudden blindness (typically unilateral)
Extracranial Sx: dyspnoea, morning stiffness, unequal or weak pulses

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25
Mx of suspected GCA
Order ESR and commence prednisolone 60mg/day PO IMMEDIATELY Risk is irreversible bilateral vision loss which can occur suddenly (some advocate IV methylpred for 3 days if there are visual Sx)
26
Ix findings in GCA
Increased ESR and CRP Increased platelets, decreased Hb Increased ALP Definitive: temporal artery biopsy (within 7 days of starting steroids; skip lesions occur so don't be put off by negative biopsy)
27
Prognosis of GCA
Typically a 2 year course then complete remission Reduce prednisolone once Sx have resolved and ESR has decreased (increase if Sx recur) Main cause of death and morbidity is long-term steroid treatment so consider risks and benefits, provide gastric and bone protection (PPI and bisphosphonate)
28
What is polyarteritis nodosa (PAN)?
Necrotising vasculitis that causes aneurysms and thrombosis in medium-sized arteries, leading to infarction in affected organs and severe systemic symptoms
29
Epidemiology of PAN
More common in males | May be associated with hepatitis B
30
Sx of PAN
Typically systemic Predominantly skin: rash and "punched out" ulcers Renal, cardiac, GI and GU involvement
31
Kawasaki disease
Childhood PAN variant (may get coronary aneurysms)
32
Ix findings in PAN
Increased WCC, mild eosinophilia, anaemia Increased ESR/CRP ANCA -ive Renal or mesenteric angiography (showing multiple aneurysms) or renal biopsy can be diagnostic
33
Mx of PAN
Control BP meticulously Specialist r/v Most respond to corticosteroids and cyclophosphamide Any HBV should be managed with an antiviral after initial treatment with steroids
34
What is microscopic polyangiitis?
Necrotising vasculitis affecting small- and medium-sized vessels
35
Sx of microscopic polyangiitis
Rapidly progressive glomerulonephritis (RPGN) usually features Pulmonary haemorrhage in up to 30% Other features rare
36
Ix findings in microscopic polyangiitis
p-ANCA (MPO) positive
37
Mx of microscopic polyangiitis
As for PAN (specialist involvement; most respond to corticosteroids and cyclophosphamide)
38
Features of vasculitis by organ system
Systemic: fever, malaise, LOW, arthralgia, myalgia Skin: purpura, ulcers, livedo reticularis, nailbed infarcts, digital gangrene Eyes: episcleritis, scleritis, visual loss ENT: epistaxis, nasal crusting, stridor, deafness Pulmonary: haemoptysis and dyspnoea secondary to pulmonary haemorrhage Cardiac: angina or MI (due to coronary arteritis), HF, pericarditis GI: pain or perforation (infarcted viscus), malabsorption (chronic ischaemia) Renal: HTN, haematuria, proteinuria, casts, renal failure (renal cortical infarcts; glomerulonephritis in ANCA +ive vasculitis) Neurological: stroke, fits, chorea, psychosis, confusion, impaired cognition, altered mood, arteritis of vasa nervorum (arterial supply to peripheral nerves) may cause mononeuritis multiplex or sensorimotor polyneuropathy GU: orchitis (testicular pain or tenderness)
39
What is Takayasu's arteritis?
AKA aortic arch syndrome, pulseless disease Systemic vasculitis affecting the aorta and its major branches Granulomatous inflammation causes stenosis, thrombosis and aneurysms
40
Epidemiology of Takayasu's arteritis
Rare outside of Japan! | Often affects women aged 20-40 years
41
Sx of Takayasu's arteritis
Dependent on arteritis involved Aortic arch often involved, with cerebral, opthalmological and upper limb Sx (e.g. dizziness, visual changes, weak arm pulses) Systemic features common: fever, LOW, malaise HTN often a feature due to renal artery stenosis
42
Complications of Takayasu's arteritis
Aortic valve regurgitation Aortic aneurysm and dissection Ischaemic stroke (due to HTN or thrombus) IHD
43
Ix findings in Takayasu's arteritis
Increased ESR and CRP | MRI/PET allows earlier Dx than standard angiography
44
Mx of Takayasu's arteritis
Predinisolone (1mg/kg/day PO) Methotrexate or cyclophosphamide have been used in resistant cases Angioplasty +/- stenting or CABG is performed for critical stenosis
45
What is Henoch-Schonlein purpura (HSP)? Epidemiology, presentation, complications, Mx
Small vessel vasculitis, presenting with purpura often over buttocks and extensor surfaces, typically affecting young males Complications: glomerulonephritis, arthritis, abdominal pain +/- intussusception (which may mimic "acute abdomen") Mx: mostly supportive
46
What are purpura?
Non-blanching purple papules due to intradermal bleeding
47
What is Churg-Strauss syndrome?
Triad of adult-onset asthma, eosinophilia and vasculitis (+/- vasospasm +/- MI +/- DVT) affecting lungs, nerves, heart and skin
48
Complications of Churg-Strauss syndrome
Can get septic-shock picture (systemic inflammatory response syndrome, SIRS), may be accompanied by glomerulonephritis/renal failure (esp ANCA +ive)
49
Mx of Churg-Strauss syndrome
Steroids | Biological agents if refractory disease (e.g. rituximab)
50
What is Wegener's granulomatosis?
Granulomatosis with polyangiitis (GPA) Multisystem disorder of unknown cause characterised by necrotising granulomatous inflammation and vasculitis of small and medium vessels Has a predilection for the upper respiratory tract, lungs and kidneys
51
Sx of Wegener's granulomatosis
Upper airways disease: nasal obstruction, ulcers, epistaxis, destruction of the nasal septum causing characteristic "saddle-nose" deformity, sinusitis Renal disease: RPGN with crescent formation, haematuria and proteinuria Pulmonary involvement: cough, haemoptysis, pleuritis Others: skin purpura or nodules, peripheral neuropathy, mononeuritis multiplex, arthritis/arthralgia, ocular involvement
52
Ix for Wegener's granulomatosis
c-ANCA directed against PR3 is most specific Increased ESR/CRP Urinalysis: proteinuria, haematuria CXR: nodules +/- fluffy infiltrate of pulmonary haemorrhage
53
Mx for Wegener's granulomatosis
Severe: corticosteroids and cyclophosphamide (or rituximab) to induce remission Maintenance: azothioprine, methotrexate Co-trimoxazole for prophylaxis against PJP and staphylococcal colonisation
54
General principles of vasculitis Mx
Large vessels: steroids in most cases Medium/small: steroids and IV cyclophosphamide (15mg/kg) Azathioprine may be useful as steroid-sparing maintenance treatment
55
Goodpasture's syndrome
Pulmonary-renal syndrome Characterised by acute glomerulonephritis + lung symptoms (haemoptysis/diffuse pulmonary haemorrhage) caused by anti-GBM Abs binding the kidney's BM and alveolar membrane
56
Ix findings in Goodpasture's syndrome
CXR: infiltrates due to pulmonary haemorrhage, often in lower zones Renal biopsy: crescenteric GN
57
Mx of Goodpasture's syndrome
Treat shock | Vigorous immunosuppressive treatment and plasmapheresis
58
Raynaud's syndrome
Peripheral digital ischaemia due to paroxysmal vasospasm, precipitated by cold or emotion Fingers or toes ache and change colour: pale (ischaemia) to blue (deoxygenation) to red (reactive hyperaemia)
59
Raynaud's disease vs Raynaud's phenomenon
Raynaud's disease: idiopathic | Raynaud's phenomenon: underlying cause
60
Mx of Raynaud's syndrome
Keep warm (gloves) Stop smoking Nifedipine Evening primrose oil Sildenafil Prostacyclin for severe attacks/digital gangrene In severe disease, consider chemical or surgical (lumbar or digital) sympathectomy
61
Conditions in which Raynaud's phenomenon may be exhibited
CTDs: systemic sclerosis, SLE, RA, dermatomyositis/polymyositis Occupational: using vibrating tools Obstructive: thoracic outlet obstruction, Buerger's disease, atheroma Blood: thrombocytosis, cold agglutinin disease, polycythaemia rubra vera, monoclonal gammopathies Drugs: B-blockers Endocrine: hypothyroidism
62
Behcet's disease
Systemic inflammatory disorder of unknown aetiology, common in Mediterranean and Chinese
63
Sx of Behcet's disease
``` Recurrent oral and genital ulceration Uveitis Skin lesions (e.g. erythema nodosum) Arthritis (non-erosive large joint oligoarthropathy) Thrombophlebitis Vasculitis Myo/pericarditis CNS involvement (pyramidal signs) Colitis ```
64
Mx of Behcet's disease
Colchicine for orogenital ulceration | Azathioprine or cyclophosphamide

MD2 Core Conditions (12 decks)

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