Abdo Flashcards
What signs of chronic liver disease may be visible on the hands?
Palmar erythema
Dupuytren’s contracture
Leuconychia
Clubbing
What disease may be indicated by a greyish skin colour?
Haemochromatosis
What signs must you look for to check for decompensation of chronic liver disease?
Ascites
Asterixis with ‘liver flap’
Encephalopathy
What are some causes of hepatomegaly?
Cirrhosis (alcoholic)
Carcinoma
Congestive cardiac failure
Infection eg Hep B or C
Immune eg PBC, PSC, AIH
Infiltrative eg amyloid or myeloproliferative disorders
What blood tests constitute a ‘liver screen?
Autoantibodies and immunoglobulins for PBC/PSC/AIH - ANA, anti smooth muscle, anti-mitochondrial
Hep B and Hep C serology
EBV and CMV serology
Ferritin
Caeruloplasmin
Alpha 1 antitrypsin
AFP for HCC
INR
Albumin
FBC, U&Es, LFTs, glucose
Aside from blood tests, what other investigations should be done in a liver screen?
Ulstrasound scan of abdomen
Tap of ascites if present
+/- ERCP/Biopsy
What are some complications of cirrhosis?
Variceal haemorrhage
Hepatic encephalopathy
Spontaneous bacterial peritonitis
Hepatorenal syndrome
Hepatocellular carcinoma
What is the Child-Pugh classification and what does it predict?
Prognosis of classification in liver cirrhosis, based on bilirubin, INR, albumin, ascites and encephalopathy. Higher score relates to lower chance of survival at 1 year
What are the most common causes of chronic liver disease?
Alcoholic cirrhosis
Viral hepatitis
Non-alcoholic fatty liver disease
How is chronic liver disease managed?
MDT approach
Abstain from alcohol
Vitamin and thiamine replacement
Optimise nutrition
Salt restriction
Diuretics if ascites
Propanolol if varices
Laxatives for encephalopathy prevention
+/- TIPS/transplantation
What is a TIPS procedure?
Transjugular intrahepatic portal shunt. Diverts blood from portal vein to hepatic vein to reduce portal hypertension
What are some common precipitants for decompensation of chronic liver disease?
Infection
GI bleed
Increased alcohol intake
Malignancy
Constipation
Dehydration
Hepatotoxic drugs
What are some abdominal causes for finger clubbing?
Hepatocellular carcinoma
IBD
Cirrhosis
Coeliac disease
What are some complications of haemochromatosis?
Diabetes
Hypogonadism
Congestive cardiac failure
Arthopathy secondary to pseudogout
What is the genetic basis of haemochromatosis?
Autosomal recessive with high incidence of heterozygous carriers
How is haemochromatosis diagnosed?
Blood tests - raised ferritin with high transferrin saturation
Liver biopsy
What is the definition of massive splenomegaly?
Spleen that crosses the midline and the umbilicus
What are some causes of massive splenomegaly?
HIV
Myeloproliferative disorders eg AML CML and myelofibrosis
Infections eg malaria and visceral leishmaniasis
What are some causes of moderate splenomegaly?
Myeloproliferative disorders
Lymphoproliferative disorders eg lymphoma and CLL
Infiltrative disorders eg amyloidosis and gaucher’s
What are some causes of mild splenomegaly?
Myeloproliferative disorders
Lymphoproliferative disorders
Infections eg epstein barr and viral hepatitis
Infective endocarditis
Portal hypertension
Haemolytic anaemia
Autoimmune conditions eg SLE
What are indications for splenectomy?
Rupture due to trauma
ITP
Hereditary spherocytosis
What long term management is required following splenectomy?
Vaccination (ideally 2 weeks prior if elective) against encapsulated bacteria, ie pneumococcus
Meningococcus
Haemophilus influenza
Lifelong prophylactic penicillin
Medialert bracelet
What is the inheritance pattern of polycystic kidney disease?
Autosomal dominant defect of ADPKD1/2 gene
What are some causes of bilateral kidney enlargement?
Polycystic kidney disease
Amyloidosis
Bilateral renal cell carcinoma
Bilateral hydronephrosis
Tuberous sclerosis
What are some causes of unilateral kidney enlargement?
Polycystic kidney disease with other kidney either not palpable or resected (look for flank scar)
Renal cell carcinoma
Simple cysts
Hydronephrosis due to ureteric obstruction
What are some extra-renal manifestations of polycystic kidney disease?
Polycystic liver disease. Usually asymptomatic but may cause mass effect or haemorrhage/infection
Seminal vesicle cysts leading to male infertility
Subdural haematoma due to arachnoid membrane cysts
Recurrent pancreatitis due to pancreatic cysts
Intracranial berry aneurysms
Aneurysms elsewhere in vasculature
Mitral valve prolapse
Aortic root dilataion and valve insufficiency
How does polycystic kidney disease present?
Hypertension
Haematuria, often after trauma
Recurrent UTIs
abdominal pain
What is the prognosis of adult polycystic kidney disease?
50% end stage renal disease/transplantation by age 60
Increased risk of progression if:
afro-carribbean
Male
Multiple pregnancies
Hypertension
Large kidneys
Younger age of onset
How is polycystic kidney disease managed?
Tolvaptan (vasopressin receptor antagonist) approved by NICE for rapidly progressing deterioration of renal dunction starting from CKD 2/3
MDT approach
Consider family planning/genetic counselling
Modify cardiovascular risk factors
Hypertension management
Monitor for progression
manage symptoms/complications
MRA for aneurysms if symptoms/family history of aneurysms/stroke or high risk occupation
dialysis/transplant/nephrectomy if anecessary
When is nephrectomy indicated in polycystic kidney disease?
Recurrent bleeds or infections or very large size
What are some extra-intestinal manifestations of inflammatory bowel disease
Skin - erythema nodosum, pyoderma gangrenosum, apthous ulcers
Joints - seronegative arthritis
Eyes - uveitis episcleritis, scleritis, conjunctivitis
HPB - primary sclerosing cholangitis (esp in UC), cholangiocarcinoma
Renal - oxalate stones
How should inflammatory bowel disease be investigated?
Stool MC+S and CDiff toxin
Faecal calprotectin
Bloods, including FBC, CRP, LFTS (inc albumin as marker of severity and lfts for associated liver disease)
Flexi sig/colonoscopy and biopsy for diagnosis
AXR in acute presentations for ?toxic megacolon
How is Crohn’s disease managed?
MDT approach including specialist IBD nurses.
Induce remission with steroids +/- methotrexate, azathioprine
Maintain remission with azathioprine/methotrexate/mercaptopurine
Can consider biologic therapy if ongoing active disease eg infliximab
Surgery if limited disease/severe flare/refractory disease
Nutritional support
How is ulcerative colitis managed?
MDT approach including specialist IBD nurses
Mesalazine is mainstay, including mesalazine enemas as often purely rectal disease
Can add in steroids to induce/maintain remission if needed
Surgery potentially curative so consider for severe refractory disease, lifethreatening flares or colorectal cancer
What is the genetic basis for tuberous sclerosis?
Mutations of TSC1 (chromosome 9) or TSC 2 (chromosome 16) leading to growth dysregulation via mTORC1
TSC2 mutations are more common and associated with more severe disease.
What is the presentation of tuberous sclerosis?
Neurological - seizures - due to cortical tubers, subependymal giant cell astrocytoma-caues mass effect, retinal hamartoma
Cutaneous - ash leaf macules, facial angiofibromas, shagreen patches, ungual fibromas
Renal -Angiomyolipoma, PKD
Pulmonary - lymphangioleiomyomatosis
Cardiac - rhabdomyoma
May have learning difficulties, autistic spectrum disorder and mood disorders
How is renal tuberous sclerosis managed?
Bleeding angiomyolipomas require embolisation
Can have everolimus (mTOR inhibitor) to reduce growth of angiomyolipomas and reduce risk of bleed and subsequent loss of kidney function.
Monitor and treat risk factors such as BP
What are the side effects of tolvaptan?
Polyuria, nocturia, polydipsia, dehydration, liver injury
