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PACES PACES PACES VIVA > Abdo > Flashcards

Abdo Flashcards

1
Q

Which immunosuppressant causes gingival hyperplasia and which causes a tremor?

A

Tremor = tacrolimus
Gingival hyperplasia = Ciclosporin

If these are present - say in ix you want to check serum levels of these agents to check for toxicity

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2
Q

What are all the different types of surgical abdo scars and what do they mean?

A
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3
Q

What ix should you do in a liver transplant pt?

A
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4
Q

What are the possible complications of organ transplants?

A
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5
Q

Differentials for CLD?

A

3 most common causes of CLD
1. Alcohol-induced liver disease
2. Non-alcoholic fatty liver disease
3. Viral Hepatitis (Hep B and C)
Rarer causes include
4. Genetic: HH
5. AI: Autoimmune hepatitis
6. Drug induced: methotrexate

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6
Q

Causes of Jaundice?

A
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7
Q

Ix for Chronic liver disease?

A

Beside:
1. Basic Obs - looking for tachycardia, hypotension

Bloods:
1. FBC & inflammatory markers - Spontaneous bacterial peritonitis
2. LFTs - Bilirubin, liver enzymes, albumin
3. INR - As a measure of LIVER SYNTHETIC FUNCTION
4. Hepatitis screen - Looking for viral and autoimmune hepatitis
5. U&E - Hepatorenal syndrome

Imaging
US of abdomen to check for
- Ascites
- Portal vein/hepatic vein thrombosis
- Any focal lesions in liver

Special Tests:
1. Liver biopsy
2. OGD
a. Look for varices

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8
Q

Signs of CLD decompensation?

A

● Jaundice
● Ascites 🡪 SBP
● Encephalopathy
● Upper GI bleed (varices)

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9
Q
A

Alcohol

(Bacterial) infection e.g. hepatitis, pneumonia

Constipation = most common cause

Drug-induced e.g.
a. Statins
b. Nicotinic acid
c. Amiodarone
d. Methotrexate

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10
Q

Complications of CLD?

A

● Portal hypertension
o Ascites
o Hypersplenism
o Oesophageal and rectal varices

● Synthetic dysfunction
o Hypoalbuminaemia
o Coagulopathy

● Hepatopulmonary syndrome
● Hepatorenal syndrome
● Encephalopathy
● HCC

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11
Q

Mx of CLD?

A

Conservative Mx to slow down progression
● MDT: GP, hepatologist, dietician
● Alcohol abstinence = most important
● Good nutrition
● Cholestyramine for pruritis
● Screening:
o HCC: US & AFP
o Varices: OGD

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12
Q

Diagnostic criteria for hepatorenal syndrome + tx?

A

Diagnostic criteria
▪ Creatine > 133
▪ Cirrhosis with ascites
▪ No evidence of intrinsic renal disease

Tx with IV albumin + terlipressin

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13
Q

What are some causes of smooth hepatomegaly?

A

o Hepatitis
▪ Alcohol
▪ Viral
▪ NAFLD

o CLD

o Cardiac disease e.g. CCF, cor pulmonale, TR

o Budd-Chiari syndrome
▪ Also see ascites & jaundice
▪ US with Doppler flow of hepatic vein shows thrombus (gold
standard diagnostic Ix)

o Sarcoidosis
▪ Liver granulomas

o Amyloidosis
▪ Due to excessive serum amyloid A secretion in chronic
conditions
▪ Secondary amyloidosis (AA) + renal failure
▪ AL amyloid + Macroglossia, CCF, peripheral neuropathy, carpal
tunnel

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14
Q

What are some causes of irregular hepatomegaly?

A

Malignancy (1 or 2O)
o Benign lesions e.g. haemangioma, hepatic adenoma

o Normal anatomical variant

o Carcinoid syndrome

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15
Q

Hepatomegaly + lots of strokes = suggestive of what disease?

A

Amyloidosis - would also get nephrotic syndrome

Budd Chiari syndrome - Occulision of hepatic vein - primary due to thrombosis or secondary due to compression eg due to tumour

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16
Q

Causes of Ascites?

A

Portal hypertension (portal pressure > 10mmHg)
Pre-hepatic
● Nephrotic syndrome
● PV, ET
Hepatic = most common
● Cirrhosis (alcohol, viral, NAFLD)
Post-hepatic
● Cardiac
RHF
TR
● Budd-Chiari

Non-portal hypertension causes
▪ Intra-abdominal malignancy e.g. ovarian, gastric cancer
▪ Infection e.g. TB peritonitis

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17
Q

Mx of Ascites?

A

Conservative: Fluid and salt restrict

Medical: Spironolactone

Surgical: For drug-resistant ascites:
▪ Serial paracentesis
▪ TIPSS (Transjugular intrahepatic portosystemic shunt)

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18
Q

Ix of ascites?

A

Diagnostic tap = KEY INVESTIGATION

Ask for:
Serum-ascites albumin gradient (SAAG) = serum albumin –
ascites albumin
● SAAG >1.1g/dL = portal HTN
● SAAG < 1.1g/dL = non-portal HTN

Cell count
▪ Neutrophils = bacterial peritonitis - > 250 = SBP

Cytology
▪ For malignant cells

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19
Q

Mx of PBC?

A

● Cholestasis: URSO (delays progression to cirrhosis)
● Pruritis: Cholestyramine - severe pruritis is indication for liver transplantation
● Hypercholesterolaemia: statin
● Osteoporosis: Calcium supplements & bisphosphonates
● Fat-soluble vitamin deficiency: Vit supplements

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20
Q

Poor prognostic features in PBC?

A

● High bilirubin level
● Female
● High anti-M2 and anti-M4 subtypes

21
Q

Ix for HH?

A

Markers of iron stores
● Serum iron ↑
● Ferritin ↑
● TIBC ↓

HFE gene testing
● C282Y = most common mutation
● H63D

22
Q

Mx of HH?

A

Regular phlebotomy (2x a week)
- Remove 1 unit of blood each time (
- Target ferritin level of 50ng/ml
- Then monthly phlebotomy

23
Q

Common causes of renal failure?

A

Common
1. Diabetes mellitus
2. Hypertension

Rarer
3. Polycystic kidney disease
4. Pyelonephritis (usually 2o to VUR)
5. Drug-induced e.g. analgesic nephropathy
6. Glomerulonephritis e.g. SLE, RA,

24
Q

Complications of CKD?

A

CRF HEALS

  1. Cardiovascular disease
    a. Anaemia (↓ EPO)
    b. Hypertension 🡪 MI, stroke
  2. Renal osteodystrophy
    a. May see parathyroidectomy scar!
  3. Fluid = ascites
  4. HTN
  5. Electrolyte disturbances (↑K)
  6. Anaemia
  7. Leg restlessness
  8. Sensory neuropathy
25
Q

What type of Ix are needed for renal failure

A

Check for severity of ESRF:
Bedside
- Basic obs
- Urinanalysis

Bloods:
- FBC - anaemia
- CRP, ESR - check for inflammatory markers
- U+Es - Urea, Creatinine, Creatinine clearance, eGFR

Bone:
- low ca, raised phosphate, raised PTH, raised ALP

Check for cause?
- DM
- Immune
- Renal US
- CT KUB - scarring from pyelonephritis
- Renal biopsy

26
Q

Mx of renal failure?

A
  1. Renal replacement therapy – see later
  2. Tx complications
    a. Hypertension: target <140/90 (<130/8p if DM)
    b. Oedema: furosemide
    c. Bone disease
    i. Phosphate binders e.g. calcichew
    ii. Vit D analogues: alfacalcidiol (1 OH-Vit D)
    iii. Ca supplements
    d. Anaemia: EPO to raise Hb to 11g/dL
    e. Restless legs: clonazepam
27
Q

What is an AV fistula used for?

A

Permanent haemodialysis

28
Q

What is a AV fistula?

A

Surgically created connection between artery and vein
- Radio-cephalic @ wrist = Cimino-Brescia
- Brachio-cephalic @ elbow

29
Q

What causes the thrill in a AV fistula

A

Arterial blood from the radial artery in the superficial vein

30
Q

Advantages v disadvantages of fistula?

A
31
Q

Complications of AV fistula?

A

● Thrombosis & stenosis

● Infection

● Bleeding

● Steal syndrome
o Distal tissue ischaemia
o Sx: pallor, pain, ↓ pulses
o May 🡪 necrosis
o Rx: banding the fistula

32
Q

What are the indications for dialysis

A

When eGFR <15ml/min = Stage 5 ESRF

Symptomatic uraemia despite conservative tx

Volume overload despite fluid restriction & diuretics

33
Q

What are the complications of dialysis?

A

General:
- Infection
- Renal cysts -> RCC
- Dialysis related amyloidosis

Haemodialysis:
- Infection, stenosis and thrombosis
- Disequilibriation syndrome - rapid change in plasma osmolality -> cerebral oedema
- Fluids balance - either low BP or pulmonary oedema

Peritoneal dialysis:
- Peritonitis
- Exit site infection
- Obesity

34
Q

Present a CKD w/ renal transplant?

A

Performed abdo exam, seems to have end-stage renal failure with a functioning renal transplant with no signs of immunosuppression or incisional hernias.

Main positive findings to support this are:
- An oblique (likely Rutherford-Morrison scar) in the R iliac fossa with a palpable mass in the same region that was dull to percussion indicating a renal allograft.

Negatives = standard

These signs are consistent with a functioning renal transplant.

The cause of the renal transplant is unclear.
Absence of …

There are no signs of post-op complications such as incisional hernias.

There are no signs of immunosuppressant use
o Classic Cushingoid features (corticosteroids)
o Gingival hyperplasia, tremor (cyclosporin)
o Skin lesions e.g. SCC (immunosuppression)

35
Q

Indications for renal transplant?

A

End stage renal failure (eGFR <10ml/min) usually due to
o DM
o PKD
o Hypertension
o Glomerulonephritis

36
Q

CI of renal transplant?

A

Cardiac/respiratory insufficiency
Liver disease
RCC
Active infection

37
Q

CI for liver transplant?

A
  1. Cardiac/respiratory insufficiency
  2. Active alcohol use
  3. HIV
  4. Life-limiting co-morbidities
38
Q

Indications for liver transplant?

A
  1. Alcoholic cirrhosis (dependent on criteria):
    a. Abstinence of alcohol for 6 months
    b. Ongoing participation in formal alcohol treatment programmes
    c. Adequate psychosocial support
  2. Autoimmune diseases:
    a. PBC, PSC
    b. Autoimmune hepatitis
  3. Viral hepatitis:
    a. Hep B, C, D
  4. Metabolic diseases:
    a. Haemochromatosis
    b. Wilson’s disease
    c. Alpha-1-antitrypsin deficiency
  5. Primary hepatic tumours
    a. Select patients with hepatocellular carcinoma
39
Q

Differentials for Mercedes Benz Scar?

A

● Liver transplant
● Segmental resection
● Whipples = pancreaticoduodenectomy

40
Q

Present ADPKD pt

A

● I performed an abdominal examination, seems to have PKD

● My main positive findings were:
o 2 well-defined palpable masses in both the lumbar regions indicating
enlarged kidneys
▪ Ballotable
▪ Not notched
▪ Irregular surface
▪ Move minimally with inspiration
▪ Resonant to percussion due to overlying bowel

● My relevant negative findings were:

This all points towards a diagnosis of CKD secondary to PKD.

I would also like to look for signs of associated diseases:
● Liver cysts
● Intracerebal aneurysms
● Mitral valve prolapse
I would also like to US to screen family members.

41
Q

Classification of PKD?

A
  1. Autosomal dominant PKD (most common)
  2. Autosomal recessive PKD
  3. Non-hereditary PKD
42
Q

Causes of enlarged kidneys?

A

Bilateral
● ADPKD
● Bilateral cysts
- VHL disease (cysts in pancreas, liver, epididymis)
- Tuberous sclerosis

Unilateral
● Simple renal cyst
● RCC
● Compensatory hypertrophy following contralateral nephrectomy

43
Q

Complications of PKD?

A

Early:
● Hypertension

Late:
● CKD
● Cysts in other parts of the body (commonly in liver) 🡪 therefore maybe some hepatomegaly
● Aneurysm in brain
● Mitral valve prolapse
● Pregnancy complications (pre-eclampsia)

44
Q

Mx of ADPKD?

A

Conservative
- Monitor BP
- Genetic counseling
- MRA screening for Berry aneurysms

Medical
- Rx HTN with ACE-I

Surgical: nephrectomy indicated if:
- Recurrent bleeds/infections
- Pain

Mx complications of ESRF (CRF HEALS)

45
Q

How would you examine a stoma?

A

I’m going to examine your stoma now if that’s ok.
On general inspection of the stoma,
Site: It is located in X

Stoma bag contents:
▪ Stoma bag contains well formed brown stool (colostomy)
▪ Stoma bag contains liquid green stool (ileostomy)
▪ Stoma bag contains urine (urostomy)

On closer inspection of the stoma
Surface:
It is flushed (colostomy)
Spouted (ileostomy)

No. of lumens
- With a single lumen (end stoma)
- Two lumens
● 2 separate lumens (double barreled)
● 2 lumens with a common abdominal opening (loop
stoma)
● Looking around the stoma
- No skin irritation around the stoma
- No parastomal hernias
● Could you cough for me- Inspect for parastomal hernias
● Cough again - Feel for parastomal hernias
● On auscultation around the stoma
o Normal bowel sounds

46
Q

Presentation of midline laparotomy + end colostomy?

A

I performed an abdominal examination, who had a midline laparotomy and an end colostomy

● My main positive findings to support this
- A midline laparotomy scar on her abdomen
- There was also a stoma bag in the LIF:
▪ It contains well-formed brown stools
▪ Is flushed at the skin
▪ Has a single lumen

● My relevant negatives are: No evidence of digital clubbing:
- No evidence of digital clubbing
- A soft non-tender abdomen with no palpable masses
- No hepatosplenomegaly
- No evidence of ascites

This all seems to point towards a well-functioning end-colostomy.
Reassuringly, the end colostomy seems to be working well with no evidence of any complications such as:
● Stoma retraction
● Parastomal hernias
● Skin dermatitis

47
Q

What are the main differentials for a midline laparotomy and end colostomy?

A
  1. An abdomino-perineal resection for a rectal cancer <4cm from the anal
    verge
  2. Modified Hartmann’s procedure for an acute obstruction or perforation in the distal colon.
48
Q

Midline laparotomy + end-ileostomy - presentation?

A

● Had a midline laparotomy and an end ileostomy

● My main positive findings to support this
- A midline laparotomy scar on her abdomen
- There was also a stoma bag in the RIF:
▪ It contains liquid green stools
▪ Is spouted at the skin
▪ Has a single lumen

● My relevant negatives are (same as above):
This all seems to point towards a well-functioning end-ileostomy.

49
Q

Complications of stomas?

A

Early (<1 month)
- High output stoma 🡪 electrolyte imbalance esp low K
- Stoma retraction
- Ischaemia 🡪 gangrene/necrosis

Late
- Stenosis 🡪 constipation
- Parasternal hernia (peritoneal contents herniate through abdo wall defect)
- Reduced risk if stoma is within the rectus muscle
o Skin dermatitis secondary to bowel contents (esp ileostomy)
o Increased risk of gallstones and renal stones (only ileostomy)

PACES PACES PACES VIVA (10 decks)

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