Abdo Flashcards
Which immunosuppressant causes gingival hyperplasia and which causes a tremor?
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
What are all the different types of surgical abdo scars and what do they mean?
What ix should you do in a liver transplant pt?
What are the possible complications of organ transplants?
Differentials for CLD?
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
Causes of Jaundice?
Ix for Chronic liver disease?
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
Signs of CLD decompensation?
● Jaundice
● Ascites 🡪 SBP
● Encephalopathy
● Upper GI bleed (varices)
Alcohol
(Bacterial) infection e.g. hepatitis, pneumonia
Constipation = most common cause
Drug-induced e.g.
a. Statins
b. Nicotinic acid
c. Amiodarone
d. Methotrexate
Complications of CLD?
● Portal hypertension
o Ascites
o Hypersplenism
o Oesophageal and rectal varices
● Synthetic dysfunction
o Hypoalbuminaemia
o Coagulopathy
● Hepatopulmonary syndrome
● Hepatorenal syndrome
● Encephalopathy
● HCC
Mx of CLD?
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
Diagnostic criteria for hepatorenal syndrome + tx?
Diagnostic criteria
▪ Creatine > 133
▪ Cirrhosis with ascites
▪ No evidence of intrinsic renal disease
Tx with IV albumin + terlipressin
What are some causes of smooth hepatomegaly?
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
What are some causes of irregular hepatomegaly?
Malignancy (1 or 2O)
o Benign lesions e.g. haemangioma, hepatic adenoma
o Normal anatomical variant
o Carcinoid syndrome
Hepatomegaly + lots of strokes = suggestive of what disease?
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
Causes of Ascites?
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
Mx of Ascites?
Conservative: Fluid and salt restrict
Medical: Spironolactone
Surgical: For drug-resistant ascites:
▪ Serial paracentesis
▪ TIPSS (Transjugular intrahepatic portosystemic shunt)
Ix of ascites?
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
Mx of PBC?
● 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
Poor prognostic features in PBC?
● High bilirubin level
● Female
● High anti-M2 and anti-M4 subtypes
Ix for HH?
Markers of iron stores
● Serum iron ↑
● Ferritin ↑
● TIBC ↓
HFE gene testing
● C282Y = most common mutation
● H63D
Mx of HH?
Regular phlebotomy (2x a week)
- Remove 1 unit of blood each time (
- Target ferritin level of 50ng/ml
- Then monthly phlebotomy
Common causes of renal failure?
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,
Complications of CKD?
CRF HEALS
- Cardiovascular disease
a. Anaemia (↓ EPO)
b. Hypertension 🡪 MI, stroke - Renal osteodystrophy
a. May see parathyroidectomy scar! - Fluid = ascites
- HTN
- Electrolyte disturbances (↑K)
- Anaemia
- Leg restlessness
- Sensory neuropathy
What type of Ix are needed for renal failure
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
Mx of renal failure?
- Renal replacement therapy – see later
- 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
What is an AV fistula used for?
Permanent haemodialysis
What is a AV fistula?
Surgically created connection between artery and vein
- Radio-cephalic @ wrist = Cimino-Brescia
- Brachio-cephalic @ elbow
What causes the thrill in a AV fistula
Arterial blood from the radial artery in the superficial vein
Advantages v disadvantages of fistula?
Complications of AV fistula?
● Thrombosis & stenosis
● Infection
● Bleeding
● Steal syndrome
o Distal tissue ischaemia
o Sx: pallor, pain, ↓ pulses
o May 🡪 necrosis
o Rx: banding the fistula
What are the indications for dialysis
When eGFR <15ml/min = Stage 5 ESRF
Symptomatic uraemia despite conservative tx
Volume overload despite fluid restriction & diuretics
What are the complications of dialysis?
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
Present a CKD w/ renal transplant?
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)
Indications for renal transplant?
End stage renal failure (eGFR <10ml/min) usually due to
o DM
o PKD
o Hypertension
o Glomerulonephritis
CI of renal transplant?
Cardiac/respiratory insufficiency
Liver disease
RCC
Active infection
CI for liver transplant?
- Cardiac/respiratory insufficiency
- Active alcohol use
- HIV
- Life-limiting co-morbidities
Indications for liver transplant?
- Alcoholic cirrhosis (dependent on criteria):
a. Abstinence of alcohol for 6 months
b. Ongoing participation in formal alcohol treatment programmes
c. Adequate psychosocial support - Autoimmune diseases:
a. PBC, PSC
b. Autoimmune hepatitis - Viral hepatitis:
a. Hep B, C, D - Metabolic diseases:
a. Haemochromatosis
b. Wilson’s disease
c. Alpha-1-antitrypsin deficiency - Primary hepatic tumours
a. Select patients with hepatocellular carcinoma
Differentials for Mercedes Benz Scar?
● Liver transplant
● Segmental resection
● Whipples = pancreaticoduodenectomy
Present ADPKD pt
● 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.
Classification of PKD?
- Autosomal dominant PKD (most common)
- Autosomal recessive PKD
- Non-hereditary PKD
Causes of enlarged kidneys?
Bilateral
● ADPKD
● Bilateral cysts
- VHL disease (cysts in pancreas, liver, epididymis)
- Tuberous sclerosis
Unilateral
● Simple renal cyst
● RCC
● Compensatory hypertrophy following contralateral nephrectomy
Complications of PKD?
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)
Mx of ADPKD?
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)
How would you examine a stoma?
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
Presentation of midline laparotomy + end colostomy?
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
What are the main differentials for a midline laparotomy and end colostomy?
- An abdomino-perineal resection for a rectal cancer <4cm from the anal
verge - Modified Hartmann’s procedure for an acute obstruction or perforation in the distal colon.
Midline laparotomy + end-ileostomy - presentation?
● 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.
Complications of stomas?
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)
