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Sarah's Yr6 PACES > Abdo > Flashcards

Abdo Flashcards

1
Q

Signs of CLD on general inspection

A

Cachexia
Icterus
Excoriation
Bruising

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2
Q

Signs of CLD in hands

A

Leuconychia
Clubbing
Dupuytren’s contracture
Palmar erythema

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3
Q

Signs of CLD in face

A

Xanthelasma
Parotid swelling
Fetor hepaticus

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4
Q

Signs of CLD on inspection of chest and abdomen

A

Spider naevi and caput medusa
Reduced body hair
Gynaecomastia
Testicular atrophy

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5
Q

How to examine hepatomegaly

A

Mass in RUQ that moves with respiration, that you are not able to get above and is dull to percussion

Estimate size as finger breadths below diaphragm

Smooth or craggy/nodular

Pulsatile (TR in CCF)

Bruit over liver (hepatocellular carcinoma)

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6
Q

General inspection evidence of underlying causes of hepatomegaly

A

Tattoos and needle marks –> infectious hepatitis
Slate-grey pigmentation –> haemochromatosis
Cachexia –> malignancy
Mid-line sternotomy scar –> CCF

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7
Q

Evidence of decompensation in CLD

A

3As
Ascites
Asterixis
Altered consciousness

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8
Q

Causes of hepatomegaly

A 
3Cs and 3Is
Cirrhosis (alcoholic)
Carcinoma (secondaries)
Congestive cardiac failure
Infectious (HBV, HCV)
Immune (PBC, PSC, AIH)
Infiltrative (amyloid and myeloproliferative)
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9
Q

Investigations for CLD patient

A

Bloods: FBC, clotting, U+E, LFT, glucose
USS abdomen
Tap ascites

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10
Q

Investigations for cirrhosis

A

Liver screen bloods:

  • Autoantibodies and immunoglobulins (PBC, PSC, AIH)
  • Hepatitis B and C serology
  • Ferritin (haemochromatosis)
  • Caeruloplasmin (Wilson’s)
  • Alpha-1 antitrypsin
  • AFP (hepatocellular carcinoma)

Hepatic synthetic function:

  • INR
  • Albumin

Liver biopsy

ERCP

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11
Q

Ix for suspected liver malignancy

A

Imaging: CXR and CT abdo/chest
Colonoscopy/gastroscopy
Biopsy

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12
Q

Complications of cirrhosis

A

Variceal haemorrhage due to portal hypertension
Hepatic encephalopathy
Spontaneous bacterial peritonitis

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13
Q

Causes of ascites

A

3Cs
Cirrhosis (80%)
Carcinomatosis
CCF

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14
Q

Treatment of ascites in cirrhotics

A

Abstinence from alcohol
Salt restriction
Diuretics (aim for 1kg weight loss/day)
Liver transplantation

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15
Q

Causes of palmar erythema

A 
Cirrhosis
Hyperthyroidism
RA
Pregnancy
Polycythaemia
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16
Q

Causes of gynaecomastia

A 
Physiological: puberty and senility
Kleinfelter's syndrome
Cirrhosis
Drugs e.g. spironolactone, digoxin
Testicular tumour/orchidectomy
Endocrinopathy e.g. hyper/hypothyroidism and Addisions
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17
Q

PBC antibodies

A

Anti-mitochondrial antibody

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18
Q

PSC antibodies

A

ANA

Anti-smooth muscle

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19
Q

AIH antibodies

A

Anti-smooth muscle
Anti-liver/kidney microsomal type 1 (LKM1)
ANA

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20
Q

Clinical signs of haemochromatosis

A

Increased skin pigmentation (slate-grey)
Stigmata of CLD
Hepatomegaly

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21
Q

Possible scars in haemochromatosis

A

Venesection
Liver biopsy
Joint replacement
Abdominal rooftop incision (hemihepatectomy for HCC)

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22
Q

Complications of haemochromatosis

A

Endocrine: bronze diabetes, hypogonadism, testicular atrophy

Cardiac: CCF

Joints: arthropathy (pseudogout)

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23
Q

Inheritance of haemochromatosis

A

AR

HFE gene mutation - regulates gut iron absorption

24
Q

Presentation of haemochromatosis

A

Fatigue and arthritis
CLD
Incidental diagnosis/family screening

25
Q

Investigations for haemochromatosis

A 
Iron studies: increased serum ferritin and transferrin saturation
Blood glucose
ECG, CXR, Echo
Liver USS, AFP, liver biopsy (for HCC) 
Genotyping
26
Q

Treatment for haemochromatosis

A 
Regular venesection (1 unit at a time)
Avoid alcohol
Surveillance for HCC
27
Q

Haemochromatosis prognosis

A

200x increased risk of HCC and reduced life expectancy if cirrhotic

Normal life expectancy without cirrhosis + effective treatment

28
Q

How to describe splenomegaly

A

LUQ mass that moves inferomedially with respiration, has a notch, dull to percuss, cannot get above or ballot

Check for hepatomegaly

29
Q

Signs of underlying cause of splenomegaly

A

Lymphadenopathy –> haematological/infective

Stigmata of CLD –> cirrhosis with portal HTN

Splinter haemorrhages, murmur –> bacterial endocarditis

Rheumatoid hands –> Felty’s syndrome

30
Q

Causes of massive splenomegaly (>8cm)

A

Myeloproliferative disorders - CML, myelofibrosis

Tropical infections - malaria, visceral leishmaniasis

31
Q

Causes of moderate splenomegaly (4-8cm)

A

Myelo/lymphoproliferative disorders

Infiltration (Gaucher’s and amyloidosis)

32
Q

Causes of minor splenomegaly (<4cm)

A

Myelo/lymphoproliferative disorders
Portal hypertension
Infections (EBV, IE, infective hepatitis)
Haemolytic anaemia

33
Q

Investigations for splenomegaly

A 
USS abdomen
FBC and film 
Thick and thin films (malaria)
Viral serology
CT chest and abdomen
Bone marrow aspirate and trephine
Lymph node biopsy
34
Q

Indications for splenectomy

A

Rupture (trauma)

Haematological (ITP and HS)

35
Q

Splenectomy work-up

A

Vaccination (ideally 2/52 prior to protect against encapsulated bacteria):

  • Pneumococcus
  • Meningococcus
  • Hib

Lifelong prophylactic penicillin

Medic alert bracelet

36
Q

Peripheral signs of renal disease

A

Hypertension
AV fistulae
Tunnelled dialysis line
Immunosuppressant stigamata e.g. Cushingoid (steroids), gum hypertrophy (ciclosporin)

37
Q

Abdominal signs of renal disease

A

Palpable kidney - ballotable, can get above it, moves with respiration

Polycystic kidney - both palpable (unless one removed), grossly enlarged, ‘cystic’ or nodular

Iliac fossae - scar +/- transplanted kidney

Ask to dip urine - proteinuria and haematuria

Ask to examine external genitalia - varicocele in males

38
Q

Causes of unilateral kidney enlargement

A

PCKD (other kidney not palpable or contralateral nephrectomy with flank scar)
Renal cell carcinoma
Simple cysts
Hydronephrosis due to ureteric obstruction

39
Q

Causes of bilateral kidney enlargement

A 
PCKD
Bilateral renal cell carcinoma (5%)
Bilateral hydronephrosis
Tuberous sclerosis (renal angiomyolipomata and cysts)
Amyloidosis
40
Q

Investigations for renal enlargement

A 
U+E
Urine cytology
USS abdomen +/- biopsy
IVU
CT is carcinoma suspected
Genetic studies (ADPKD)
41
Q

Presentation of ADPKD

A

Hypertension, recurrent UTIs, abdo pain (bleeding and infection in cysts), haematuria

End-stage renal failure by age 40-60

Other organ involvement:

  • Hepatic cysts and hepatomegaly
  • Berry aneurysms
  • Mitral valve prolapse
42
Q

Treatment for PCKD

A

Genetic counselling and family screening (10% are new mutations)
Nephrectomy for recurrent bleeds/infection/size
Dialysis
Renal transplantation

43
Q

Evidence of ciclosporin use

A

Gum hypertrophy

Hypertension

44
Q

Evidence of steroid use

A

Cushingoid appearance
Thin skin
Ecchymoses

45
Q

Top 3 reasons for liver transplantation

A

Cirrhosis
Acute hepatic failure (hep A and B, paracetamol OD)
Hepatic malignancy (HCC)

46
Q

Causes of gum hypertrophy

A 
Drugs: ciclosporin, phenytoin, nifedipine
Scurvy
Acute myelomonocytic leukaemia
Pregnancy
Familial
47
Q

Skin signs in transplant patients

A

Malignant:
Actinic keratoses (dysplastic change)
SCC (100x risk)
BCC and malignant melanoma (10x risk)

Infective:
Viral warts
Cellulitis

48
Q

Signs of renal patient on inspection

A

Arms: AV fistulae (working, currently in use, failed?)

Neck: tunnelled dialysis line, scars from previous line

Abdo: flank scar (nephrectomy), iliac fossa scar (kidney transplant), peritoneal dialysis catheter/scars (two scars below and lateral to umbilicus)

Legs: peripheral oedema

49
Q

Three things to consider when examining a renal patient

A
  1. Underlying reason for renal failure
  2. Current treatment modality
  3. Complications of past/current treatment
50
Q

Signs of underlying reason for renal failure

A

Polycystic kidneys - ADPKD
Visual impairment, fingerprick marks, injection sites/pumps - diabetes
Sclerodactyly, typical facies - systemic sclerosis
Rheumatoid hands, nodules - RA
(Hepato)splenomegaly - amyloidosis
Other organ transplant (liver/heart/lungs) - calcineurin inhibitor nephrotoxicity
Ungual fibromata, adenoma sebaceum, polycystic kidneys - tuberous sclerosis

51
Q

Evidence of current treatment modality in renal patient

A

Haemodialysis: working fistula, tunnelled neck lines, AV grafts
Peritoneal dialysis: abdominal catheter
Functioning transplant: no evidence of other current dialysis access (in use)

52
Q

Side effects of immunosuppressive treatment in transplant patients

A 
Fine tremor - tacrolimus
Steroid side effects
Gum hypertrophy - ciclosporin
HTN - ciclosporin, tacrolimus
Skin damage and malignancy - ciclosporin and azathioprine
53
Q

Signs of kidney-pancreas transplantation

A

Lower midline abdominal incision with palpable kidney in iliac fossa (but no overlying scar)

Evidence of previous diabetes e.g. visual impairment

Younger patient (often 30-40s)

54
Q

Top 3 causes of renal transplantation

A

Glomerulonephritis
Diabetic nephropathy
ADPKD

55
Q

Problems following transplantation

A

Rejection - acute or chronic

Infection 2’ to immunosuppression - Pneumocystis carinii, CMV

Increased risk of other pathology - skin malignancy, post-transplant lymphoproliferative disease, HTN and hyperlipidaemia

Immunosuppressant drug SE/toxicity

Recurrence of original disease

Chronic graft dysfunction

Sarah's Yr6 PACES (3 decks)

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