Abdo Flashcards
Dupuytren’s contractures causes
liver cirrhosis, diabetes, heavy labour, phenytoin, trauma, familial
Clubbing causes
IBD, cirrhosis, lymphoma, coeliac’s
McBurney’s point
distal 1/3 of umbilicus and ASIS
McBurney’s sign
pressuring on Mcburney’s area causes pain in that point acute appendicitis
Aaron sign is when it causes pain to epigastric when at that area
Hepatomegaly (IIBBCC) causes
Infection (viral hepatitis, EBV, malaria)
Infiltration (sarcoid, amyloid, fatty liver, haemochromatosis)
Blood related (lymphoma, leukaemia, myeloproliferative disorders, haemolytic anaemias*)
Biliary (PBC, PSC)
Cancer (primary HCC, metastatic deposit)
Congestion (RHF, tricuspid regurg, budd-chiari syndrome)
*causes of hepatosplenomegaly
Causes of hepatosplenomegaly
lymphoma, leukaemia, myeloproliferative disorders, haemolytic anaemias, sarcoid, amyloid, viral hepatitis, EBV, malaria
Massive splenomegaly (past umbilicus) causes
malaria
myelofibrosis
CML
splenomegaly - IE, RA (if low WCC = Felty’s syndrome)
Extra-intestinal manifestation of IBD
finger clubbing mouth ulcers (Crohn's) eyes (episcleritis, conjunctivitis) skin (erythema nodosum, pyoderma gangrenosum) joints (seronegative arthropathy) PSC (esp UC) amyloidosis (Crohn's)
portal hypertension leads to…
causes splenomegaly, caput medusae, oesophageal varices, gastropathy and ascites
AV fistula types
radio-cephalic (Cimino)
branchio-cephalic fistula
never measure BP on fistula arm
LIF mass
renal transplant loaded colon diverticular mass colorectal carcinoma ovarian mass / cysts
RIF mass
renal transplant appendix mass crohn's disease caecal carcinoma ovarian mass / cysts
Bilateral enlarged kidneys
APKD (autosomal dominant PKD)
bilateral hydronephrosis
amyloidosis
Spleen (vs left kidney)
Can get over a kidney percussion note is resonant over a kidney kidney is balottable spleen has notch spleen moves more on respiration
unilateral enlarged kidney
hydronephrosis
renal cancer
renal cyst
indications for dialysis in CRF
CKD stage 5 (GFR <15 ml/mins)
symptomatic uraemia despite conservative Rx
Renal bone disease
pericarditis
volume overload despite fluid restriction and diurectics
hyperkalaemia despite Rx
Complications of haemodialysis
hypotension hypovolaemia hypokalaemia cerebral oedema dialysis related amyloidosis (beta-2)
Side effects of post transplant immunosuppression
high dose steroids
ciclosporin (gingival hypertrophy, warty skin lesions, hypertrichosis = werewolf syndrome)
Pseudomembranous colitis
Severe disease if one of: WCC >15 Cr >50% above baseline Temp >38.5 Clinical / radiological evidence of severe colitis
Normal 1st line: metronidazole 400mg TDS
Severe 1st line: vancomycin
Urgent colectomy needed if: toxic megacolon; elevated LDH; deteriorating condition
Recurrence in up to 30% cases; first relapse can repeat metro, on further relapses give vanco
Constipation causes
OPENED IT Obstruction Pain (anal fissure) Endocrine/Electrolyte (hypothy; hypocalc -kae, uraemia) Neuro: MS, cauda equina Elderly Diet/Dehydration IBS Toxins (opioids/anti-mAch)
Must exclude obstruction, cauda equina!
IBS diagnosis
ROME Criteria: Abdo discomfort / pain for ≥ 12wks which has 2 of: Relieved by defecation Change in stool frequency (D or C) Change in stool form: pellets, mucus \+ 2 of: Urgency Incomplete evacuation Abdo bloating / distension Mucous PR Worsening symptoms after food
Exclusion criteria >40yrs Bloody stool Anorexia Wt. loss Diarrhoea at night
Perform colonoscopy if >60 years or features of organic disease
IBS Rx
Exclusion diets can be tried
Bulking agents for constipation and diarrhoea (e.g. fybogel or bran).
Antispasmodics for colic/bloating (e.g. mebeverine)
Amitriptyline may be helpful
CBT
Plummer-Vinson syndrome
Benign oesophageal web causing dysphagia
Pharyngeal pouch: zenker’s diverticulum
Outpouching at Killian’s dehiscence with swelling usually to left side and posterior
Pres: regurgitation, halitosis, gurgling sounds
Rx: excision, endoscopic stapling
Diffuse oesophageal spasm
Intermittent dysphagia ± chest pain
Ba swallow shows corkscrew oesophagus
Gastric ulcer stress causes
Cushing’s: intracranial disease
Curling’s: burns, sepsis, trauma
Hiatus hernia classification
- Sliding (80%) - gastro-oesophageal junction slides into chest and associated with GORD
- Rolling (15%) - gastro-oesophageal junction remains in abdomen with bulge into chest and so no GORD as LOS intact; can strangulate. Should repair therefore
- Mixed (5%)
Typically treat reflux and advise to lose weight
Rockall score
Prediction of re-bleeding and mortality in upper GI bleed
40% of re-bleeders die
Initial score pre-endoscopy:
Age
Shock: BP, pulse
Comorbidities
Final score post-endoscopy: Final Dx + evidence of recent haemorrhage Active bleeding Visible vessel Adherent clot
Initial score ≥3 or final >6 are indications for surgery
AST:ALT
> 2 = EtOH
< 1 = Viral
LFT in liver failure
↓ albumin in chronic failure
↑ PT in acute failure
Hepatorenal syndrome
Renal failure in patients with advanced liver failure
Type 1: rapidly progressive deterioration (survival <2wks)
Type 2: steady deterioration (survival ~6mo)
Rx:
IV albumin + splanchnic vasoconstrictors (terlipressin)
Haemodialysis as supportive Rx
Liver Tx is Rx of choice
Complications of liver failure Mx Bleeding Sepsis Ascites Hypoglycaemia Encephalopathy Seizure Cerebral oedema
Bleeding: Vit K, platelets, FFP, blood
Sepsis: tazocin (avoid gent: nephrotoxicity)
Ascites: fluid and salt restrict, spiro, fruse, tap, daily wt
Hypoglycaemia: regular BMs, IV glucose if <2mM
Encephalopathy: avoid sedatives, lactulose ± enemas, rifaximin
Seizures: lorazepam
Cerebral oedema: mannitol
Prescribing in liver failure
Avoid: opiates, oral hypoglycaemics, Na-containing IVI
Warfarin effects ↑
Hepatotoxic drugs: paracetamol, methotrexate, isoniazid, salicylates, tetracycline
Liver transplant decisions
Types
Cadaveric: heart-beating or non-heart beating
Live: right lobe
Can use the Kings College Hospital Criteria in Acute failure which has different criteria depending on whether paracetamol induced or not
Immunosuppression:
Ciclosporin / Tacrolimus +
Azathioprine / Mycophenolate Mofetil +
Prednisolone
Child-Pugh grading of cirrhosis
Predicts risk of bleeding, mortality and need for Tx
Graded A-C using severity of 5 factors Albumin Bilirubin Clotting Distension: Ascites Encephalopathy
Score >8 = significant risk of variceal bleeding
Mx of Cirrhosis
General
Good nutrition
EtOH abstinence: baclofen helps ↓ cravings
Colestyramine for pruritus
Screening for HCC (US and AFP) & Oesophageal varices (endoscopy)
Specific
HCV: Interferon-α
PBC: Ursodeoxycholic acid
Wilson’s: Penicillamine
Portosystemic anastomoses
- left and short gastric veins + infer. oesophageal veins = oesophageal varices
- peri-umbilical veins + superficial abdominal wall veins = caput medusae
- Super. rectal veins + inf. and mid. rectal veins = haemorrhoids
Abdominal veins seen
More common than caput medusa
Blood flow down below the umbilicus: portal HTN
Blood flow up below the umbilicus: IVC obstruction
Causes of portal HTN
Pre-hepatic: portal vein thrombosis (e.g. pancreatitis)
Hepatic: cirrhosis (80% in UK), schisto (commonest
worldwide), sarcoidosis.
Post-hepatic: Budd-Chiari, RHF, constrictive
pericarditis, TR
Leads to SAVE Splenomegaly Ascites Varices Encephalopathy
Classification of liver encephalopathy
1: Confused – irritable, mild confusion, sleep inversion
2: Drowsy – ↑ disorientated, slurred speech, asterixis
3: Stupor – rousable, incoherence
4: Coma – unrousable, ± extensor plantars
Important to give lactulose (+/- phosphate enemas) to these patients with encephalopathy
Ascites
Caused calculated via serum ascites albumin gradient (serum albumin – ascites albumin)
If >1.1g/dL = portal HTN
If <1.1g/dL = NINI Neoplasia Inflammation (pancreatitis) Nephrotic syndrome Infection (TB)
Rx: reduce weight by 0.5kg/d via fluid restriction, spironolactone and frusemide and can drain via paracentesis with HAS infusion
Alcoholism Mx
Group therapy or self-help (e.g. AA)
Baclofen: ↓ cravings
Acamprosate: ↓ cravings
Disulfiram: aversion therapy
Alcoholic hepatitis prognosis
Maddrey score predicts mortality
Mild: 0-5% 30d mortality
Severe: 50% 30d mortality
1yr after admission: 40% mortality
Hep B prognosis and Rx
Carrier: 10%
HBsAg +ve > 6mo
Chronic hepatitis: 10%
Cirrhosis: 5%
Rx: PEGinterferon
Hep C prognosis and Rx
Carrier: 80%
HCV RNA+ve >6mo
Chronic hepatitis: 80%
Cirrhosis: 20%
Rx: PEGinterferon + ribavarin
Budd-Chiari Syndrome presentation
Presentation
RUQ pain: stretching of Glisson’s capsule
Hepatomegaly
Ascites: SAAG ≥1.1g/dL
Jaundice (and other features of liver failure)
Can be from JAK2 mutation analysis; anticoagulate unless varices
Hereditary Haemochromatosis Rx
Iron removal
Venesection: aim for Hct <0.5
Desferrioxamine is 2nd line
General
Monitor DM
Low Fe diet
Screening
Se ferritin and genotype
Screen 1st degree relatives
Transplant in cirrhosis
Venesection returns life expectancy to normal if non-cirrhotic and non-diabetic
Wilson’s disease Rx
Diet: avoid high Cu foods: liver, chocolate, nuts
Penicillamine lifelong (Cu chelator). SE: nausea, rash, ↓WCC, ↓Hb, ↓plats, lupus,
haematuria
Monitor FBC and urinary Cu excretion
Liver Tx if severe liver disease
Screen siblings
Autoimmune hepatitis
Predominantly in early and middle aged women
Type 1 is anti-smooth muscle +ve
Ix: Raised IgG and LFTs
Mx: immunosuppression with pred and azathioprine (steroid sparing)
Prognosis: remission in 80% of patients
Primary Biliary Cirrhosis
Intrahepatic bile duct destruction via granulomatous inflammation
Jaundice is late sign
Ix: antimitochondrial ab and raised IgM and LFTs (ALP), US
Liver biopsy shows non-caseating granuloma
Rx: ADEK vitamins, UDCA, symptomatic relief for pruritus (naltrexone), diarrhoea and osteoporosis
Ultimately need liver transplant with survival of 2 years if jaundice develops
Primary sclerosing cholangitis
Inflammation and fibrosis of intra- and extra-hepatic ducts.
More likely to get abdo pain
Increased risk of ascending cholangitis, cholangiocarcinoma and associated with UC and autoimmune hepatitis
Ix: pANCA (80%), ANA and SMA; ALP raised
ERCP: “beaded” appearance of ducts and biopsy shows fibrous, obliterated cholangitis
Rx: ADEK vitamins, UDCA, symptomatic relief for pruritus (naltrexone), diarrhoea
Ultimately need liver transplant with 30% recurrence
Dermatitis herpetiformis from Coeliac’s
Symmetrical vesicles, extensor surfaces Esp. elbows Very itchy biopsy shows granular deposition of IgA Rx: gluten free diet or dapsone
Malabsorption causes
Common in UK: Coeliac, Chronic pancreatitis, Crohn’s
Rarer
↓Bile: PBC, ileal resection, colestyramine
Pancreatic insufficiency: Ca, CF, chronic panc
Small bowel: resection, tropical sprue, metformin
Bacterial overgrowth: spontaneous, post-op
blind loops, DM, PPIs
Infection: Giardia, Strongyloides, Crypto parvum
Hurry: post-gastrectomy dumping
Trousseau Sign
Thrombophlebitis migrans in cancer, e.g. pancreatic cancer
Chronic pancreatitis Mx
Drugs Analgesia: may need coeliac plexus block Creon ADEK vitamins DM Rx Diet No EtOH ↓ fat, ↑ carb Surgery - Pancreatectomy Ind: unremitting pain, wt. loss
Carcinoid syndrome Ix
↑ urine 5-hydroxyindoleacetic acid
↑ plasma chromogranin A
CT/MRI: find primary; can be appendix, ileum, colorectum, stomach
Carcinoid Rx
Symptoms: octreotide or loperamide
Curative
Resection: tumours are v. yellow
Give octreotide to avoid carcinoid crisis
Carcinoid Crisis
Tumour outgrows blood supply or is handled too
much → massive mediator release
Vasodilatation, hypotension, bronchoconstriction,
hyperglycaemia
Rx: high-dose octreotide
Vit A deficiency (Xerophthalmia)
Dry conjunctivae, develop spots (Bitots spots)
Corneas become cloudy then ulcerate
Night blindness → total blindness
Thiamine B (Beri Beri) deficiency
Wet: heart failure + oedema
Dry: polyneuropathy
Wernicke’s: ophthalmoplegia, ataxia, confusion
Niacin B3 (Pellagra) deficiency
Diarrhoea, Dermatitis, Dementia
Also: neuropathy, depression, ataxia
Causes: dietary, isoniazid, carcinoid syndrome
Pyridoxine (B6) deficiency
Peripheral sensory neuropathy
Cause: PZA
Cyanocobalamin (B12) deficiency
Glossitis → sore tongue
Peripheral neuropathy
Paraesthesia
Early loss of vibration and proprioception → ataxia
Subacute Combined Degeneration of spinal Cord
Dorsal and corticospinal tracts
Sensory loss and UMN weakness
Overall mixed UMN and LMN signs with sensory
disturbance
Extensor plantars + absent knee and ankle
jerks
Monitoring of NaCl in kidneys occurs
in macula densa
Regulation of water reabsorption
At cortical Collecting ducts
controlled by aquaporin-2 channels
Carbonic Anhydrase Inhibitors (acetazolamide)
MOA: inhibit carbonic anhydrase in PCT (which reabsorbs carbonic anhydrase)
Effect: ↓ HCO3 reabsorption → small ↑ Na loss
Use: open angle glaucoma
SE: drowsiness, renal stones, metabolic acidosis
Loop Diuretics (fursemide, bumetanide)
MOA: inhibit Na/K/2Cl symporter in thick ascending limb
Effect: massive NaCl excretion, Ca and K excretion, creating a weaker gradient so water not reabsorbed
Use: Rx of oedema – CCF, nephrotic syndrome,
hypercalcaemia
SE: hypokalaemic met alkalosis, ototoxic, Hypovolaemia
Thiazide Diuretics (bendroflumethazide)
MOA: inhibit NaCl co-transporter in DCT
Effect: moderate NaCl excretion, ↑ Ca reabsorption
Use: HTN, ↓ renal stones, mild oedema
SE: ↓K, hyperglycaemia, ↑ urate (C/I in gout)
K-Sparing Diuretics (spironolactone, amiloride)
MOA:
Spiro: aldosterone antagonist
Amiloride: blocks DCT/CD luminal Na channel
Effect: ↑ Na excretion, ↓K and H excretion
Use: used with loop or thiazide diuretics to control K loss,
spiro has long-term benefits in aldosteronsim (LF, HF)
SE: ↑K, anti-androgenic (e.g. gynaecomastia)
Osmotic Diuretics (mannitol)
MOA: freely filtered and poorly reabsorbed
Effect: ↓ brain volume and ↓ ICP
Use: glaucoma, ↑ICP, rhabdomyolysis
SE: ↓Na, pulmonary oedema, n/v
False -ve for haematuria
myoglobin, porphyria
False -ve for proteinuria
Bence-Jones proteins
Post-renal causes
SNIPPIN Stone Neoplasm Inflammation: stricture Prostatic hypertrophy Posterior urethral valve Infection: TB, shisto Neuro: post-op, neuropathy
Presentation of renal failure
- Protein loss and Na retention (HTN and overload)
- Acidosis (Kussmaul respiration)
- Hyperkalaemia
- Anaemia
- Uraemia (need GFR <15ml/min)
Sterile Pyuria
TB Treated UTI Appendicitis Calculi TIN Papillary necrosis Polycystic Kidney Chemical cystitis (e.g. cyclophosphamide)
UTI classification
Uncomplicated: normal GU tract and function
Complicated: abnormal GU tract, outflow obstruction, ↓ renal function, impaired host defence, virulent organism
Recurrent: further infection with new organism
Relapse: further infection with same organism
Pyelonephritis Rx
1st line: Cefotaxime 1g IV BD for 10d
No response: Augmentin 1.2g IV TDS + gentamicin
GN causes
Idiopathic Immune: SLE, Goodpastures, vasculitis (e.g. Wegener's) Infection: HBV, HCV, Strep, HIV Drugs: penicillamine, gold Amyloid
Can present with:
- asymptomatic haematuria 2. nephrotic syndrome
- nephritic syndrome
Asymptomatic haematuria causes
- IgA Nephropathy (Berger’s) - typically in young males few days post URTI with raised IgA. Rx = steroids or cyclophosphamide if renal function impaired. ESRF in 20% after 20 years
- Thin basement membrane disease - AD and commonest causes. Very small risk of ESRF
- Alport’s syndrome - X-linked. Progressive renal failure, deafness and cataracts; in female haematuria only
Nephritic syndrome
Triad of:
Haematuria; proteinuria (oedema); HTN
Causes:
- Proliferative/post-strep
- Crescentic / RPGN
Proliferative/post-strep
Features Young child develops malaise and nephritic syndrome with smoky urine 1-2wks after sore throat or skin infection. ↑ ASOT ↓C3 Biopsy: IgG and C3 deposition Rx: Supportive
Prognosis
95% of children recover fully
Cresentic / RPGN
Type 1: Anti-GBM (Goodpasture’s) – 5%
Haematuria and haemoptysis
CXR shows infiltrates
Rx: Plasmapheresis and immunosuppression
Type 2: Immune Complex Deposition – 45%
Complication of any immune complex deposition e.g. Berger’s, post-strep, endocarditis, SLE
Type 3: Pauci Immune (ANCA) – 50%; i.e. no features of systemic vasculitis
cANCA: Wegener’s
pANCA: microscopic polyangiitis, Churg-Strauss
Even if ANCA+ve, may still be idiopathic
Nephrotic syndrome causes
Primary:
- Minimal change - associated with URTI in children, biopsy shows normal light micro and fusion of podocytes on EM. Rx = steroids
- Membranous nephropathy - biopsy shows subepithelial immune complex deposits. Rx = immunosuppression if RF declines, but 40% have spontaneous remission
- Focal Segmental Glomerulosclerosis - common in Afro-Cari; biopsy shows focal scarring and IgM depositions. Rx = steroids or cyclophosphamide/ciclosporin
- Membranoproliferative - rare and associated with HBV, HCV and endocarditis; 50% develop ESRF
Secondary:
DM: glomerulosclerosis
SLE: membranous
Amyloidosis
In general, if symptomatic / complications give frusemide and salt + fluid restrict, give ACEi for proteinuria
Indications for Acute Dialysis
AEIOU
- acidosis <7.2
- Electrolytes - refractory hyperkalaemia >6.5
- Intoxication (SLIME toxins) - salicyclates, lithium, isopropanol, methanol, ethyl glycerol
- oedema (pulmonary)
- uraemia - leading to encephalopathy or pericarditis
Hyperkalaemia Mx
10ml 10% calcium gluconate
50ml 50% glucose + 10u insulin (Actrapid)
Salbutamol 5mg nebulizer
Calcium resonium 15g PO or 30g PR
Haemofiltration (usually needed if anuric)
Pulmonary oedema Mx
Sit up and give high-flow O2
Morphine 2.5mg IV (± metoclopramide 10mg IV)
Frusemide 120-250mg IV over 1h
GTN spray ± ISMN IVI (unless SBP <90)
If no response consider: CPAP +/- Haemofiltration / haemodialysis ± venesection
Surgical complications for colectomy
Abdominal:
SBO
Anastomotic stricture
Pelvic abscess
Stoma: retraction stenosis prolapse dermatitis
Pouch
Pouchitis (50%): metronidazole + cipro
↓ female fertility
Faecal leakage
Tubulointerstitial nephritis causes
Drug hypersensitivity in 70%: NSAIDs Abx: Cephs, penicillins, rifampicin, sulphonamide Diuretics: frusemide, thiazides Allopurinol Cimetidine
Infections in 15%:
Staphs, streps
Immune disorders:
SLE, Sjogren’s
Tubulointerstitial nephritis presentation and Rx
Presentation:
[] AKI, uveitis, fever, arthralgia, rashes
[] elevated IgE and eosinophilia
[] dip: haematuria, proteinuria, sterile pyuria
Rx:
[] stop offending drug
[] prednisolone
Prognosis - most recover GFR
Chronic tubulointerstitial nephritis
Fibrosis and tubular loss Commonly caused by: Reflux and chronic pyelonephritis DM SCD or trait
Analgesic Nephropathy
Prolonged heavy ingestion of compound analgesics
Features
Sterile pyuria ± mild proteinuria
Slowly progressive CRF
Sloughed papilla can → obstruction and renal colic
Ix: CT w/o contrast (papillary calcifications)
Rx: stop analgesics
Nephrotoxic drugs
NSAIDs Antimicrobials: AVASTA Aminoglycosides Vancomycin Aciclovir Sulphonamides Tetracycline Amphotericin ACEi Immunosuppressants: Ciclosporin Tacrolimus Contrast media Anaesthetics: enflurane Myoglobin Urate
CKD causes
Common
DM
HTN
Other RAS GN Polycystic disease Drugs: e.g. analgesic nephropathy Pyelonephritis: usually 2O to VUR SLE Myeloma and amyloidosis
Complications of CKD
CRF HEALS Cardiovascular disease Renal osteodystrophy - sevelamer is phosphate binder; give calcium supplements Fluid (oedema) HTN Electrolyte disturbances: K, H Anaemia - EPO raised to 11 (any higher is thrombosis risk) Leg restlessness - clonazepam Sensory neuropathy
Kidney transplant C/I and immunosuppression
Active infection
Cancer
Severe HD or other co-morbidity
Pre-op: alemtuzumab (anti-CD52)
Post-op: prednisolone short-term and tacro/ciclo long term
Kidney transplant complications
Post-op Bleeding Graft thrombosis Infection Urinary leaks
Hyperacute rejection (minutes)
ABO incompatibility
Thrombosis and SIRS
Acute Rejection (<6mo)
↑ing Cr (± fever and graft pain)
Cell-mediated response
Responsive to immunosuppression
Chronic Rejection (>6mo)
Interstitial fibrosis + tubular atrophy
Gradual ↑ in Cr and proteinuria
Not responsive to immunosuppression
Ciclosporin / tacrolimus nephrotoxicity
Acute: reversible afferent arteriole constriction → ↓GFR
Chronic: tubular atrophy and fibrosis
↓ Immune Function
↑ risk of infection: opportunists, fungi, warts
↑ risk of malignancy: BCC, SCC, lymphoma (EBV)
Cardiovascular Disease
Hypertension and atherosclerosis
Myeloma renal complications
Can cause ARF / CRF; amyloidosis
Rx - ensure fluid intake of 3L/d to prevent further impairment
Dialysis may be required in ARF
RA renal complications
NSAIDs → ATN
Penicillamine and gold → membranous GN
AA amyloidosis occurs in 15%
SLE renal complications
Involves glomerulus in 40-60% → ARF/CRF
Proteinuria and ↑BP common
Rx
Proteinuria: ACEi
Aggressive GN: immunosuppression
Diffuse Systemic Sclerosis renal complciations
Renal crisis: malignant HTN + ARF. Commonest cause of death
Rx: ACEi if ↑BP or renal crisis
Renal Tubular Acidosis
Features = hyperchloraemic met acidosis; hypokal
Type 1 (Distal)
Inability to excrete H+, even when acidotic.
Causes
Hereditary: Marfan’s, Ehler’s Danlos
AI: Sjogren’s, SLE, thyroiditis
Drugs
Features
Rickets / osteomalacia (bone buffering)
Renal stones and UTIs
Nephrocalcinosis → ESRF
Dx - Failure to acidify urine (pH >5.5) despite acid load
Type 2 (Proximal)
Defect in HCO3 reabsorption in PCT usually assoc. Fanconi syndrome
Dx - Urine will acidify with acid load (pH <5.5)
Fanconi Syndrome
Disturbance of PCT function → generalised impaired
reabsorption
amino acids, K+, HCO3, phosphate, glucose
Features:
Polyuria (osmotic diuresis)
Hypophosphataemic rickets (Vit D resistant)
Acidosis, ↓K
Bartter’s syndrome
Blockage of NaCl reabsorption in loop of Henle (like frusemide)
Hypokalaemia and met alkalosis with normal BP with salt wasting
Gitelman Syndrome
Blockage of NaCl reabsorption in DCT (like thiazides)
hypokalaemia and metabolic alkalosis + hypocalciuria with normal BP
Polycystic Kidney disease presentation
MISSHAPES Mass: abdo mass and flank pain Infected cyst Stones SBP ↑ Haematuria or haemorrhage into cyst Aneurysms: berry → SAH Polyuria + nocturia Extra-renal cysts: liver Systolic murmur: mitral valve prolapse
PKD1 is Chr16, polycystin 1
PKD2 is Chr4, polycystin 2
Recessive PKD you get congenital hepatic fibrosis as well
Polycystic Kidney disease Rx
General ↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation) Monitor U+E and BP Genetic counselling MRA screen for Berry aneurysms
Medical
Rx HTN aggressively: <130/80 (ACEi best)
Rx infections
Surgical
Pain may be helped by laparoscopic cyst removal or
nephrectomy.
ESRF in 70% by 70yrs
Dialysis or transplant
Medullary Sponge Kidney
Multiple cystic dilatations of the CDs in the medulla, in young females. Renal function usually normal but can predispose to stones
Tuberous sclerosis
AD condition with hamartomas in skin, brain, eye, kidney
Skin: nasolabial adenoma sebaceum, ash-leaf
macules, peri-ungual fibromas
Neuro: ↓IQ, epilepsy
Renal: cysts, angiomyolipomas
Renal Enlargement Differential
PHONOS Polycystic kidneys: ADPKD, ARPKD, TS Hypertrophy 2O to contralateral renal agenesis Obstruction (hydronephrosis) Neoplasia: RCC, myeloma, amyloidosis Occlusion (renal vein thrombosis) Systemic: early DM, amyloid
Ecchymosis
A discoloration of the skin resulting from bleeding underneath, leading to bruising
Left varicocele can be sign of
renal malignancy due to compression of the renal vein between the abdominal aorta and the superior mesenteric vein - known as the nutcracker angle
Cowden syndrome
PTEN mutation and intestinal hamartomas
Investigations to differentiate IBS from IBD
FBC U&E ESR and CRP Coeliac screen Faecal calprotectin
Causes of large bowel obstruction
Luminal:
[] Impacted faeces
[] Foreign body
Intramural:
[] Colorectal carcinoma*
[] Diverticular stricture*
[] Crohn’s stricture
Extramural:
[] Sigmoid volvulus*
[] Caecal volvulus
[] Adhesions and hernias (rare in LBO)
Causes of small bowel obstruction
Luminal:
[] foreign body
[] gallstones
Intramural: [] Crohn's strictures [] Small bowel tumour [] Congenital atresia [] Malignancy (rare in SMO)
Extramural: [] Adhesion* [] Hernia* [] Intussusception [] Small bowel volvulus
*Common causes
