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Abdo & haem Flashcards

1
Q

Causes of a single palpable kidney

A

Hydronephrosis
Compensatory renal hypertrophy if renal agenesis
Carcinoma
PKD with only one palpable kidney

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2
Q

Contraindications for renal transplant

A

Sepsis or active infection (AIDS with opportunistic infection, Active viral hepatitis)
Severe obesity
Uncontrolled IHD or extensive peripheral vascular disease
Malignancy not curative or expected remission for >5yrs
Uncontrolled vasculitis

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3
Q

Indications for nephrectomy in PKD?

A 
1 - to allow renal transplant
2 - cyst haemorrhage / persistent haematuria 
3 - cyst infection 
4 - mass effects
5 - chronic pain
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4
Q

Causes of isolated hepatomegaly

A

Alcoholic liver disease
Malignancy - benign, malignant and mets
Heart failure

Infection
Haematological
haemachromatosis

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5
Q

What systems are affected in haemachromotosis

A

Liver - micro nodular cirrhosis
Testes - hypogonadism, erectile dysfunction
Heart - heart block, cardiomyopathy and heart failure
Pancreas - DM
Skin - slate grey appearance
Joints - pseudo gout

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6
Q

Liver biopsy in the presence of ascites must be done by which route

A

Transjugular

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7
Q

Complications of PBC

A

Progression to chronic liver disease and cirrhosis

Increased risk of malignancy, typically HCC

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8
Q

Criteria for liver transplant for chronic disease (Non-Kings)

A 
Child Pugh B/C - BRAIN
Bili elevated (3-5mg/dL)
Refractory ascites 
Albumin <27 (synthetic hepatic failure)
INR <1.7 - coagulopathy 
Encephalopathy
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9
Q

Ix for hereditary spherocytosis

A

EMA test - flow cytometry with eosin binding

Osmotic fragility test

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10
Q

Causes of haemolytic anaemia

A

Hereditary
H. spherocytosis and elliptocytosis
Thalassaemia
Sickle cell anaemia

Acquired
Non-immune - sepsis, malaria
MAHA - HUS, TTP, DIC

Immune - Warm (malignancy, SLE) and cold (mycoplasma, CLL)

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11
Q

Causes of a kyphoscoliosis

A

Idiopathic (commonest)
Congenital (fused vertebrae, hemivertebrae)
Paralytic - anterior poliomyelitis
Neuropathic - neurofibromatosis, spina bifida, Friedrich’s ataxia
Muscular - muscular dystrophy

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12
Q

How does PRV normally present

A

Hyperviscosity sx: headache, visual change, dizziness

Thrombotic: DVT, splenic artery thrombosis, stroke

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13
Q

Complications of HS

A

Anaemia

Aplastic crisis post infection (EBV - increases spleen size)

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14
Q

How does AD PKD present

A 
1 - htn
2 - evidence of renal failure 
3 - finding of CKD / proteinuria / haematuria 
4 - extra-renal manifestations - MR, SAH
5 - familial screening
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15
Q

Complications of PRV

A

Progression - myelofibrosis or AML
Thrombosis - DVT, PE
Hyperviscosity

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16
Q

Ddx of RIF scar without a palpable mass

A 
Ovarian tumour
Asbcess - appendiceal / ileocaecal
Crohn's resection 
Diverticular mass
Caecal malignancy
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17
Q

How to present chronic liver disease

A

This patient has chronic liver disease, as evidenced by (peripheral findings) and hepatomegaly

Evidence of decompensation - jaundice, encephalopathy (liver flap), ascites

Evidence of portal htn - peripheral oedema, splenomegaly

Signs of the underlying cause - tattoos, diabetes

Nutritional status

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18
Q

Associations of AD PKD

A

Hepatomegaly (more common in AR PKD)
Intracranial aneurysms
Mitral valve prolapse

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19
Q

Haemolysis screen

A

LDH, haptoglobin, split bilirubin, Coomb’s test, blood film

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20
Q

Complications of liver transplant

A

Rejection - acute and chronic

Recurrence of disease - viral hepatitis, B-C syndrome, PBC

Related to immunosuppression - infection, malignancy and PTLPD, metabolic syndrome

Acute and chronic kidney disease - hepatorenal, drugs, DM, htn

Biliary complications - strictures and leaks

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21
Q

What are the treatments. for PKD in advance of ESRF

A

BP control
Increased fluid intake to suppress ADH release
Inhibition of RAAS with ACEi
minimal salt intake

Aim to minimise cardiovascular risk

Early treatment of UTI

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22
Q

What kind of haemolysis does hereditary spherocytosis cause

A

Extravascular haemolysis - splenomegaly, anaemia and jaundice

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23
Q

Indications for liver transplant (adults)

A

Acute
Paracetamol OD (see Kings criteria)
Trauma
Fulminant hepatic failure - viral hepatitis A/B

Non-acute
Cirrhosis:
Alcoholic liver disease (abstinent >6mths); 
NAFLD
Viral hepatitis - B/C
Autoimmune hepatitis
Haemachromotosis
Wilsons
A1AT def.

Malignancy:
HCC
Liver metastasis where primary malignancy has been fully resected

Biliary disease:
PBC, PSC

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24
Q

Contraindications to receiving a renal transplant:

A

Sepsis or active infection
Active viral hepatitis

Unable to manage:
Mental incapacity

Poor prognosis
AIDS with opportunistic infection
Uncontrolled IHD or extensive peripheral vascular disease
Malignancy not curative or expected remission for >5yrs

Uncontrolled underlying cause
Uncontrolled vasculitis

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25
Q

Causes of bilateral enlarged kidneys

A 
AD PKD
Bilateral hydronephrosis
Amyloidosis
Tuberous sclerosis
Von Hippel Lindau syndrome
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26
Q

Complications of immunosuppression

A

Infection - typical and atypical
Malignancy - skin and haematological
Specific SE of immunosuppressive drugs - steroids (Cushingoid), tacrolimus (tremor, nephrotoxicity), cyclosporin (gum hyperplasia)

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27
Q

Causes of hepatosplenomegaly

A

Haematological:
Myelo- / lymphs-proliferative disorders
CLL
Lymphoma

Hepatic:
Cirrhosis with portal htn

Infection:
EBV, CMV, viral hepatitis

Storage diseases:
Gauchers
amyloidosis

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28
Q

How does AD PKD present

A 
1 - htn
2 - evidence of renal failure 
3 - finding of CKD / proteinuria / haematuria 
4 - extra-renal manifestations - MR, SAH
5 - familial screening
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29
Q

Complications of splenectomy

A

Surgical risk
Early post-op risk of VTE
Infection - strep, meningococcus, haemophilus, salmonella

Advise:
Prior vaccination 2wks before procedure - men A and C, haemophilus, pneumococcus
Annual flu vaccine
5yrly pneumococcal vaccination 
Penicillin prophylaxis
Medic alert bracelet
30
Q

Tx of PRV

A

Venesection
Cytoreductive tx if unable to tolerate: hydroxycarbamide, , anagrelide

Aspirin

31
Q

Features of haemachromatosis

A 
Chronic liver disease
DM
Arthropathy (pseudo gout)
Cardiac features 
Hypopituitarism

Weekly venesection until Hb is <110, ferritin <10.
Desferrioxamine can be used if venesection not possible

32
Q

Cardiac features of Marfans

A

Mitral valve prolapse
Aortic root dilatation
Aortic dilatation at any point along its length

33
Q

Causes of a distal myopathy

A

Myotonic dystrophy

Inclusion body myositis

34
Q

Complications of nephrotic syndrome

A

AKI and CKD
Thrombosis (urinary loss of antithrombin)
Hypercholesterolaemia
Immunodeficiency

35
Q

What are the indications for a peg tube

A

Head and neck cancer - risk of cancer seeding

Neurological - risk of aspiration
Stroke, cerebal palsy, head injury

Neuromuscular conditions - MS, MND, Parkinson’s

36
Q

Contraindications for liver transplant

A 
Absolute
Severe infection or sepsis
AIDS infection
Extrahepatic malignancy
Advanced cardiopulmonary disease 
Ongoing alcohol or drug use 
Non-compliance 
Relative 
HIV
Severe chronic renal disease 
Extra-biliary sepsis
Prev extensive biliary tract surgery 
Psychosocial issues
37
Q

Causes of pain over renal graft in transplant pt?

A

Hyperacute or acute rejection
Abscess
Pyelonephritis

Causes of abdominal pain independent of renal transplant

38
Q

Causes of jaundice post liver transplant

A

Graft dysfunction - look for other signs of decompensated liver disease

Extra-hepatic causes of jaundice - haemolysis, obstruction

39
Q

What are the complications of peg tube insertion

A

Surgical risk - infection, failure, pain, scarring, perforation, leak. Wound complications

Persistent, but reduced risk of aspiration

Occlusion, displacement

40
Q

Mx of hereditary spherocytosis

A

Folate
Blood transfusion as needed
Splenectomy with prior vaccination

41
Q

How would you treat somebody with chronic liver disease

A

Tx the cause - antivirals, alcohol abstinence, reduce HbA1c, penicillamine, workup for transplant

Tx the complications - nutrition, laxatives

42
Q

Causes of lymphadenopathy

What else will you examine for

A

Haematological - CLL, lymphoma,
Infection - EBV, HIV
Sarcoid

Assess for splenomegaly

43
Q

Causes of ascites

A 
Portal htn
Peritoneal disease - TB
Malignancy - ovarian and GI
Meig's 
Pancreatitis 
Transudative - Low albumin, heart/liver/kidney failure, gut-losing enteropathy, B-C syndrome, constructive pericarditis
44
Q

Complications of renal transplant

A

Surgical complications
Rejection - hyper acute, acute and chronic
Recurrence of underlying disease
Complications related to immunosuppression
Complications relating to original ESRF - tertiary hyper-PTHism

45
Q

Ddx of RIF scar without a palpable mass

A 
Ovarian tumour
Asbcess - appendiceal / ileocaecal
Crohn's resection 
Diverticular mass
Caecal malignancy
46
Q

How to investigate nephrotic syndrome

A

Observations

Urine - microscopy (casts) and PCR (quantify proteinuria)

Bloods - FBC, UE, LFT, HIV, viral hepatitis, Serum and urine electrophoresis (BJP), Ig, complement, ANCA, GBM, cholesterol, HbA1c

Renal biopsy

47
Q

Ddx of RIF scar without a palpable mass

A 
Ovarian tumour
Asbcess - appendiceal / ileocaecal
Crohn's resection 
Diverticular mass
Caecal malignancy
48
Q

Causes of nephrotic syndrome

A 
Diabetic nephropathy 
Glomerulonephritis 
Amyloidosis 
Infection - hepatitis, HIV
Drugs - NSAIDs
Malignancy - myeloma
Lupus nephritis
49
Q

Sites of inappropriate EPO secretion

A

Renal, adrenal, hepatic, ovarian

50
Q

Kings criteria for liver transplant

A

Kings criteria for paracetamol OD
Acidosis (pH <7.3)
OR all 3 of coagulopathy (PT > 100, INR >6.5), Creat >300, severe encephalopathy (Gr 3-4)

Non-paracetamol fulminant liver failure:
Coagulopathy - PT >100s (INR >6.5)

Or 3 of:
Age <11 or >40;
Bilirubin >300;
Coagulopathy - INR >3.5 (PT >50)
Disease - 2° to non-A or -E hepatitis or drugs;
Extended time period - Time from jaundice -> encephalopathy/coma >7 days (non-acute)

51
Q

Indications for a renal transplant

A

Commonest causes:
Glomerulonephritis
Diabetic nephropathy
AD polycystic kidney disease

52
Q

Signs of malnutrition / indications for creon in chronic pancreatitis

A

Steatorrhoea
Hypo-Ca/Mg
Low Hb, albumin, vit D
Low BMI

Measurements of faecal elastase

53
Q

What mode of RRT is preferred in PKD? Why.

A

HD preferred over PD

PD increases risk of cyst infection
Also size of kidneys and presence of fluid can be uncomfortable inside the abdomen

54
Q

Investigations for splenomegaly

A

Bloods - FBC with blood film (malaria, leukaemia), viral markers (EBV), bilirubin

Abdo USS

CT CAP for lymphadenopathy (leukaemia / lymphoma / myeloproliferative disease)

Bone marrow aspirate, trephine, LN biopsy

55
Q

causes of ESRF

A

Diabetes
Hypertensive renal disease / vascular disease
Glomerulonephritis

56
Q

Noonan syndrome
Inheritance
Features
Cardiac features

A

AD

Cubitus valgus (wide carrying angle at elbows), webbed neck, short stature, mild learning disabilities, widely spaced nipples, strabismus, ptosis, pacts excavatum

Pul stenosis, hypertrophic cardiomyopathy, septal defects

57
Q

Causes of decompensation in chronic liver disease

A 
GI bleed
Sepsis
Drugs - benzos
Alcohol
Constipation
58
Q

Diseases where renal transplant can be a problem

A

Haemolytic uraemia syndrome - recurrence and cyclosporin worsens risk
Sickle cell - improved haematocrit increases the risk of subsequent crises
Systemic sclerosis - recurrence
FSGS - recurrence

59
Q

Complications of coeliac disease

A

Malabsorption
Fe deficiency
Functional hyposplenism
Enteropathy-assocaited T-cell lymphoma (EATL) - duodenal

60
Q

Features of Kartageners syndrome

A

Dextrocardia and situs inversus
Bronchiectasis
Sinusitis
Otitis media

61
Q

Extra GI manifestations of IBD

A 
Clubbing
Arthritis - migratory oligoarthritis, sacroiliitis, myositis 
Eyes - uveitis 
Stomatitis 
PSC (UC>Crohns)
Erythema nodosum / pyoderma gangrenous
Osteoporosis 
Bile acid malabsorption
62
Q

Mx of Marfans

A

Ongoing echocardiograms to track aortic root dilatation

Conservative
Lifestyle - avoid sudden or high stresses on aortic wall ie intense exercise

Medical
BP control - B-blockers or ARB

Surgical
Prophylactic aortic root graft repair if aortic root diameter >5cm

63
Q

Which glomerulonephritides can cause nephrotic syndrome

A

1 - minimal change disease
2 - membranous GN (hepatitis, HIV, SLE, dermatomyositis, malignancy)
3 - mesangiocapillary GN (SLE, cryo, scleroderma)
4 - FSGS (HIV, drugs)

64
Q

Causes of isolated splenomegaly

A

Haematological - myelo/lympho-proliferative disorders, CML

Infiltration - Myelofibrosis, sarcoid, amyloidosis, Lipid storage disease - Gauchers, thyrotoxicosis

Infection (immune hyperplasia ) - endocarditis, EBV, malaria, visceral leishmaniasis

Liver related - Cirrhosis with portal htn

Felty’s syndrome (RA)

Increased function - haemolytic anaemia (hereditary spherocytosis), early sickle cell, thalassaemia, nutritional anaemia

65
Q

Causes of chronic liver disease (Cs and Is)

A

C - Cirrhosis (normally alcoholic)
C - congestion - CHF and B-C syndrome
C - Carcinoma

I - infiltration - amyloidosis, Wilsons
I - infection - viral hepatitis
I - Iron - haemachromatosis
I - immune - autoimmune hepatitis, PBC

66
Q

Causes of ascites split by SAAG gradient

A 
Low gradient (<11g/L)
Peritoneal TB
Peritoneal carcinomatosis 
Pancreatitis 
Bowel infarction
Biliary ascites 
High gradient (>11g/L) - portal htn
Prehepatic - splenic / portal vein thrombosis
Hepatic - Cirrhosis, metastatic liver disease, fibrosis
Post hepatic - Cardiac (HF, constrictive pericarditis), B-C syndrome
67
Q

How would you work up somebody presenting with chronic liver disease

A

Hx
Bloods - incl viral screen, autoantibodies (ANA, AMA, ANCA, anti-smooth muscle, anti-LKM), caeruloplasmin, ferritin, tumour markers (AFP)
Imaging - USS +/- CT
Biopsy

68
Q

What is the treatment for PBC

A

Ursodeoxycholic acid - improves elimination of bile acid and can cause disease remission in 25%

69
Q

How does AD PKD present

A 
1 - htn
2 - evidence of renal failure 
3 - finding of CKD / proteinuria / haematuria 
4 - extra-renal manifestations - MR, SAH
5 - familial screening
70
Q

Indications for splenectomy

A

Elective
Hypersplenism: Haemolytic anaemia (HS, HE), autoimmune haemolytic anaemia, Thalassaemia, ITP refractory to steroids

Associated with other resection - stomach malignancy

Vascular - Aneurysmal dilatation

Mass effect - myelofibrosis

Emergency
Traumatic rupture
Spontaneous rupture (EBV)

71
Q

Management of hepatorenal syndrome

A

Type 1 - rapid onset
Terlipressin to constrict the splanchnic circulation.
20% HAS

Type 2 - slow onset
Treat underlying liver disease - TIPPS

Both supported with RRT (likely HD)
Ultimately if renal function does not improve they may need a liver and kidney transplant

72
Q

Target Hb for venesection in haemochromatosis

A

Hb <110

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