Abdo- medicine Flashcards
Causes of ascites
3 Cs:
Cirrhosis
Cardiac failure
Cancer
How to determine the cause of ascites?
Serum Ascites Albumin Gradient
(serum - ascites)
>1.1 –> cirrhosis
<1.1 –> malignancy, pancreatitis, TB peritonitis
Causes of portal HTN
Nephrotic syndrome, PCV (pre hepatic)
Cirrhosis (hepatic)
Heart failure (post hepatic)
Conservative, medical, surgical management of ascites
Conservative: Restrict fluid + Na, monitor weight loss, stop EtOH
Medical: spironolactone
Surgical: Therapeutic paracentesis
Risk of paracentesis in ascites?
- Major hypovolemia (must give IV albumin!)
2. Spontaneous bacterial peritonitis
Mx of Spontaneous bacterial peritonitis?
Tazocin until sensitivities are known
Later: long term ciprofloxacin
Causes of CKD vs causes of Renal transplant
CKD: DM, HTN
Transplant: DM, Glomerulonephritis, PCKD
Features of CKD
ABCEF
- Anemia
- Acidosis (confusion, SOB)
- Bone: Osteitis fibrosis cystica
- Clearance - uraemia (confusion, periph neuropathy, restless legs, pericarditis)
- Electrolytes - hyperkalemia (palpitations)
- Fluid overload - pedal edema, pulmonary edema
Indications for acute dialysis
1) Acidosis <7.2
2) Hyperkalemia >7 persistently
3) Pulmonary oedema
4) Uraemia (pericarditis, encephalopathy, peripheral neuropathy)
Management of CKD
1) ACEi + statin (unless RAS)
2) Anemia –> EPO (once ACD + IDA are exc)
3) Bone –> phosphate binders, vitD3
4) K+ –> 10mL 10% calcium gluconate + 10U insulin + 100mL 20% dextrose + salbutamol nebs
5) pulm edema –> furosemide
6) restless legs –> clonazepam
Renal transplants: what types of transplant are there?
what immunosuppression is given?
Types: DCD, DBD, LD
Immunosuppression: induction + maintenance
Induction = atelezumab
Maintenance = triple therapy = Pred + antimetabolite (azathioprine) + calcineurin inhibitor (tacrolimus)
eg of maintenance immunosuppression in renal transplant pt
Prednisolone
Azathioprine (anti-metabolite)
Tacrolimus (calcineurin inhibitor)
Compilations of renal transplant
Surgical:
- Urinary leak
- infection
- bleed
- thrombosis
- rejection (can be acute or chronic)
- delayed graft function (in 40%)
Immunosuppression:
- malignancy - skin SCC
+ viral assoc
- Opportunistic infection: PCP, cryptococcus, Candida
- Tremor, gingival hypertrophy, bone marrow suppression
O/E findings of a pt with renal transplant
Renal transplant: Rutherford morrison scar w smooth mass + dull PN
Hands + arms:
- DM finger pricks
- (AV fistula or Tesio scar that is no longer used)
Bruising, striae, moon face –> cushingoid from immunosuppression
Face:
- Gingival hypertrophy (cyclosporin)
Abdo:
Insulin induced lipodystrophy (DM)
Huge ballot able kidneys (PCKD)
Nephrectomy scars
O/E of a pt with immunosuppression from renal transplant
Gingival hypertrophy
Tacrolimus tremor
Cushingoid appearance
List bare causes for CKD
DM, HTN, Glomerulonephritis, PCKD
CTD - RA, scleroderma, SLE Amyloidosis RAS Myeloma Pyelonephritis
Ataxia, hallucinations, liver failure , in a young pt
wilsons
Dx of wilsons
low serum caeruloplasmin
high urinary copper
Liver failure
DM
Impotence
Bronzed skin
Haemochromatosis
Dx of haemochromatosis
serum transferrin is high
Ix in ?haemochromatosis
serum transferrin Ferritin LFTs, liver MRI + biopsy Glucose (DM) Echo, ECG (DCM)
Mx of haemochromatosis
Low iron diet + low vit C
Desferrioxamine
HepA + B vaccine
Mx of hepatic encephalopathy
Lactulose
Preceding trauma + brown casts in urine
ATN following rhabdomyolysis
Dapaglifozin - what is it? and what condition can it aggravate?
SGLT2 inhibitor
Increases urinary glucose excretion –> worsens thrush!
Mx of malaria falciparum
Stable: quinine
Severe: artesunate
stages of AKI
1) <0.5ml/kg/h for 6 hours or Cr >1.5x baseline
2) “” for 12 hours or Cr 2-2.9x
3) <0.3 “ “ for 24 hours or 12 hrs of anuria. Cr >3x baseline
Renal causes of AKI
ATN: due to ischemia or deposition of urate/IgG/myoglobin/Hb
Glomerulonephritis
SLE, sarcoid
NSAIDs, Abx, allopurinol
Causes of hyperkalemia
CKD or AKI
Addisons
ACEIs
Rhabdomyolysis, tumour lysis syndrome, haemolysis
Metformin + CKD?
Avoid metformin if egfr<30 –> lactic acidosis
LMWH + CKD?
avoid LMWH if eGFR<30 –> risk of bleeding
Opioid analgesia + CKD?
Avoid morphine
Opt for OXYCODON
Urgent dialysis - indications?
Acidosis Hyperkalemia Intoxication (aspirin, lithium, methanol) Oedema - pulmonary Uraemia (pericarditis, encephalopathy)
Types of renal transplant rejection
Hyper acute (hours)
Acute (1-12 weeks): cell mediated.
- Pain + oliguria
Chronic: fibrosis and scarring of transplant vessels
Renal transplant immunosuppression?
Induction: alemtezumab + basiliximab
Maintenance
1) calcineurin inhibitor (tacrolimus, ciclosporin)
2) antimetabolite (azathioprine, MMF)
3) prednisolone
Renal causes of AKI
ATN: due to ischemia or deposition of urate/IgG/myoglobin/Hb
Glomerulonephritis
SLE, sarcoid
NSAIDs, Abx, allopurinol
Causes of hyperkalemia
CKD or AKI
Addisons
ACEIs
Rhabdomyolysis, tumour lysis syndrome, haemolysis
Metformin + CKD?
Avoid metformin if egfr<30 –> lactic acidosis
LMWH + CKD?
avoid LMWH if eGFR<30 –> risk of bleeding
Opioid analgesia + CKD?
Avoid morphine
Opt for OXYCODON
Urgent dialysis - indications?
Acidosis Hyperkalemia Intoxication (aspirin, lithium, methanol) Oedema - pulmonary Uraemia (pericarditis, encephalopathy)
Types of renal transplant rejection
Hyper acute (hours)
Acute (1-12 weeks): cell mediated.
- Pain + oliguria
Chronic: fibrosis and scarring of transplant vessels
Mx of Nephrotic syndrome
Diuretics (furosemide) ACEis (BP) - prevent complications!!! 1) VTE prophylaxis 2) statin 3) Vaccination for infection
3 causes of membraneous GN
Hepatitis
SLE
NSAIDs
3 causes of focal segmental glomerulosclerosis
HIV
DM
Amyloid
mx of anti-GBM/wegeners
IV pred
Immunosuppression
Plasmapheresis
1st line induction treatment in UC?
5-ASA (mesalazine/sulfasalazine)
+/-steroids
1st line maintenance treatment in UC?
5-ASA!!!!! Pr/PO (this is also used to induce remission)
1st line induction treatment in Crohns?
STEROIDS
1st line maintenance treatment in Crohns?
Azathioprine/Mercaptopurine
mx of severe exacerbation of IBD?
Admit IV access + ABC resus (fluids) IV hydrocortisone LMWH dietician review \+/- ABx
Indications for surgery in Crohns disease? Give 6 (emergency and elective)
Failure to respond to medical treatment
Perforation, fistula
Massive haemorrhage
Elective: Perianal disease
Rest distal bowel (loop ileostomy)
Cancer
N.B. surgery in Crohns is never curative
Indications for surgery in UC?
Emergency:
Toxic megacolon
Perforation
Massive haemorrhage
Elective:
Failure of medical Mx
Malignancy
FTT in children
Features of short gut syndrome (seen in Crohns, SI <2m)
Steatorrhoea Deficiency in Vit ADEK B12 and folate deficiency Gallstones Renal stones
Mx of short gut syndrome
Dietitian
Supplements or TPN
Loperamide
Food which coeliacs must avoid
Barley
Rye
Oats
Wheat
Carcinoid tumours - features?
Diarrhoea
Flushing
Wheeze
Pellagra - dermatitis, dementia, diarrhoea
Mx of carcinoid tumour
Octreotide
