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Abdo Mushkies Flashcards

1
Q

Liver screen?

A
  1. Alcohol = FBC, LFT, GGT
  2. Viral = Hep B and C Serology
  3. NASH = Lipids
  4. Abs = SMA, AMA, pANCA, ANA
  5. Ig = IgG (AIH), IgM (PBC)
  6. Malignancy = AFP, Ca19-9
  7. Genetic = caeruloplasmin, ferritin, a1-AT
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2
Q

Management of chronic liver disease classification?

A
  1. General
  2. Cause
  3. Complications
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3
Q

General Mx of chronic liver disease?

A
  1. MDT = GP, hepatologist, dietician, palliative care
  2. Alcohol abstinence
  3. Good nutrition
  4. Cholestyramine for pruritis
  5. Screening = HCC (US + AFP), OGD for varices
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4
Q

Complications of chronic liver disease?

A

VACESHH

  1. Varices
  2. Ascites
  3. Coagulopathy
  4. Encephalopathy
  5. Sepsis/SBP
  6. Hypoglycaemia
  7. Hepatorenal syndrome
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5
Q

Mx of complications of chronic liver disease?

A
  1. Varices = BB, banding
  2. Ascites = fluid and salt restrict, spiro, furos, tap, daily wt, TIPSS
  3. Coag = Vit K, FFP, plts
  4. Encephalopathy = avoid sedatives, lactulose, rifaximin
  5. Sepsis/SBP = tazocin or cefotaxime
  6. Hypoglycaemia = dextrose
  7. Hepatorenal syndrome = IV albumin + terlipressin
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6
Q

Causes of chronic liver disease?

A
  1. Alcohol
  2. Autoimmune = AIH, PBC, PSC
  3. Drugs = methotrexate, isoniazid, amiodarone
  4. Viral = HCV, HBV
  5. Metabolic = HH, Wilsons, a1ATD, CF
  6. Malignancy = HCC or mets
  7. Vascular = Budd-Chiari, RHF, Constrictive pericarditis
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7
Q

Child-Pugh Grading of Cirrhosis?

A

ABCDE

  1. Albumin
  2. Bilirubin
  3. Clotting
  4. Distension (Ascites)
  5. Encephalopathy
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8
Q

Child-Pugh Gradindg A,B,C scores?

A
  1. A = 5-6
  2. B = 7-9
  3. C = 10-15
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9
Q

Precipitants of hepatic decompensation?

A

HEPATICS

  1. Haemorrhage = varices
  2. Electrolytes, hypokalaemia/natraemia
  3. Poisons = diuretics, sedatives, anaesthetics
  4. Alcohol
  5. Tumour = HCC
  6. Infection = SBP, pneumonia, UTI, HDV
  7. Constipation (most common cause)
  8. Sugar = low calorie diet
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10
Q

Monitoring of hepatic decompensation?

A
  1. Fluids = urinary and central venous catheters
  2. Bloods = daily FBC, U&E, LFT, INR
  3. Glucose = 1-4hrly + 10% dextrose IV 1L/24hrs
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11
Q

Pathophysiology of hepatic encephalopathy?

A

Reduced hepatic metabolic function –> diversion of ammonia from liver directly into systemic circulation –> brain where astrocytes cause conversion of glutamate into glutamine –> causes osmotic imbalance –> cerebral oedema

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12
Q

Presentation of hepatic encephalopathy?

A

ACDCS

  1. Asterixis, Ataxia
  2. Confusion
  3. Dysarthria
  4. Constructional apraxia
  5. Seizures
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13
Q

MOA of lactulose for hepatic encephalopathy?

A

Reduces nitrogen forming bowel bacteria

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14
Q

What is hepatorenal syndrome?

A

Renal failure in patients with advanced CLD

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15
Q

What is the pathophysiology of hepatorenal syndrome?

A

‘Underfill theory’

  1. Cirrhosis –> splanchnic arterial vasodilatation –> reduced effective circulatory volume –> RAS activation –> renal arteriole vasoconstriction
  2. Persistent underfilling of renal circulation –> failure
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16
Q

3 most common SBP organisms?

A
  1. E. coli
  2. Klebsiella
  3. Strep
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17
Q

Mx of SBP?

A

Tazocin or cefotaxime until sensitivities known

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18
Q

SBP cell level?

A

> 250/mm3

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19
Q

3 commonest causes of ascites?

A

3 Cs

  1. Cirrhosis
  2. Cancer
  3. CCF
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20
Q

SAAG?

A

Serum ascites albumin gradient

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21
Q

SAAG <1.1g/dL?

A

Portal HTN (97% accuracy), due to cirrhosis in 80%

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22
Q

SAAG >1.1g/dL?

A
  1. Infection = TB peritonitis
  2. Inflammation = pancreatitis
  3. Malignancy = peritoneal mets/ovarian Ca
  4. Nephrotic syndrome
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23
Q

HVPG?

A

Hepatic Venous Pressure Gradient

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24
Q

Portal HTN HVPG?

A

HVPG greater than or equal to 5 mm Hg and is considered to be clinically significant when HVPG exceeds 10 to 12 mm Hg

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25
Causes of portal HTN?
1. Pre-hepatic 2. Hepatic 3. Post-hepatic
26
Pre-hepatic causes of Portal HTN?
1. Portal vein thrombosis 2. Splenic vein thrombosis 3. AV fistula 4. Splenomegaly (increased portal blood flow)
27
Hepatic causes of portal HTN?
All hepatic disease tings
28
Post-hepatic causes of portal HTN?
1. Cardiac = RHF, TR, constrictive pericarditis 2. Budd-Chiari 3. IVC obstruction
29
Ascites bloods?
FBC, U&E, LFTs, INR, Glucose, Liver screen
30
Mx of ascites?
1. General = fluid restrict (<1.5L). low Na diet (40-100mmol/d), daily wts (<0.5kg/d reduction) 2. Medical = spironolactone and furosemide if response poor 3. Therapeutic paracentesis 4. Refractory ascites = TIPSS/transplant
31
3 indications for therapeutic paracentesis?
1. Resp compromise 2. Pain/discomfort 3. Renal impairment
32
2 risks of therapeutic paracentesis?
1. Severe hypovolaemia (replenish albumin) | 2. SBP
33
Urobilinogen in causes of jaundice?
1. Prehepatic = yes 2. Hepatic = yes 3. Posthepatic = no
34
3 immunosuppressant stigmata?
1. Cushingoid 2. Skin tumours 3. Gingival hypertrophy (ciclosporin)
35
Liver transplant scar?
Mercedes Benz
36
DDx for Mercedez Benz scar?
HPB surgery 1. Liver transplant 2. Segmental resection 3. Whipples
37
2 types of liver transplant?
1. Cadaveric | 2. Live segmental
38
3 most common indications for liver transplant?
1. Cirrhosis 2. Malignancy 3. Acute liver failure = Hep A/B, paracetamol OD
39
Liver transplant prognosis?
1. 80% 1 yr survival | 2. 70% 5 yr survival
40
Immunosuppression regimen for liver transplant?
TAP 1. Tacrolimus/ciclosporin 2. Azathioprine 3. Prednisolone +/- withdrawal at 3mo
41
Causes of hepatomegaly?
3Cs, 2Is, 2Bs 1. Cancer = primary or secondary 2. Cirrhosis = early, usually alcoholic 3. Cardiac = CCF, congestive pericarditis 4. Infiltration = fatty, haemochromatosis, amyloidosis, sarcoidosis 5. Infection = Viral, Malaria, Abscess 6. Blood = leukaemia, lymphoma, myeloproliferative, haemolytic 7. Biliary = PBC, PSC
42
3 features of hepatomegaly?
1. Moves inferiorly on inspiration 2. Cant get above it 3. Dull percussion note
43
Features to note about hepatomegaly?
1. Edge = smooth/craggy/nodular 2. Tenderness 3. Pulsatile
44
What is Riedel's lobe?
A common anatomical variant of the liver, which is a tongue-like, inferior projection of the right lobe of the liver beyond the level of the most inferior costal cartilage, wrongly assumed to be hepatomegaly
45
Hepatomegaly bloods?
1. FBC 2. U&E 3. LFT 4. Clotting 5. Liver screen
46
Hepatomegaly Ix?
1. Bedside = urine dip (protein, urobilinogen) 2. Bloods 3. Imaging = US, CT, MRI
47
What are we looking for on liver US?
1. Liver size and texture 2. Focal lesions 3. Ascites 4. Portal vein flow 5. Hepatic veins: thrombosis
48
What must one check before performing a liver biopsy>
Clotting
49
Causes of macronodular and micronodular cirrhosis (cut-off 3mm)?
1. Micro = alcohol, HH, Wilsons | 2. Macro = viral
50
Stains for liver biopsy?
1. Perl's Prussion Blue = Iron 2. Rhodamine = Copper 3. a1ATD = PAS (a1AT globules accumulate in liver) 4. Amyloid = apple green birefringence with Congo Red
51
Features of splenomegaly on palpation/
1. Cant get above it 2. Moves towards RIF on respiration 3. Notch 4. Dull PN 5. Not ballotable
52
What other examinations must you do with splenomegaly?
1. Cardio = IE | 2. Resp = Sarcoid
53
Causes of splenomegaly?
1. Myeloproilferative = CML, MF 2. Lymphoproliferative = CLL, lymphoma 3. Infective = Visceral leishmaniasis, Malaria 4. Infiltrative = Gaucher's, amyloidosis
54
Gaucher's disease?
A genetic disorder in which glucocerebroside accumulates in cells (esp. WBCs and macrophages) and certain organs, caused by a hereditary deficiency of the enzyme glucocerebrosidase
55
CML defn?
A leukaemia characterised by clonal proliferation of myeloid cells
56
CML Fx?
1. Constitutional 2. Anaemia, Bleeding, Infections 3. Massive HSM --> abdo discomfort 4. Gout 5. Hyperviscosity
57
Most common cause of CML?
t(9;22) translocation leading to formation of BCR-ABL fusion gene
58
CML FBC?
1. Raised WBC | 2. Low Hb and Plts
59
Mx of CML?
1. Imatinib = tyrosine kinase inhibitor with 90% ham response, leading to 80% survival at 5 years 2. Allogeneic SCT = indicated if blast crisis or TK-refractory
60
Myelofibrosis film?
Leukoerythroblastic with teardrop poikilocytes
61
Myelofibrosis Mx?
1. Supportive = blood products 2. Splenectomy 3. Allogeneic BMT may be curative in younger pts
62
Prognosis of primary myelofibrosis?
5 year median survival
63
Anatomy of the spleen?
1. Intraperitoneal structure lying in the LUQ 2. Measuring 1x3x5 inches 3. Weighing 7 oz 4. Lying anterior to ribs 9-11
64
Function of the spleen?
Part of the mononuclear phagocytic system 1. Phagocytosis of old RBCs and WBCs 2. Phagocytosis of opsonised pathogens 3. Ab production 4. Sequestration of formed blood elements 5. Haemopoiesis
65
Hypersplenism?
1. An overactive spleen, that can either be primary or secondary to being an enlarged spleen 2. Leads to a pancytopenia --> anaemia, bruising, infections
66
Massive splenomegaly defn?
>1kg
67
What transiently rises after splenectomy?
Platelets
68
Hyposplenism film?
1. Howell-Jolly bodies 2. Pappenheimer bodies 3. Target cells
69
Mx of hyposplenism?
1. Conservative = Alert card/bracelet | 2. Medical = Immunisations (Pneumovax, HiB, Men C, influenza) and Abx (Pen V/erythromycin)
70
Indications for splenectomy?
1. Trauma 2. Rupture = e.g. secondary to EBV 3. AIHA 4. ITP 5. Hereditary spherocytosis 6. Hypersplenism
71
5 complications of splenectomy?
1. Infections = haemophilus, pneumo, meningo 2. Pancreatitis = tail shares blood supply with spleen 3. LLL atelectasis 4. Gastric dilatation due to transient ileus 5. Redistributive thrombocytosis --> early VTE
72
Why to give early post-op aspirin after splenectomy?
To prevent early VTE due to redistributive thrombocytosis
73
Why can gastric dilatation occur post splenectomy?
May disturb gastro-omental vessel ligatures
74
Features of a palpable kidney?
1. Flank mass 2. Cant get above it 3. Ballottable 4. Moves inferiorly on respiration 5. Resonant PN
75
3 things to complete examination of an enlarged kidney?
1. CVS = mitral valve prolapse 2. Urine dip = proteinuria, haematuria 3. External genitalia = hydroecele 2ary to RCC
76
5 causes of bilaterally enlarged kidneys?
1. ADPKD 2. Bilateral RCC 3. Bilateral cysts 4. Amyloidosis 5. Hydropnephrosis
77
4 causes of unilaterally enlarged kidney?
1. RCC 2. Simple renal cyst 3. Compensatory hypertrophy 4. ADPKD (with contralateral nephrectomy)
78
ADPKD genetics?
1. PKD1 on Chr16 = 85% | 2. PKD2 on Chr4 = 15%
79
ADPKD Mx?
1. Conservative = high water intake, low salt intake, less caffeine, genetic counselling 2. Medical = HTN aggressively (<130/80), Rx infections 3. Surgical = Nephrectomy if recurrent bleeds/infections or abdo discomfort --> Dialysis/Transplant
80
ADPKD Ix?
1. Bedside = Urine dip, MC&S 2. Bloods = FBC, U&E, Bone profile 3. Imaging = US, CT, MRI head 4. Genetic studies to look for mutation
81
ADPKD Prognosis?
ESRF in 70% by 70 y/o
82
ADPKD prevalence?
1/1000
83
ADPKD presentation?
1. 30-50 y/o 2. HTN 3. Recurrent UTIs 4. Haematuria 5. Loin pain: cyst haemorrhage/infection
84
3 extra-renal features of ADPKD?
1. Hepatic cysts --> hepatomegaly 2. Berry aneurysms --> SAH 3. MV prolapse --> mid-systolic click and late murmur
85
ARPKD prevalence?
1:40,000
86
ARPKD genetics?
PKHD1 (fibrocystin) gene on Chr6
87
Presentation of ARPKD?
1. Perinatal 2. Oligohydramnios, may --> potter sequence 3. Bilateral abdominal masses 4. HTN and CKD
88
ARPKD extra-renal involvement?
Congenital hepatic fibrosis --> portal HTN
89
ARPKD prognosis?
ESRF by 20yrs
90
Simple renal cysts Fx?
1. Common = 1/3rd pts >60y/o 2. May present as renal mass and haematuria 3. Contain fluid only, no solid elements 4. Main DDx is RCC
91
Dialysis associated renal cysts Fx?
1. Seen after prolonged dialysis 2. 2ary to obstruction of renal tubules by oxalate crystals 3. Increased risk of RCC in cysts
92
Tuberous sclerosis aka?
Bourneville's disease
93
Tuberous sclerosis defn?
AD condition characterised by hamartomas in skin, brain, eye and kidneys
94
Skin, neuro and renal fx of TS?
1. Skin = adenoma sebaceum, Shagreen patch, axillary freckling, ash leak macules, peri-ungual fibromas 2. Neuro = reduced IQ, epilepsy, astrocytoma 3. Renal = cysts, angiolipomas
95
RCC epidemiology?
1. 90% of renal cancer 2. 55y/o typically 3. 2M:1F
96
RCC Rfs?
1. Smoking 2. Obesity 3. HTN 4. Dialysis (15% develop RCC) 5. Congenital = e.g. vHL
97
RCC presentation triad?
1. Haematuria 2. Loin pain 3. Loin mass
98
5 paraneoplastic Fx of RCC?
1. EPO --> polycythaemia 2. PTHrP --> raised Ca 3. Renin --> HTN 4. ACTH --> Cushings 5. Amyloidosis
99
RCC spread?
1. Direct = renal vein 2. Lymph 3. Haematogenous = bone, liver, lung
100
RCC Ix?
1. Bedside = urine dip and cytology 2. Bloods = FBC, U&E, LFTs, bone, ESR 3. Imaging = CXR (cannonball), US, IVU (filling defect), CT/MRI
101
RCC Mx?
1. Medical = for pts with poor prognosis, mTOR inhibitors (e.g. Temsirolimus) 2. Surgical = radical nephrectomy
102
RCC prognosis?
45% at 5 yrs
103
5 fx of vHL?
1. Renal and pancreatic cysts 2. Bilateral RCC 3. Haemangioblastomas in cerebellum 4. Islet cell tumours 5. Phaeochromocytomas
104
vHL inheritance?
AD
105
Renal transplant palpation Fx?
1. Smooth oval mass under Rutherford Morrison scar 2. Dull PN 3. Can get below it 4. Doesnt move with respiration
106
Auscultation of renal transplant?
Maybe hear a bruit
107
5 causes of gum hypertrophy?
1. Drugs 2. Pregnancy 3. Familial 4. AML 5. Scurvy
108
3 drugs that cause gum hypertrophy?
1. Ciclosporin 2. Nifedipine 3. Phenytoin
109
Renal transplant pt bloods?
1. FBC = infection 2. U&E = eGFR trend 3. LFTs = ciclosporin 4. Glucose = ciclosporin is diabetogenic 5. Drug levels = ciclosporin, tacrolimus
110
4 commonest indications for renal transplant?
1. DM 2. GN 3. ADPKD 4. HTN
111
4 C/I to renal transplant?
1. Active infection 2. Cancer 3. Severe co-morbidity 4. Failed pre-implantation x-match
112
Types of renal transplant?
1. Cadaveric 2. DBD/DCD 3. Live related 4. Live unrelated
113
3 benefits of live related donor?
1. Optimal surgical timing 2. HLA Matched 3. Improved graft survival
114
Renal transplant immunosuppression?
1. Pre-op = Alemtuzumab (anti-CD52) 2. Post-op short term = prednisolone 3. Post-op long term = tacrolimus/ciclosporin
115
Alemtuzumab aka?
Campath
116
Half life of cadaveric grafts?
15 years
117
Half life of HLA-identical live grafts?
>20 years
118
Classification of renal transplant complications?
1. Post-op 2. Rejection 3. Drug toxicity 4. CVD
119
Renal transplant post-op complications?
1. Bleeding 2. Graft thromboses 3. Infection 4. Urinary leaks
120
Renal transplant rejection types?
1. Hyperacute 2. Acute 3. Chronic
121
Hyperacute renal transplant rejection fx?
1. Mins 2. Path = ABO incompatability 3. Presentation = thrombosis and SIRS
122
Acute renal transplant rejection fx?
1. <6m 2. Path = cell-mediated response 3. Presentation = fever and graft pain, reduced urine output, raised Cr 4. Rx = Immunosuppression
123
Chronic renal transplant rejection fx?
1. >6m 2. Path = Interstitial fibrosis and tubular atrophy 3. Presentation = gradual increase in Cr and proteinuria 4. Rx = supportive, not responsive to immunosuppression
124
Ciclosporin/Tacrolimus MOA?
Calcineurin inhibitor, blocks IL2 production
125
Ciclosporin 4 s/e?
1. Nephrotoxic 2. Hepatotoxic 3. Gingival hypertrophy 4. Hypertrichosis
126
Tacrolimus 4 s/es?
1. Nephrotoxicity (less than ciclo tho) 2. Diabetogenic 3. Cardiomyopathy 4. Neurotoxicity e.g. peripheral neuropathy
127
S/e of reduced immune function for renal transplant?
1. Infection = CMV, PCP, fungi, warts | 2. Malignancy = PTLD (EBV), Skin (SCC, BCC, MM, Kaposi's)
128
CVD complications of renal transplant?
1. HTN | 2. Atheromatous vsacular disease
129
3 types of Renal replacement therapy?
1. Haemodialysis 2. Peritoneal Dialysis 3. Haemofiltration
130
Indication for renal replacement therapy?
1. Suggested when eGFR <15ml/min + symptoms 2. Psychological preparation necessary 3. PD vs. HD depends on med, social and psych factors
131
Annual mortality of dialysis?
20%
132
Complications of dialysis?
20% annual mortality 1. Infection 2. Inflammation = amyloidosis 3. Malignancy = from renal cysts 4. Malnutrition 5. CVD
133
MOA of dialysis infections?
Uraemia --> granulocyte dysfunction --> increased sepsis related mortality
134
MOA of dialysis amyloidosis?
B2 microglobulin accumulation
135
Mechanism of haemodialysis?
1. Countercurrent flow = blood flows on one side of semipermeable membrane, dialysate flows in opposite direction on other side, solute transfer by diffusion 2. Ultrafiltration = Fluid removal by creation of negative transmembrane pressure by decreasing the hydrostatic pressure of the dialysate
136
5 complications of haemodialysis?
1. Disequilibration syndrome 2. Fluid balance = low BP and pulmonary oedema 3. E- imbalance 4. Aluminium toxicity in dialysate --> dementia 5. Psychological factors
137
What is disequilibration syndrome?
Rapid changed in plasma osmolarity that leads to cerebral oedema, that usually only occurs on the 1st dialysis
138
Peritoneal dialysis mechanism?
1. Dialysate introduced into peritoneal cavity by Tenchkoff catheter, uraemic solutes diffuse into fluid across peritoneum 2. Ultrafiltration = addition of osmotic agent e.g. glucose 3. 3L 4x/day with approx 4hr dwell times
139
Types of peritoneal dialysis?
1. CAPD = fluid exchange during day with long dwell at night | 2. APD = fluid exchanged during night by machine with long dwell throughout day
140
CAPD?
Continuous ambulatory peritoneal dialysis
141
APD?
Automated Peritoneal dialysis
142
3 advantages of peritoneal dialysis?
1. Simple to perform 2. Requires less equipment --> easier at home or holiday 3. Less haemodynamic instability (useful if CVD)
143
3 disadvantages of peritoneal dialysis?
1. Inconvenience 2. Body image 3. Anorexia
144
5 complications of peritoneal dialysis?
1. Peritonitis 2. Exit site infection 3. Catheter malfunction 4. Obesity (glucose in dialysate) 5. Mechanical = hernias and back pain
145
Where is haemofiltration typically only used?
In ITU
146
Haemofiltration MOA?
1. Uses a Vas Cath 2. Blood filtered across a highly permeable membrane by hydrostatic pressure and water and solutes are removed by convection 3. Ultrafiltrate is replaced by isotonic replacement
147
2 types of renal access?
1. AV fistula | 2. Tesio line
148
AV fistula examination?
1. Inspection = swelling with surgical scar over distal forearm or elbow, evidence of use of needle marks, evidence of infection 2. Palpation = painful, temperature, thrill 3. Auscultation = bruit 4. Significant negatives = infection, stenosis, aneurysm
149
What is an AV fistula?
A surgically created connection between an artery and vein, venous limb is proximal
150
2 types of AV fistula?
1. Radiocephalic at wrist = Cimino-Brescia | 2. Brachiocephalic at elbow
151
3 advantages of AV fistulas?
1. High flow rates, low recirculation (<10%) 2. Low infection rates 3. Less chance of stenosis cf. grafts
152
3 disadvantages of AV fistulas?
1. Takes 6 weeks to arterialise 2. Affects pt body image 3. Must take care: avoid shaving, dont take BP/blood here
153
4 complications of AV fistulas?
1. Thrombosis and stenosis 2. Infection 3. Bleeding 4. Aneurysm 5. Steal syndrome
154
(Vascular Access) Steal syndrome?
A syndrome caused by ischemia resulting from an AV fistula, presenting with distal tissue pallor, pain, and reduced pulses, with potential to eventually develop into necrosis
155
Mx of steal syndrome?
Revasculariation or Banding techniques
156
Tesio line?
Two lines tunnelled under skin and entering the IJV
157
3 disadvantages of Tesio line?
1. Lower flow rates 2. Increased risk of infection and thrombosis 3. May have increased recirculation cf. AVF
158
4 complications of Tesio line?
1. Insertion e.g. pneumothorax 2. Line/tunnel infection 3. Blockage 4. Retraction
159
CKD stages?
``` G1. >90 G2. 60-89 G3. 30-59 G4. 15-29 G5. <15 ```
160
When is CKD diagnosed?
When they have abnormalities of kidney structure or function present for at least 3 months 1. All individuals with markers of kidney damage (see below) or those with an eGFR of less than 60 ml/min/1.73m2 on at least 2 occasions 90 days apart (with or without markers of kidney damage). 2. Markers of kidney disease may include: albuminuria (ACR > 3 mg/mmol), haematuria (or presumed or confirmed renal origin), electrolyte abnormalities due to tubular disorders, renal histological abnormalities, structural abnormalities detected by imaging (e.g. polycystic kidneys, reflux nephropathy) or a history of kidney transplantation
161
How is CKD classified?
According to eGFR and ACR categories (see diagram)
162
ACR (Albumin:Creatinine ratio) categories?
A1. Normal/mildly increased <3 mg/mmol A2. Moderately increased 3-30 mg/mmol A3. Severely increased >30 mg/mmol
163
CKD Ix?
1. Urine = Dip, PCR, BJP 2. Bloods = FBC, U&E, Bone 3. Renal screen 4. Imaging 5. Renal biopsy
164
CKD Renal screen components?
1. DM 2. ESR 3. Serum protein electrophoresis 4. Immune
165
CKD Renal immune screen components?
1. SLE = ANA, C3, C4 2. Goodpasture's anti-GBM 3. Vasculitis = ANCA 4. Hepatitis = viral serology
166
CKD Imaging?
1. CXR = pulmonary oedema 2. Renal US = usually small (<9cm), may be large (polycystic, amyloid) 3. Bone X rays = renal osteodystrophy 4. CT KUB
167
Normal vs. nephrotic PCR values?
1. Normal = <20mg/mM | 2. Nephrotic = >300mg/mM
168
CKD complications?
A WET BED + 3 1. Acid-base 2. Water 3. Electrolytes 4. Toxins 5. BP --> CVD 6. Erythropoiesis 7. Vitamin D 8. Restless legs 9. Sensory neuropathy 10. Renal osteodystrophy
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What is renal osteodystrophy?
Alteration in bone morphology in pts with CKD
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5 features of renal osteodystrophy?
1. Osteoporosis = reduced BMD 2. Ostemalaxia = reduced mineralisation of osteoid 3. 2/3ary HPT --> osteitis fibrosa cystica 4. Osteosclerosis of the spine (Rugger Jersey spine) 5. Extraskeletal calcification
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Mechanism of renal osteodystrophy?
1. Reduced 1a hydroxylase activity --> raised PTH 2. Phosphate retention --> raised PTH 3. Acidosis --> bone resorption
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CKD Mx?
1. Conservative 2. Medical 3. Surgical
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Conservative CKD Mx?
1. Optimise CVD risk with smoking cessation, exercise + medical 2. Stop nephrotoxic drugs 3. Na, K, fluid and PO4 restriction
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Medical CKD Mx?
1. Underlying Cause 2. Complications a. HTN b. Oedema = furosemide c. Anaemia = EPO d. Restless legs = clonazepam e. Bone disease
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Mx of renal osteodystrophy?
1. Phosphate binders = Calcichew, sevelamer 2. Vit D analogues = alfacalcidol 3. Ca supplements 4. Cinacalcet = Ca mimetic
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Commonest cause of ESRF?
DM
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Pathology of diabetic nepropathy?
1. Hyperglycaemia --> hypertrophy and ROS production 2. Hallmark is glomerulosclerosis and nephron loss 3. Nephron loss --> RAS activation --> HTN
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Hallmark of DN on histology?
Glomerulosclerosis and nephron loss
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Detection of diabetic nephropathy clinically?
1. Microalbuminaemia = 30-300mg/d or ACR >3mg/mM, is a strong independent RF for CVD
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When should T2DM be screened for microalbuminuria?
6 monthly
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Mx of diabetic nephropathy?
1. Good glycaemic control delays onset and progression 2. Control HTN <130/80, ACEi/ARB even if normotensive 3. Combined Pancreas Kidney Transplant in select pts
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Commonest cause of death in diffuse systemic sclerosis?
Renal crisis with malignant HTN and AKI
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4 causes of RAS?
1. Atherosclerosis in 80% 2. Fibromuscular dysplasia 3. Thromboembolism 4. External mass compression
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Fibromuscular dysplasia defn?
A non-atherosclerotic, non-inflammatory disease of the blood vessels that causes abnormal growth within the wall of an artery. FMD has been found in nearly every arterial bed in the body although the most common arteries affected are the renal and carotid arteries
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RAS presentation?
1. Refractory HTN 2. Renal Bruits 3. Renal function worsening after ACEi/ARB 4. Flash pulmonary oedema
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RAS Ix?
1. CT/MR angio | 2. Renal angiography
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RAS Mx?
1. Rx medical CV risk factors 2. Angioplasty and stenting 3. AVOID ACEi/ARB
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IBD Ix?
1. Bedside = stool culture + CDT 2. Bloods = FBC, U&E, LFTs, Clotting, ESR, CRP, haematinics 3. AXR = toxic megacolon/obstruction 4. Contrast (Ba/Gastrograffin enema) 5. MRI = perianal diseas 6. Colonoscopy 7. Wireless capsule endoscopy
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Differences between UC and CD classification?
Macroscopic and microscopic
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Macroscopic difference b/w UC and CD?
1. Location 2. Distribution 3. Strictures
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Microscopic difference b/w UC and CD?
1. Fibrosis 2. Ulceration 3. Granulomas 4. Pseudopolyps 5. Inflammation 6. Fistulae
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UC macroscopic features?
1. Location = rectum + colon + backwash ileitis 2. Distribution = contiguous 3. Strictures = No
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CD macroscopic features?
1. Location = mouth to anus, esp. terminal ileum 2. Distribution = skip lesions 3. Strictures = Yes
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UC microscopic features?
1. Fibrosis = None 2. Ulceration = Shallow, broad 3. Granulomas = None 4. Pseudopolyps = Marked 5. Inflammation = Mucosal 6. Fistulae = No
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CD microscopic features?
1. Fibrosis = Marked 2. Ulceration = Deep, thin and serpiginous (Cobblestone mucosa) 3. Granulomas = Present 4. Pseudopolyps = Minimal 5. Inflammation = Transmural 6. Fistulae = Yes
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Truelove and Witts UC criteria?
1. Symptoms = BM>6/d, Large PR bleed 2. Signs = HR > 90, Pyrexia > 37.8 3. Lab values = Hb < 10.5, ESR >30
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General Mx of acute IBD flare?
1. Resus = admit, NBM, hydration 2. Hydrocortisone = 100mg IV QDS + PR if rectal disease 3. Thromboprophylaxis = LMWH 4. Dietician review
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Acute IBD flare monitoring?
1. Bedside = daily examination, vitals, stool chart | 2. Bloods = FBC, U&E, ESR, CRP
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Crohns flare acute Mx?
1. Abx = metronidazole PO/IV 2. Consider parenteral nutrition 3. Improvement --> oral pred 40m/d 4. Refractory = methotrexate +/- infliximab
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UC flare acute Mx?
1. Improvement --> oral pred + 5-ASA | 2. Refractory - ciclosporin or infliximab
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Indications for surgery during acute IBD flare?
1. Obstruction 2. Perforation 3. Haemorrhage 4. Failure to respond to medical Mx 5. Megacolon
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CD complications?
1. Fistulae 2. Perianal abscess 3. Strictures 4. Malabsorption 5. Toxic dilatation
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UC complications?
1. Obstruction 2. Perforation (toxic megacolon) 3. Haermorrhage 4. Malignancy (Colorectal/cholangio) 5. VTE
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Extra-intestinal features of IBD?
1. Skin 2. Eyes 3. Mouth 4. Joints 5. Hepatic 6. Other
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IBD skin features?
1. Clubbing 2. Erythema nodosum 3. Pyoderma gangrenosum
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IBD mouth features?
Aphthous ulcers
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IBD eye features?
1. Anterior uveitis | 2. Episcleritis
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IBD joint features?
1. Large joint arthritis | 2. Sacroiliitis
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IBD hepatic features?
1. Fatty liver 2. Cirrhosis due to chronic hepatitis 3. Gallstones (esp. CD) 4. PSC + Cholangiocarcinoma (esp. UC)
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IBD 'other' features?
AA amyloidosis | Oxalate renal stones
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General Mx of mild-moderate IBD?
1. MDT = GP, gastroenterologist, dietician, nurses, surgeon 2. Nutrition = ADEK vitamins, high fibre diet (esp. CD) 3. Induction 4. Maintenance
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UC induction meds?
1. 5-ASAs 2. Prednisolone 3. Ciclosporin/infliximab 4. Topical = enemas/foams: 5-ASA/pred
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CD induction meds?
1. Ileocaecal = budesonide 1. Colitis = sulfasalazine 2. Prednisolone 3. Methotrexate 4. Infliximab/adalimumab
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UC maintenance meds?
1. 5-ASA 2. Azathioprine 3. Infliximab/Adalimumab
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CD maintenance meds?
1. Azathioprine 2. Methotrexate 3. Infliximab/adalimumab
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Which drug classes are largely used for each of CD and UC?
1. UC = aminosalicylates | 2. CD = methotrexate

Medicine and Surgery Mushkies (52 decks)

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