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MRCP PACES > Abdomen > Flashcards

Abdomen Flashcards

1
Q

Stigmata of Chronic Liver Disease

A

Spider Naevi
Gynaecomastia
Palmar Erythema
Dupeytrens Contracture
Testicular atrophy
Hair loss

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2
Q

Signs of portal HTN

A

Ascites
Caput Medusae
Splenomegaly

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3
Q

Signs of decompensation of liver disease

A

Jaundice
Ascites
Asterixis
Encephalopathy

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4
Q

Causes of Liver Cirrhosis

A

1 - Alcohol
2 - NAFLD
3 - Hepatitis

Others:
- Autoimmune - autoimmune hepatitis, PBC, PSC
- Metabolic - Haemochromatosis, Wilsons
- Drugs - methotrexate, amiodarone
- Idiopathic

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5
Q

Ascites + High Temperature?

A

?SBP

Ascitic tap
- neutrophils >250
- Gram stain
- Culture

Start Prophylactic Abx
Blood culture + bloods

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6
Q

Investigating Ascites?

A

FBC - anaemia, infection, platelets
Renal Function - ?co-existent renal impairment
Synthetic liver function - Coag, Albumin
LFT’s inc GGT and AST

Ascitic Tap - albumin, glucose, amylase, LDH, cytology etc.

AFP - ?HCC

Echo
Abdo US - with doppler if ?Budd Chiari
Urine Dip
Endoscopy - look for Varices, GAVE syndrome, portal hypertensive gastropathy
Fibroscan - if ?cirrhosis
CXR - ?congestive cardiac failure
CTAP ?malignancy

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7
Q

Bloods in a liver screen?

A

FBC - anaemia, platelets
U&E - renal impairment
Coag - synthetic
LFT inc. AST/Gamma GT
Ferritin/Transferrin - Haemochromatosis
Copper, caeruloplasmin - Wilsons
Immunoglobulins
Hepatitis Serology
Glucose/HbA1C - ?Metabolic syndrome –> NAFLD
Cholesterol - ?NAFLD
Alpha 1 antitrypsin
AFP

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8
Q

What immunoglobulins are tested for in Cirrhosis screen?

A

IgM - PBC
IgG - Autoimmune hepatitis
AMA M2 - raised in PBC
LKM1 - Autoimmune Hep
Ro - Autoimmune Hep
Smooth Muscle - Autoimmune Hep

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9
Q

How is ascites managed?

A

Treat underlying cause
Salt restrict and optimise nutrition
Diuretics - Spiro then add in loop diuretics if needed
Daily weights
Therapeutic paracentesis - if severely breathless/discomfort
TIPS - Portal HTN and req. frequent paracentesis

Exudative less likely to respond to diuretics

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10
Q

Signs to look for in ascites

A

Signs of chronic liver disease

JVP - ?RH failure ?CCF

Lymphadenopathy - trossier sign - left supraclavicular node

Large abdominal scars - ?tumour resection

Small abdominal scars - ?prev. paracentesis

Peripheral oedema

Umbilical nodule - ?malignancy

Signs of fistulae/Renal Replacement Therapy

Diabetic - finger pricks/sensor, acanthosis nigricans

Corneal arcus/xanthelasma/tendon xanthoma

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11
Q

Completing an abdominal examination

A

Hernial orifices
External genitalia
Urinalysis
PR exam

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12
Q

What are you looking for when assessing to see if a patient is on dialysis?

A

Neck - ?CVC
Tunnelled Line
Fistula - is there a bruit/can you feel a thrill? Is it recently needled
Abdomen - multiple scars suggestive of peritoneal dialysis
Hockey stick - J shaped renal transplant scar

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13
Q

Patient with palpable mass under J shaped RIF scar - what are you now thinking about?

A

Patient with Renal Transplant:
1 Is it functioning
- evidence of overload
- Recently needled fistula
- Tunnelled/CV line in situ
- PD catheter in situ

2 Cause - Diabetes and HTN most common.
3 Treatment
- Gum hypertrophy - ciclosporin
- Thin skin/easy bruising/cushingoid - steroids
- Fine tremor - Tacrolimus

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14
Q

Causes of palmar erythema

A

Chronic Liver Disease
Hyperthyroid
Pregnancy
RA
Polycythaemia

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15
Q

Precipitants of decompensated liver disease

A

Alcohol
Infection
GI bleed
Malignancy
Constipation
Hepatotoxic drugs
Dehydration

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16
Q

How is chronic liver disease managed?

A

Conservative:
- Alcohol cessation
- Stop hepatotoxic drugs
- Optimise nutrition
- Salt Restrict

Medical
- Vitamin & Thiamine replacement
- Diuretics for ascites
- Prophylactic Propranolol - varices
- Laxatives - reduce risk of encephalopathy

Surgical
- TIPS
- Liver Transplant

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17
Q

Abdominal Causes of finger clubbing?

A

IBD
Coeliac
Hepatocellular Ca
Cirrhosis

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18
Q

What is a TIPS procedure and when is it done?

A

Transjugular Intrahepatic Portal Shunt - shunt blood from portal vein to hepatic vein –> alleviate portal HTN

Used when:
- Multiple episodes of variceal UGI bleed
- Refractory ascites
- UGI bleed refractory to endoscopy

Sometimes done in Budd Chiari, Hepatorenal and Hepatopulmonary syndrome

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19
Q

How is a liver transplant decision made?

A

MDT approach
Significant liver impairment
Use UK End Stage Liver Disease score or MELD score
Placed on waiting list

Ultimately depends on the cause + response to treatment thus far

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20
Q

What are some contraindications for liver transplant?

A

IV drug abuse
Ongoing alcohol consumption - in ARLD
Significant other co-morbidities making transplant unlikely to be successful
Malignancy with high risk of metastasis

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21
Q

Which patients with severe alcoholic hepatitis may be eligible for transplant?

A

Expected survival without transplant < survival with

Use Glasgow and Maddrey scores to predict prognosis.
All patients must have 5 year post-transplant prognosis >50%

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22
Q

What is the criteria for super urgent liver transplant in paracetamol poisoning?

A

Kings College Criteria
pH <7.3

or

PT>100 or INR >6
+
Creat >300 or anuria
+
Grade 3/4 encephalopathy

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23
Q

What conditions are treated with liver transplant?

A

1 Chronic Liver Failure - alcohol, hepatitis B/C, Autoimmune hepatitis, PBC, PSC, Haemochromatosis, HCC

2 Acute - paracetamol, budd-chiari, acute fulminant autoimmune hepatitis, Wilsons

3 Surgical gene therapy - familial amyloidosis/hypercholesterolaemia

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24
Q

What features of chronic liver disease warrant liver transplant?

A

Worsening jaundice
Diuretic resistant ascites
Hepatocellular Ca

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25
Q

What conditions can recur post liver transplant?

A

Budd Chiari
Hep B&C
Hepatocellular Ca
PBC

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26
Q

If there is a scar of both liver and renal transplants, what does this make you consider?

A

If liver transplant first –> may develop renal failure secondary to calcinurin inhibitor use

Hepatorenal syndrome

Hep C with concurrent cryoglobulinaemia

Multiple pathology

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27
Q

What is the commonest cause of SBP?

A

E. Coli

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28
Q

How would you diagnose PBC?

A

Evidence of Cholestasis - raised ALP/GGT with absence of extra hepatic cholestasis on imagine

Presence of Anti AMA M2, anti gp210 or sp-100

Usually raised IgM

ALT not normally raised - if it is, consider other causes for this.

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29
Q

How is PBC managed?

A

Avoid alcohol

Replace Vit ADEK - fat solubles

Ursodeoxycholic acid - improve LFT’s - obeticholic acid/fibrates are second line + initiated in secondary care

Cholestyramine - itch

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30
Q

What causes Wilson’s disease?

A

Autosomal recessive defect in ATP7B on Chromosome 13

Reduced copper excretion into bile –> accumulate in liver and brain

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31
Q

Investigation findings for Wilson’s

A

Low caeruloplasmin

Raised 24hour urinary copper

Slit lamp - Kayser-Fleischer rings

Liver biopsy - raised liver copper

Can also do MRI brain and DNA testing for ATP7B

32
Q

How does Wilson’s disease present?

A

Acute or Chronic liver failure
Haemolysis
Neuro involvement - abdominal pain + psychosis
Movement disorders - asymmetrical tremor or choreiform movements

33
Q

How is Wilson’s managed?

A

Avoid copper high foods - shellfish, avocados

Avoid hepatotoxic agents

Copper chelation - penicillamine + zinc acetate

Liver transplant - surgical gene therapy

34
Q

What are some complications of Wilson’s?

A

Liver failure

Cardiomyopathy

Fanconi’s syndrome

35
Q

Complications of Chronic Liver Disease?

A

Portal HTN and varices
Ascites
Jaundice
Encephalopathy
SBP
Hepatorenal syndrome
Hepatopulmonary syndrome
Hepatocellular Ca

36
Q

What things in the scenario lead may prompt you to consider hereditary haemochromatosis?

A

Tanned skin
Thirst
Weight loss
Arthralgia
Jaundice
Haematemesis
Erectile Dysfunction

37
Q

How is haemachromatosis inherited? What gene is affected?

A

Autosomal Recessive

HFE gene - chromosome 6

38
Q

How does haemachromatosis typically present?

A

Screening of 1st degree relatives

Asymptomatic with raised ferritin

Symptomatic:
- Arthralgia
- Sexual dysfunction
- Lethargy

39
Q

What are some complications of haemachromatosis?

A

Pseudogout
Diabetes
Bronze skin
Erectile Dysfunction
Dilated Cardiomyopathy
Chronic Liver Disease
Hepatocellular Ca
Synovitis

40
Q

What may you see on examination in a patient with haemachromatosis?

A

Skin - tanned, scars in antecubital fossa from venesection

CV - irregular pulse, raised JVP, displaced apex, 3rd heart sound, bibasal creps, peripheral oedema

Abdo - chronic liver disease, jaundice, hepatosplenomegaly, hepatic mass

MSK - swollen, red, tender joints. Scar from joint replacement

41
Q

What is haemachromatosis?

A

Common genetic disorder leading to increased iron absorption.

Particularly affect liver, heart, pancreas and anterior pituitary

42
Q

What are important differentials for haemachromatosis?

A

Alcohol excess - can lead to raised ferritin, inc. risk of diabetes and joint disease and can lead to cirrhosis and HCC

43
Q

How is haemachromatosis diagnosed?

A

Ferritin raised - >200 women, >300 men

Transferrin >55% in men, >50% in women

HFE genotyping

Liver biopsy can be done to confirm severity of disease

44
Q

How is haemachromatosis investigated?

A

Bedside:
- blood sugar - raised
- urine dip - glycosuria
- ECG - AF/other arrhythmia, conduction abnormalities

Blood:
- FBC - polycythaemia
- LFT - deranged depending on disease stage
- INR
- Ferritin
- Transferrin sat
- Fasting flucose
- AFP - if concerned r.e. HCC

Imaging
- US Abdo
- Echo - dilated CM
- Plain films joints - chondrocalcinosis

Special
- Ferriscan - est. liver iron load
- Genetic testing - ?homozygois
- Liver biopsy - degree of fibrosis/cirrhosis

45
Q

How is haemachromatosis screened?

A

Patients with first degree relatives should be screened

Ferritin and Transferrin sats

46
Q

How is haemochromatosis managed?

A

Conservative:
- Counselling
- Weekly/biweekly venesection - aim for ferritin <50 then 3-4 times a year
- Abstain from alcohol - inc. risk of cirrhosis

Medical
- Treat comorbidities

Surgical
- Liver transplant

47
Q

What is the prognosis of haemachromatosis?

A

All complications tend to improve with regular venesection

If cirrhotic - reduced life expectance + 200x increased risk of HCC
If not cirrhotic + treated - normal life expectancy

48
Q

Which patients with haemachromatosis req. further specialist Ix?

A

Ferritin >1000
AND
Raised transaminase

Refer to hepatology for fibrosis assessment.
Elastography done for these patients - may need biopsy

49
Q

Signs on general inspection for IBD?

A

Young, pale, cachectic patient
TPN line
Finger clubbing
Skin signs - erythema nodosum/pyoderma

50
Q

Abdo examination features to look for in IBD?

A

Scars - laparotomy, previous stoma, healed enterocutaneous fistula

Masses - RIF

Tenderness

Stoma

Bowel sounds

51
Q

Other signs to look for when considering IBD?

A

Immunosuppression - steroids, ciclosporin, azathioprine

Extraintestinal:
- aphthous ulcers in mouth
- Arthropathy
- Conjunctivitis/episcleritis/ant. uveitis

52
Q

Investigations to order when considering IBD as a primary differential?

A

Bedside:
- Stool MC&S + C. Diff + Virology
- Faecal calprotectin

Bloods:
- FBC, U&E, LFT, inflammatory markers, albumin

Imaging:
- AXR - toxic megacolon/lead pipe colon
- CR AP

Special
- Flexi sig/ colonoscopy + biopsy
- Barium follow through
- Capsule endoscopy

53
Q

How is a flare of Crohns managed?

A

Hospital admission if severe/systemically unwell

Mild/Mod - PO steroid –> 5ASA
Severe - IV steroid –> IV infliximab

54
Q

What is the maintenance therapy for Crohn’s?

A

Azathioprine
MTX
TNF alpha inhibitors - infliximab/adalimumab

55
Q

How is a flare of UC managed?

A

Mild/Mod
-Topical 5ASA (mesalazine) –> PO –> Steroids

Severe
- IV steroids
- IV ciclosporin

56
Q

Maintenance management for UC?

A

Oral 5-ASA
PO steroids
PO Azathioprine

Surgery - can be curative for disease refractory to medical mx.

57
Q

What non disease modifying treatment is considered in IBD?

A

Antibiotics - metronidazole in Crohn’s - perianal infections, fistulae, small bowel bacterial overgrowth

Nutritional support

Surgery
- Crohns - strictures obstruction, fistula complications, perianal disease, failure to respond to Medical Mx
- UC - Symptomatic relief, emergency in severe refractory colitis, colonic dysplasia/carcinoma

Smoking cessation

MDT - surgeons, Psych, dieticians, gastro, IBD nurses

58
Q

What are the complications associated with Crohn’s disease?

A

Malabsorption - in particular B12
Anaemia
Strictures
Fistula
Fissures
Abscess
Intestinal Obstruction
Renal stones
Pyoderma/erythema nodosum

59
Q

What complications are associated with UC?

A

Colorectal Ca
Anaemia - bleeding
Toxic megacolon
Perforation
PSC
Cholangiocarcinoma

60
Q

What is the surveillance plan for patients with UC?

A

If pancolitis or have PSC - high risk

3 yearly colonoscopy if pancolitis >10yr. After every decade, increase freq. of imaging.

Colectomy if detect dysplasia.

61
Q

What are some differentials for IBD?

A

Infection - TB, Yersinia, Campylobacter
Ischaemia
Coeliac
Malignancy
Radiation

62
Q

What are the types of renal transplant?

A

Live donor
Cadaveric - brain/cardiac

63
Q

What should you be looking for when you suspect renal transplant?

A

Signs of renal replacement

Signs of prev. renal replacement

Clues for aetiology

Side effects of treatment

Complications of ESRF

Adequacy of renal replacement

64
Q

Signs of renal replacement to look for?

A

RIF scar - ?mass underneath
May be a LIF scar - ?failed prev. transplant

AV fistula - palpate and auscultate for thrill. Look for needling

Peritoneal catheter scars

Scars on chest from HD

65
Q

Signs of complications of ESRF?

A

Pallor - anaemia

Parathyroidectomy scar - secondary or tertiary hyperparathyroidism

Renal osteodystrophy

66
Q

Side effects of immunosuppresion to look for?

A

Ciclosporin - gum hypertrophy, hirsutism, HTN

Steroids - cushingoid, purpura, thin skin

Evidence of skin malignancy

Tacrolimus - fine tremor

67
Q

Clues to aetiology for Renal Transplant

A

Palpable kidneys - PKD
Nephrectomy scar - likely PKD
HTN
Fingerprick marks - CBG testing

68
Q

How to check for adequacy of renal replacement?

A

Fluid status
Signs of uraemia

69
Q

Possible causes for renal failure?

A

HTN
Diabetes
Glomerulonephritis
ADPKD

SLE, Alports, Tuberous Sclerosus, MPGN 2

70
Q

Investigations to order prior to renal transplant

A

Renal screen to find cause
Bloods - FBC, U&E, LFT, Coag, Inflammatory markers
Viral - Hep, HIV, CMV
G&S/X Match

ECG
Urine dip - blood/glucose/protein
BP
Echo
Pulm. Function Tests
CXR

Cervical smear
Dental check

71
Q

How are renal transplants managed?

A

Regular specialist monitoring
Routine bloods - FBC, UE, LFT
BP/CVS monitoring
Assess function of transplant
Monitor side effects/immunosuppressant complications
Regular cervical screen
Medic aware bracelet
Inform Dr’s if fever or prolonged illness
Annual influenza
Stop smoking/weight loss
Regular skin checks - risk of skin malignancy

72
Q

What are the indications for urgent dialysis?

A

Refractory hyperkalaemia, acidosis or fluid overload

Uraemic pericarditis/encephalopathy

Removal of drugs in severe OD - salicylates/Lithium

73
Q

What are some complications of renal transplant?

A

Graft complications
- Rejection
- Nephrotoxicity of calcinurin inhibitors
- recurrence of disease
- Renal artery stenosis/thrombosis

Others:
- Malignancy secondary to immunosuppresion
- Accelerated CV risk

74
Q

When would RRT be considered?

A

CKD stage 4/5 - GFR <30 OR
CKD stage 3 but rapidly progressing (30-60)

75
Q

What are the complications of AV fistula?

A

Infection - cellulitis, abscess, bacteraemia, septic emboli

Thrombosis
Stenosis
Aneurysm
Steal syndrome - weak pulse, cold painful hand, contracture
Ischaemic polyneuropathy
High output cardiac failure

76
Q

What are the options for vascular access in RRT?

A

AV fistula
AV graft
Tunnelled venous catheter
Non-tunnelled venous catheter

MRCP PACES (6 decks)

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