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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
What conditions can recur post liver transplant?
Budd Chiari Hep B&C Hepatocellular Ca PBC
26
If there is a scar of both liver and renal transplants, what does this make you consider?
If liver transplant first --> may develop renal failure secondary to calcinurin inhibitor use Hepatorenal syndrome Hep C with concurrent cryoglobulinaemia Multiple pathology
27
What is the commonest cause of SBP?
E. Coli
28
How would you diagnose PBC?
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.
29
How is PBC managed?
Avoid alcohol Replace Vit ADEK - fat solubles Ursodeoxycholic acid - improve LFT's - obeticholic acid/fibrates are second line + initiated in secondary care Cholestyramine - itch
30
What causes Wilson's disease?
Autosomal recessive defect in ATP7B on Chromosome 13 Reduced copper excretion into bile --> accumulate in liver and brain
31
Investigation findings for Wilson's
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
How does Wilson's disease present?
Acute or Chronic liver failure Haemolysis Neuro involvement - abdominal pain + psychosis Movement disorders - asymmetrical tremor or choreiform movements
33
How is Wilson's managed?
Avoid copper high foods - shellfish, avocados Avoid hepatotoxic agents Copper chelation - penicillamine + zinc acetate Liver transplant - surgical gene therapy
34
What are some complications of Wilson's?
Liver failure Cardiomyopathy Fanconi's syndrome
35
Complications of Chronic Liver Disease?
Portal HTN and varices Ascites Jaundice Encephalopathy SBP Hepatorenal syndrome Hepatopulmonary syndrome Hepatocellular Ca
36
What things in the scenario lead may prompt you to consider hereditary haemochromatosis?
Tanned skin Thirst Weight loss Arthralgia Jaundice Haematemesis Erectile Dysfunction
37
How is haemachromatosis inherited? What gene is affected?
Autosomal Recessive HFE gene - chromosome 6
38
How does haemachromatosis typically present?
Screening of 1st degree relatives Asymptomatic with raised ferritin Symptomatic: - Arthralgia - Sexual dysfunction - Lethargy
39
What are some complications of haemachromatosis?
Pseudogout Diabetes Bronze skin Erectile Dysfunction Dilated Cardiomyopathy Chronic Liver Disease Hepatocellular Ca Synovitis
40
What may you see on examination in a patient with haemachromatosis?
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
What is haemachromatosis?
Common genetic disorder leading to increased iron absorption. Particularly affect liver, heart, pancreas and anterior pituitary
42
What are important differentials for haemachromatosis?
Alcohol excess - can lead to raised ferritin, inc. risk of diabetes and joint disease and can lead to cirrhosis and HCC
43
How is haemachromatosis diagnosed?
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
How is haemachromatosis investigated?
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
How is haemachromatosis screened?
Patients with first degree relatives should be screened Ferritin and Transferrin sats
46
How is haemochromatosis managed?
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
What is the prognosis of haemachromatosis?
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
Which patients with haemachromatosis req. further specialist Ix?
Ferritin >1000 AND Raised transaminase Refer to hepatology for fibrosis assessment. Elastography done for these patients - may need biopsy
49
Signs on general inspection for IBD?
Young, pale, cachectic patient TPN line Finger clubbing Skin signs - erythema nodosum/pyoderma
50
Abdo examination features to look for in IBD?
Scars - laparotomy, previous stoma, healed enterocutaneous fistula Masses - RIF Tenderness Stoma Bowel sounds
51
Other signs to look for when considering IBD?
Immunosuppression - steroids, ciclosporin, azathioprine Extraintestinal: - aphthous ulcers in mouth - Arthropathy - Conjunctivitis/episcleritis/ant. uveitis
52
Investigations to order when considering IBD as a primary differential?
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
How is a flare of Crohns managed?
Hospital admission if severe/systemically unwell Mild/Mod - PO steroid --> 5ASA Severe - IV steroid --> IV infliximab
54
What is the maintenance therapy for Crohn's?
Azathioprine MTX TNF alpha inhibitors - infliximab/adalimumab
55
How is a flare of UC managed?
Mild/Mod -Topical 5ASA (mesalazine) --> PO --> Steroids Severe - IV steroids - IV ciclosporin
56
Maintenance management for UC?
Oral 5-ASA PO steroids PO Azathioprine Surgery - can be curative for disease refractory to medical mx.
57
What non disease modifying treatment is considered in IBD?
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
What are the complications associated with Crohn's disease?
Malabsorption - in particular B12 Anaemia Strictures Fistula Fissures Abscess Intestinal Obstruction Renal stones Pyoderma/erythema nodosum
59
What complications are associated with UC?
Colorectal Ca Anaemia - bleeding Toxic megacolon Perforation PSC Cholangiocarcinoma
60
What is the surveillance plan for patients with UC?
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
What are some differentials for IBD?
Infection - TB, Yersinia, Campylobacter Ischaemia Coeliac Malignancy Radiation
62
What are the types of renal transplant?
Live donor Cadaveric - brain/cardiac
63
What should you be looking for when you suspect renal transplant?
Signs of renal replacement Signs of prev. renal replacement Clues for aetiology Side effects of treatment Complications of ESRF Adequacy of renal replacement
64
Signs of renal replacement to look for?
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
Signs of complications of ESRF?
Pallor - anaemia Parathyroidectomy scar - secondary or tertiary hyperparathyroidism Renal osteodystrophy
66
Side effects of immunosuppresion to look for?
Ciclosporin - gum hypertrophy, hirsutism, HTN Steroids - cushingoid, purpura, thin skin Evidence of skin malignancy Tacrolimus - fine tremor
67
Clues to aetiology for Renal Transplant
Palpable kidneys - PKD Nephrectomy scar - likely PKD HTN Fingerprick marks - CBG testing
68
How to check for adequacy of renal replacement?
Fluid status Signs of uraemia
69
Possible causes for renal failure?
HTN Diabetes Glomerulonephritis ADPKD SLE, Alports, Tuberous Sclerosus, MPGN 2
70
Investigations to order prior to renal transplant
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
How are renal transplants managed?
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
What are the indications for urgent dialysis?
Refractory hyperkalaemia, acidosis or fluid overload Uraemic pericarditis/encephalopathy Removal of drugs in severe OD - salicylates/Lithium
73
What are some complications of renal transplant?
Graft complications - Rejection - Nephrotoxicity of calcinurin inhibitors - recurrence of disease - Renal artery stenosis/thrombosis Others: - Malignancy secondary to immunosuppresion - Accelerated CV risk
74
When would RRT be considered?
CKD stage 4/5 - GFR <30 OR CKD stage 3 but rapidly progressing (30-60)
75
What are the complications of AV fistula?
Infection - cellulitis, abscess, bacteraemia, septic emboli Thrombosis Stenosis Aneurysm Steal syndrome - weak pulse, cold painful hand, contracture Ischaemic polyneuropathy High output cardiac failure
76
What are the options for vascular access in RRT?
AV fistula AV graft Tunnelled venous catheter Non-tunnelled venous catheter
77
How is hereditary spherocytosis inherited?
Autosomal Dominant - most common chromosome 8 Defect in one of 5 genes encoding RBC proteins
78
How does hereditary spherocytosis present?
Anaemia Jaundice Splenomegaly Can be picked up through screening Neonatal jaundice
79
What are the complications of hereditary spherocytosis?
Aplastic crisis - typically infection Anaemia Gallstones
80
How is hereditary spherocytosis diagnosed?
FBC - reticulocyte count and MCH - raised Blood smear - spherocytes/haemolysis Haemolytic screen - LDH (high), haptoglobin (low), split bilirubin (high unconjugated) Coombs test with EMA binding Osmotic fragility test
81
How is hereditary spherocytosis managed?
Folic acid Anaemia --> blood transfusions Splenectomy - need prior vaccinations Cholecystectomy if gallstones Prophylactic Abx Vaccinations inc meningococcal, pneumococcal + influenza
82
Differentials for isolated splenomegaly
CML Myelofibrosis Malaria
83
Some symptoms which may lead you to suspect splenomegaly?
Anaemia Fatigue Lymphadenopathy Early Satiety Easy Bruising Night Sweats Weight loss
84
What is Felty's Syndrome?
Triad: - RA - Neutropaenia - Splenomegaly
85
How can splenomegaly be subcategorised by size?
Mild - 1-3cm Mod - 4-8 cm Massive - >8cm
86
What signs would you look for if you palpate splenomegaly?
Massive - only a few causes Anaemic Lymphadenopathy Purpura CLD signs - portal HTN Peripheral stigmate IE RA - Felty's Jaundice - haemolytic anaemia
87
Causes of massive splenomegaly?
CML Myelofibrosis Malaria Visceral Leishmaniasis HIV
88
Causes of splenomegaly
Haematological - lymphoma, myelodysplastic syndromes Pressure - portal HTN, splenic vein thrombosis Infection - malaria, EBV, leischmaniasis, bacterial endocarditis, Hep B/C Inflammatory - Felty Infiltration - Gauchers, amyloidosis
89
How would you investigate splenomegaly?
Bedside - urine dip Bloods: FBC, U&E, LFT, Coag Blood film LDH/haemolytic screen Autoimmune screen BC's HIV test Viral serology - inc. EBV Malaria Film Imaging: CXR - look for bihilar lymphadenopathy Echo CT TAP - if suspected malignancy US abdominal- spleen size and hepatic disease/portal HTN/splenic vein thrombosis Special: Bone marrow aspirate/trephine LN biopsy
90
What are the indications for splenectomy?
Traumatic injury + significant blood loss, haemodynamic instability, progressive anaemia Haematological disease not responding to medical mx - ITP, hereditary spherocytosis, thalassaemia major Lymphoma (rare)
91
What are the complications of splenectomy?
Infection - encapsulated organisms, malaria, babeosis Thrombocytosis
92
What are some examples of encapsulated organisms?
Neisseria Pneumococcus Haemophilus
93
What measures are taken to protect people with splenectomy?
Pre-op vaccines >2weeks before ideally Prophylactic Pen V Medical alert bracelet
94
When to consider chronic pancreatitis as a differential?
Normal exam Epigastric pain (may say go through to back) Fentanyl patch Look for signs of steroid use/ETOH xs/cholecystectomy scar
95
Common causes of pancreatitis?
Gallstones Ethanol Trauma Drugs - Steroids, azathioprine Hypertriglyceridaemia, hypercalcaemia Smoking ERCP Genetic - CF, PRSS1, SPINK
96
Key things in clinical assessment of pancreatitis
Diarrhoea Weight loss Features of malabsorption Bloods - albumin, FBC, Mg, Vit D Faecal elastase (low if exocrine insufficiency)
97
How is chronic pancreatitis managed?
Stop ETOH and smoking Treat underlying cause Replace Vit D if required. Creon with PPI Analgesia - paracatamol, NSAID's, opioids ERCP if ductal stricturing Whipple's resection/pancreatectomy can be done
98
Complications of pancreatitis
Pseudocysts Ductal stricturing Chronic calcific plaques --> biliary obstruction Duodenal strictures Pancreatic malignancy Acute - SIRS/Sepsis response/Resp Failure

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