Abdomen Flashcards
Stigmata of Liver Disease in the nails
Leuconychia
Nail clubbing
Terry’s nails (2/3 white, 1/3 red)
Stigmata of Liver Disease in the hands
Palmar erythema
Dupuytren’s contracture
Needle track marks
Xanthelasma
Asterixis
Stigmata of Liver Disease in the arms
Jaundice
Bruising
Excoriations
Spider naevi
Tattoos
Skin bronzing
Paper money skin
Abdominal causes of nail clubbing
IBD
Coeliac disease
AV fistulae
Infected grafts of the aorta
Hyperthyroidism
Signs of portal hypertension
Splenomegaly
Caput medusa
Oesophageal varices on endoscopy
Ascites
Three most common causes of CLD
ETOH excess
Chronic viral hepatitis
Non-alcoholic hepatic steatosis
Causes of CLD
Alcohol
Chronic viral hepatitis
Non-alcoholic hepatic steatosis
Autoimmune - AIH, PBC
Metabolic - haemochromatosis
Complications of CLD
Portal hypertension
Haemorrhage
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Hepatorenal syndrome
Hepatopulmonary syndrome
Criteria for grading of hepatic encephalopathy
West Haven
Parameters of Child-Pugh score for cirrhosis
Encephalopathy
Bilirubin
INR
Ascites
Albumin
Classification of jaundice
Pre-hepatic - excessive breakdown of RBCs
Hepatic - hepatocyte injury
Post-hepatic - obstruction of normal flow of bile
Pathology of hepatorenal syndrome
Inadequate hepatic breakdown of vasoactive substances, leading to excessive renal vasoconstriction.
Can be rapid (T1) or slow (T2).
Kidneys attempt to conserve salt and water due to presumed hypovolaemia. Results in low volume, highly concentrated, low sodium urine.
Management of ascites with associated CLD
No-added-salt diet
Spirinolactone
Loop diuretics
Therapeutic parecenthesis
TIPS
Surgery
Common causes of ascites
Cirrhosis with portal hypertension
Malignancy
Congestive cardiac failure
Nephrotic syndrome
Uncommon causes of ascites
Budd-Chiari syndrome
Portal vein thrombosis
Constrictive pericarditis
Malabsorption
Peritoneal mesothelioma
Tuberculosis peritonitis
Myxoedema
Ovarian diseases
Pathology of ascites in CLD
Renal hypoperfusion increases renin -> increases aldosterone
Deficient hepatic metabolism reduces aldosterone and ADH breakdown
Hypoalbuminaemia reduces oncotic pressure
Third-spacing further reduces renal perfusion
Most common causes of hepatomegaly
Congestive cardiac failure
Malignancy
Lymphoma
Scoring systems for acute alcoholic hepatitis
Maddrey’s discriminant function test - score >32 indicates 50% mortality and need for steroids (40mg prednisolone)
Mayo End Stage Liver Disease score (MELD)
Glasgow alcoholic hepatitis score
Felty’s syndrome triad
Rheumatoid arthritis
Splenomegaly
Neutropenia
Complications of Felty’s syndrome
Recurrent infection
Hypersplenism (anaemia and thrombocytopenia)
Skin hyperpigmentation
Cutaneous ulceration
Hepatosplemomegaly + Parkinsonism, dysarthria, Kayser Fleischer rings, neuropsychiatric issues
Wilson’s disease
Hepatosplenomegaly + xanthoma and xantholasma
Primary biliary cirrhosis
Hepatosplenomegaly + arthropathy
Haemochromatosis
Common causes of hepatosplenomegaly
Infective
Myeloprolipherative and lymphoproliferative diseases
Cirrhosis with portal hypertension
Most common causes of hepatosplenomegaly worldwide
Malaria:
Vivax and ovals both have hepatic lifecycles
Falciparum may still be associated with hepatosplenomegaly
Visceral leishmaniasis (kala-azar)
Schistosomiasis
Genetic basis of Wilson’s disease
Mutation of adenosine triphosphate 7B gene
Cause for accelerated iron accumulation in haemochromatosis
Alcohol
Causes of a distended abdomen
Fat
Faeces
Fetus
Flatus
Fluid
Surface markings of the aorta
Epigastrium
Left of the midline
Bifurcates at L4/5
Surface markings of the gallbladder
Right midclavicular line crosses the right costal margin
Surface markings of the kidneys
Hila of the kidneys lies on the transpyloric plane of Addison (lowest points of left and right costal margins - L1)
Surgeries associated with Mercedes Benz scar
Top differential: Liver transplant
DDx:
Radical gastrectomy
Whipple’s procedure
Bilateral adrenalectomies
Commonest cause for liver transplantation
Alcoholic liver disease
Is chronic hepatitis C an accepted indication for liver transplantation
Yes
What is the overall estimated survival following liver transplantation?
~60% over 15 years
King’s College Hospital criteria for liver transplantation - Paracetamol-induced
Lactate >3.5 4 hours following resus
OR
pH <7.3 or lactate >3.0 12 hours following resus
OR
Any 3 of:
INR >6.5
Cr >300
Encephalopathy III or IV
King’s College Hospital criteria for liver transplantation - Non-paracetamol-induced
Lactate >3.5 4 hours following resus
OR
INR >6.5
OR
Any 3 of:
INR >3.5
Age <10 or >4
Bili >30
Jaundice >7 days
Drug reaction
Immunosuppressive drug regimens post-transplant
Corticosteroids in combination with calcineurin inhibitors (tacrolimus/ciclosporin) and antiprolipherative agent (mycophenolate mofetil)
Other forms of liver support in lieu of liver transplant
Molecular adsorbents recirculation system
Extracorporeal liver assist devices
Demetriou
Heterotopic liver transplantation
Extra abdominal features of IBD
Finger clubbing
Uveitis
Large and small joint arthropathies and sacroiliitis
Pyoderma gangrenosum
Erythema nodosum
Peripheral oedema (hypoalbuminaemia)
Cushingoid changes (steroids)
Histological differences in IBD
Crohn’s disease - granulomas
Ulcerative colitis - crypt abscesses
IBD with evidence of fat malabsorption (steatorrhoea, vitamin deficiencies)
Crohn’s disease
Grading of IBD flair
Truelove and Witts criteria
Management of ileal and colonic Crohn’s disease
Mild: aminosalicylates (mesalazine)
Severe: oral or IV steroids
Steroid sparing: azathioprine
Refractory disease: infliximab
Surgery if medical management fails
Management of perianal and fistulating Crohn’s disease
Simple: antibiotics (metronidazole/ciprofloxacin)
Infection excluded: azathioprine
Complex/refractory: surgery/infliximab
Maintenance therapy for Crohn’s disease
Smoking cessation
Azathioprine
Methotrexate
Infliximab
Management of severe exacerbation of ulcerative colitis
IV hydrocortisone
THEN
IV ciclosporin if no improvement in first 3 days
When to consider surgery in IBD
Toxic dilatation
3 days of intensive treatment with >8 stools/day and CRP >45
UC with no response after 10 days of intensive treatment
Aetiology of sclerosing cholangitis
Primary: auto-immune
Secondary: IBD (UC in particular)
Auto-antibodies associated with primary sclerosing cholangitis
p-ANCAs
ANA
Anti-SM
Sclerosing cholangitis complications
Biliary obstruction
CLD
Liver failure
Liver transplantation
Cholangiocarcinoma
When to initiate a patient with Crohn’s disease on anti-TNF therapy
All 3 of:
Severe active disease
Refractory to steroids and steroid sparing agents or intolerant to those drugs
Surgery is inappropriate
Causes of epigastric mass
Carcinoma of stomach or pancreas
Abdominal aortic aneurysm
Lymphoma
Caudate lobe of liver
Causes of right iliac fossa mass
Crohn’s disease
Caecal carcinoma
Ileocaecal mass (amoebic abscess, ileocaecal tuberculosis, appendicular mass, ileal carcinoid, lymphoma)
Ovarian tumour
Renal transplant
Causes of left iliac fossa mass
Carcinoma of sigmoid colon
Diverticular mass/abscess
Faecal mass
Ovarian tumour
Renal transplant
Causes of unilateral renal enlargement
ADPKD
Hydronephrosis (rarely palpable)
Renal tumour
Congenital renal abnormalities
Causes of bilateral renal enlargement
ADPKD
Hydronephrosis
Bilateral renal tumours
Amyloidosis
Congenital renal abnormalities
Extrarenal manifestations of ADPKD
Cysts in other organs (liver, pancreas, arachnoid cysts)
Intracranial berry aneurysms
Polycythemia
Hypertension
Valve disease (mitral prolapse most common)
Diverticular disease
Aortic aneurysm Lymphoma Caudate
Abdominal wall hernias
Causes of abdominal pain in ADPKD
Infected cysts
Haemorrhage into cyst
Complications of chronic kidney disease
Anaemia
Parathyroidectomy
Pseudoclubbing
Scratch marks
Uncontrolled hypertension
Atherosclerotic disease
Signs of RRT
Tunnelled dialysis catheter scars
AV fistula/graft
Peritoneal dialysis catheter scar
Previous renal allograft
Skin changes of chronic immunosuppression (premature ageing, malignancy, warts)
Complication of transplant in Alport’s syndrome
Defect in type IV collagen
New transplant exposes body to new antigens
May develop anti-glomerular basement membrane disease
Opportunistic infections assiciated with renal transplantation
Cytomegalovirus
Pneumocystis jiroveci
EBV
BK virus
JC virus
Most common cause of death in renal transplant
Accelerated CVD
THEN
Malignancy and infection related to chronic immunosuppression
Drainage of pancreas transplant
Now primary enteric drainage
Previously bladder drained - pancreatitis, haematuria, UTI, metabolic acidosis
Complications of post-transplant immunosuppression
Infections
Malignancy
- solid organ tumours
- post-transplant lymphoproliferative disorder
- skin malignancies
Metabolic
- HTN
- hyperlipidaemia
- post-transplant diabetes mellitus
- post-transplant anaemia
CVD
Chronic transplant injury
- nephrotoxicity
Morphological changes
- gingival hypertrophy
- hirsutism
- cushingoid changes
- acne vulgaris
Eponymous name for hereditary haemorrhagic telangiectasia
Osler-Weber-Rendu
Complications of hereditary haemorrhagic telangiectasia
Recurrent epistaxis
GI haemorrhage
Anaemia
Complications of AVM in internal organs (strokes, SAH, haemoptysis)
Heyde’s disease features
Aortic valve stenosis
Colonic angiodysplasia
Improved after aortic valve replacement
Consumptive deficiency of vWF due to sheer forces around valve
Peutz-Jeghers syndrome features
Hamartomatous polyps in the GI tract
Hyperpigmented macules on the lips and oral mucosa
Benign lesions but increased risk of malignancy in solid organs not related to polyps
How to present chronic liver disease
Clinically relevant findings
Stigmata of chronic liver disease
Evidence of decompensation
Aetiological clues
How to present kidney transplant
Presence of transplant
Is it working?
- volume status
- current RRT
Evidence of previous RRT
Aetiology of end stage renal failure
Definition of end-stage renal failure
GFR <15
Inheritance of PKD
Autosomal Dominant
PKD1 - chromosome 16
- presents earlier, faster progression to ESRF
- 80%
PKD2 - chromosome 4
Most common cause of death in PKD
Cardiovascular disease
Indication for nephrectomy in PKD
Recurrent UTI
Chronic pain
RCC
Bulky disease - planned transplant
How to present splenomegaly
Size of spleen
Evidence of liver disease
Evidence of haematological disease
- anaemia, lymphadenopathy, jaundice
Evidence of thyroid disease
Evidence of rheumatoid arthritis - Felty’s disease
Immunosuppression side effects in transplantation
Skin lesions - sebhorreic warts, actinic keratoses, excision scars for skin cancers
Steroid side effects
- diabetes (bruising to abdomen from insulin injections/finger prick marks)
- unlikely to be Cushingoid
Tremor - tacrolimus
Gum hypertrophy - ciclosporin
Most common causes for liver transplantation in the UK
Cirrhosis
HCC
Acute fulminant liver failure
Process for listing patients for liver transplant
MDT
Elective:
- must meet certain criteria: CLD and UKELD >48
- prognosis scores used: must have 5 year survival score >55%
- other specific criteria
Super-urgent:
- King’s College Criteria
Typical presentation of chronic pancreatitis
Pain
- flares can be associated with food
- gnawing pain
- epigastrium radiating to back
- worse sitting up and forwards
Malabsorption
- steatorrhoea
- weight loss
- low faecal elastase
Common causes of pancreatitis
Gallstones
Alcohol
Hypercalcaemia
Hypertriglyceridaemia
Smoking
IgG4 disease (autoimmune pancreatitis)
ERCP
Genetic
Drugs - azathioprine
Fat malabsorption sign
Steatorrhoea
When to treat pancreatic insufficiency
Even before clinically apparent
Improves long term outcome
Tests for pancreatic insufficiency
Hx:
- diarrhoea
- weight loss
BMI
Bloods
- FBC
- albumin
- vitamin D
Faecal elastase
- will only be low in moderate to severe
Magnesium levels
- most helpful
Imaging
Treatment for pancreatic insufficiency
Creon
- given before or during meals
- 75-125000
- lower for snacks
- PPI is essential
Healthy balanced diet
Complications of chronic pancreatitis
Type 3 DM
Pancreatic duct strictures
- whipples, stenting etc
Pseudocysts
- if persistent beyond 6 weeks -> axios stent
Compressive biliary obstruction
- metal stents or biliary bypass
Duodenal stricture
- covered stent or bypass
Pancreatic malignancy
- EUS with FNA
- imaging
- MDT
Management of chronic pancreatitis
Smoking and alcohol cessation
Treat underlying cause
Treat insufficiency
Manage pain
- NSAIDs
- pregabalin/gabapentin
- morphine
- fentanyl
Treat vitamin D deficiency
