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A PACES > Abdomina > Flashcards

Abdomina Flashcards

1
Q

What is murphys sign

A

Hold over liver - deep breath

Pain on inspiration

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2
Q

What may cause a Left flank scar?

If you found a readily ballotable mass on the right side that moves posteriorly with respiration what would the answer be?

A

adrenalectomy or nephrectomy

PCKD

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3
Q

Young patient with bilaterally enlarged kidneys. You suspect polycystic kidney disease.

You notice that they also have a hemiparesis.

A

subarachnoid haemorrhage

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4
Q

Partial vs complete nephrectomy pros and cons

A

Partial
Higher risk of recurrence
Preservation of renal function

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5
Q

RCC gender?
age?
Type?

A

Male predominance
30-50

Clear cell RCC (up to 70%,
Papillary RCC (2nd most common)
Chromophobe RCC

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6
Q

Where do clear cell RCC come from? Gene?

A

originating in the proximal tubule with a 3p deletion)

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7
Q

Classic symptoms of a rcc

A

Haematuria
Flank mass
Loin tenderness

Note this triad only in 10%

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8
Q

Investigations for suspected RCC

A

Full blood count - (Anaemia and polycythaemia)
Urea and electrolytes
Bone profile (especially calcium)
Liver function tests
Thyroid function tests
Clotting profile
Urine

Urine dip for haematuria and proteinuria
Culture to ensure no infection
Imaging

Staging computer tomography scan of the chest, abdomen and pelvis
If concerns about bone metastases, then magnetic resonance imaging of the brain and spine and/or nuclear medicine bone scan
Histopathology

Biopsy of identified mass

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9
Q

Gold standard management of RCC?
Name another option?

A

nephrectomy (total / partial)

Tyrosine kinase inhibitors (sunitinib (also a VEGF inhibitor) and pazopanib)

[Multikinase inhibitor (sorafenib)

Anti-vascular endothelial growth factor monoclonal antibody (bevacizumab)

Mammalian target of rapamycin inhibitors (temsirolimus and everolimus)]

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10
Q

RCC outcome predictors

A

Staging
tumour Size (</> 7cm),
Nuclear Grade
the absence/presence of tumour Necrosis)

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11
Q

Renal transplant exam?

To finish?

A

End of bed - diabetes

Hands - finger pricks
Tremor - Tacrolimus

Fistula in arm - check both
- Palpate and auscultate
- If no thrill / brui likely non functioning
- Raise up and see if collapses -> poor flow

Face
Eyes corneal arcus

Mouth
Gingival hypertophy - ciclosporin

Neck
JVP
CVC scar
Parathyroidectomy scar

Chest
Tunneled scar

Back
Scar - nephrectomy

Abdo
Scars
- Midline could be pancreas + kidney transplant
- Appendix
- Muliple transplants
-Port sites - Laproscopic / peritoneal dialysis scars
- Lipohypertrophy - diabetes
Palpation
- Dont forget spleen and liver exam + PKDs
Auscultate - bruis

Blood pressure
Urine dip
Full fluid assessment

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12
Q

Indications for polycystic kidneys nephrectomy

A

Make room for donor kidney

Recurrent infections

Impact bowel - pressure reduces absorption

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13
Q

Most common reasons for renal transplant name 5

A

Diabetes - 50%

Young - reflux neuropathy

Hypertensive renal disease

PCKD

Glomerulonephritis

CKD of uncertain aetiology sometimes with multiple risk factors

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14
Q

Present renal transplant exam

A

This patient has end stage renal disease as evidenced by…
Kidney transplant, dialysis line, fistulaetc

Then try and explain aetiology
This may be secondary to
- diabetes (finger prick marks, isulin marks.
- PCKD - balotable kidney

Previous forms of RRT - are they functioning

Any evidence of immunosupressive therapy
- Gingival hypertophy ?ciclosporin
- Tremor ? tacrolimus

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15
Q

Investigations in renal tranplant?

Extra if suspicion of Tx failure?

A

U&Es / renal function
Bone profile - Ca Po4
Consider PTH/vit D if chronic
Diabetic HbA1C

Trough levels of immunosupression if on

Imaging
Transplant ultrasound (looking at blood suply)

If concerned about acute failure - biopsy of transplant

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16
Q

Common viruses to worry about in renal transplant

A

CMV especially if donor positive

BK virus

EBV

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17
Q

What are the principles of the management of people with CKD ?

A

CKD
- Follow up based on severity / progression
- Patient education
- Sick day rules
- Medications Eg ACEi for proteinuria
- Discussion on the aetiology eg diabetes

Managment of complications
- CV health, BP, Cholesterol, smoking
- Renal anaemia - IV iron / Epo
- Acidosis - oral bicarb
- Fluid balance - diruetics
- Uraemia once symotomatic eg effusions / apetite -> Dialysis
- HyperK - diet / binders
- Bone disease - phosphate binders
- Parathyroidism - vit D supplements

As they progress discussions around management of end stage.
- Pros and cons of Haemo/Peritoneal dialysis
- Transplant

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18
Q

Drug for PCKD

A

Tolvaptan

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19
Q

Renal tranplant drugs specific side effects
Steroids
Tacrolimus
Ciclosporin
Azathioprine
Mycophenolate

A

Steroids
- Cushingoid, thin skin, easy brusing
- diabetes, bone demineralisation

Tacrolimus
- diabetes
- Nephro/Neurotoxicity

Ciclosporin
- Gum hypertrophy
- Hypertension
- nephro/Neurotoxicity
- Headaches, insomnia, hairgrowth

Azathioprine
- Pancytopenia (marrow supression)
- Pancreatitis
- TMPT deficiency -> build up of toxic products -> marrow suppression

Mycophenolate
GI upset

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20
Q

When refer CKD for RRT

A

Risk stratification tool
Kidney failure risk equation calculator
- 5 year risk over 5%

Other NICE guidance
- ACR of 70 mg/mmol or more, unless known to be caused by diabetes and already appropriately treated
- ACR of more than 30 mg/mmol (ACR category A3), together with haematuria
-a sustained decrease in eGFR of 25% or more and a change in eGFR category within 12 months
-a sustained decrease in eGFR of 15 ml/min/1.73 m2 or more per year
-hypertension that remains poorly controlled (above the person’s individual target) despite the use of at least 4 antihypertensive medicines at therapeutic doses
-known or suspected rare or genetic causes of CKD
-suspected renal artery stenosis.

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21
Q

Haemodialysis and peritoneal dialysis pros and cons

A

“There are pros and cons of each and need to come to a shared decision together with the individual patient”

Haemo
- Intermittent therapy (not daily)
- Social interaction
Cons
- Travel time
- Infection of lines
- fistula take a while to mature

Peritoneal
- Start treatment quickly (compared to fistula)
- Can do anywhere
Cons
-

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22
Q

AV fistula complications

A

Bleeding

Failure - up to 20% need extra op to work in first 6 months

Clotting

Decreased vasular supply to hand

Running out of access

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23
Q

Differences UC and crohns

A

UC
- Only affects mucosa
- Crypt abscessess
- More distal and confluent rather than patchy
- Usually presents with bloody diarrhorrea
Flare over days to weeks

Crohns
- Transmural inflammation Affects anywhere and through to muscle- hence risk of strictures and fistula
- Patchy from mouth to anus
- Cobblestoning
- Terminal ileum
- Usually abdo pain and weight loss
flare much more slowly progressive over weeks / months

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24
Q

Ibd exam

A

Hands
Clubbing rare in IBD
Palmer erythema rare
Check for arthalgia in hands

Arms
Picc lines
Enthesitis elbows

Face
Eyes Pallor and anaemia
Mouth - ulcers

Neck
Line scars

Quick look at back for scars

Precuss spine + movements

Abdo
Scars inc port scars especially umbilical

Stoma also check under bag

Legs
Ulcers

I would like to complete exam with
- perianal and PR exam
- Review a stool chart

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25
Q

IBD history? Differentials?

A

Pain Socrates

Worse after meals approx 1hr (crohns)

Anaemia symptoms
- SOBOE
- Postural hypotension

Weight loss
- are your clothes looser
- Has anyone commented if you’ve lost weight

Extra-intestinal symptoms
- Arthralgia
- Sore red eye
- Ever had issues with jaundice
- Painful mouth ulcers

Differentials
- Coeliac
Similar symptoms unlikely blood in stool
Very itchy Rash on elbows and knees
- IBS
No blood / weight loss
No night symptoms
- Infection
Giardia more chronic and may get post infective symptoms
- Older patient
Diverticular disease
Bowel Ca
Ischemic colitis - vascular hx

PMH
- CV / AF history - ischemic colitis
- Autoimmune conditions
- Recent hospital admission - C diff
- Travel history

DH
- Recent abx
- Immunocompromised

FH
- Autoimmune

Social history
- Impacting life
- Smoking worsens crohns
- Alcohol

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26
Q

IBD investigation? gold standard diagnosis?

A

Bedside
Full gastro exam
Observations esp tachycardia / pyrexia
Stool chart

Routine
FBC
LFTs - association with IBD
Haemetinics b12/folate/ferritin
U&Es

Microbiology
- Stool cultures
- Blood cultures

  • Anti TTG for coeliac

Imaging
AXR - toxic megacolon
If unwell - consider CT
If stable and for clinic consider MRI

Special
- UC - consider sigmoidoscopy
- Refer to gastroenterology to consider colonoscopy with biopsies

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27
Q

IBD management - acute?
Chronic

A

Acute flare
- IV steroids
- Clexane
- Ciclosporin / infliximab rescue therapy

Conservative
- Psych support
- Smoking cessation
- Nutritional support Eg TPN in severe flares / short bowel syndrome
- IBD nurses / stoma nurses

Mild crohns
- Oral budesonide (not absorbed out gut)
Mild UC
- Mesalazine eg rectal

Surgery
Crohns - resection of bit / perf / strictures
UC - colectomy

Maintenance
- Vit D and calcium
- aim for steroid sparing
- Azathioprine - check TPMT
(If not tollerating / pancreatitis mercaptopurine)
- May need infliximab / adalidumab

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28
Q

Before starting biologics what do you need to screen for

A

HepB/C and HIV

If anti-TNF - TB screen eg quanteferon and CXR

Herpes zoster

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29
Q

Why do people over 60 tend not to get thiopurines eg azathiopurine?

A

Risk of Ca
-> Often moved to biologic

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30
Q

Whhy high risk of VTE in flare of IBD

A

Protein losing state

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31
Q

Crohns complications

A

Fistula / perforation / strictures

Sexual confidence / psych

Cancer - especially UC -> surveillence colonoscopy

If on biologics - high risk for skin Ca

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32
Q

Screening for gestational diabetes in preg

A

Around 24 weeks with any risk factor
Pref GDM, Hypertensive, BMI >30 ethnic background, 1st degree relative, 2x glycosuria

Glucose tollerance test
fasting > 5.6, 2 hr >7.8

[5, 6, 7, 8]

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33
Q

Gestational diabetes key issues

A

Macrosomia
-> risk of shoulder dystocia

Also risk of miscarriage, preeclampsia, pregnancy hypertension

May unmask longstanding t2dm

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34
Q

Management for gestational diabetes

A

Initially lifestyle advice
- Food eg not snacking before bed., exercise
- Can use apps to monitor sugars and help with engagement

then metformin after 1-2 weeks

then insulin after 1-2 weeks - usually start in evening approx 2-4u and increase every 2 days

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35
Q

Post partum with GDM what do they need to do?

A

Usually can stop insulin and check HBA1C after 3 months
(60-70% risk of T2DM)

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36
Q

Risk of VTE in preg?

A

4x usual population and risk remains for 4-6 weeks post partum

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37
Q

d dimer in preg

A

non validated for VTE screen - usually around 2-3x baseline

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38
Q

SOB in pregnancy

A

Anaemia
Asthma (especially as reflux triggers)
PE
Pneumonia
Cardiomyopathy
Physiological breathlessness in pregnancy

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39
Q

What is physiological SOB in pregnancy

A

Often history “when I talk on the phone my friends think Im breathless”

No history orthopnea
no SOBOE up stairs

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40
Q

SOB in preg ix

A

FBC anaemia - often around 100 is normal
ECG - cardiolymopathy
CXR - pneumonia
If PE risk CTPA

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41
Q

Can you thrombolyse in pregnancy

A

Yes

Half life is around 5-10 mins

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42
Q

Hypertension in pregnancy vs pre existing

A

If before 20 weeks = pre existing

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43
Q

Hypertension in pregnancy issues?

A

Pre term delivery
Small baby
Miscarriage / stillbirth

Pre eclampsia. HELLP syndrome
Placental abruption

Longer term
CKD / HF / IHD / CVA usuals

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44
Q

How to check BP in pregnancy to confirm htn

A

Check in calm environment after 5 minutes rest

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45
Q

Management of hypertension in pregnancy

A

Ensure BP taken in correct environment

Lifestyle advice

Pre eclampsia screen Check urine dip for proteinuria
Headache, flashing lights, RUQ pain, new snoring

Treat anything over 140/90
Labetalol
Methyl dopa
Nifedipine
Hydralazine
Doxazosin

Also give aspirin 75mg OD to reduce risk of pre-eclampsia

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46
Q

Hypertensive emergency in pregnancy is? Rx?

A

160/90 and hyperreflexic

IV labetalol / hydralazine
Mgs04
High likelihood of delivering baby

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47
Q

Asthma in pregnancy management which drugs? Whatextraa?

A

All drugs safe
Check peak flows (should be nomal)

Often add in omeprazole as reflux may be trigger

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48
Q

Antiepileptics in pregnancy

A

Aim to move to 1 agent
Leveteraceitam / lamotrigine

Can treat any status
Eg IV phenytoin

Give folic acid 3 months before and throughout pregnancy

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49
Q

Heart failure in pregnancy main drugs

A

Can use b blockers
Furosemide

Going to get echo / ECG

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50
Q

basic pathophysiology PCKD ? Genes

A

Most commonly autosomal dominant PKD

ADPKD 1 - Polycystin 1 (chromosome 16) (85%)

ADPKD 2 - polycystin 2 (chromosome 4)

Genetic condition where renal tubules are abnormal -> fluid filled cysts
As they grow they can compress healthy renal tissue

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51
Q

Formal diagnosis of PKD

A

If family history -> US to diagnose

[Under 30 - at least 2 cysts on one or both kidneys
30-59 - at least 2 cysts on each kidney
60+ - 4 or more cysts on each kidney]

If no family history and young
-> Consider MRI and genetic testing as may be denovo mutation

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52
Q

PKD exam

A

End of bed
- Often younger <60 years
- Neurological deficit eg walking aids

Hands
- Nil
- Check for uraemic flap esp failing transplant or awaiting transplant

Arms
- Fistulae + auscultate and palpate for thrill
- If still being used there will be a visible needling point

Head and neck
- Anaemia and pallor (note may have polycythaemia)
- JVP

Chest
- Scars on chest from tunnelled line

Back
-scars - don’t miss left sided nephrectomy scar
Auscultate lungs at bases

Abdo
- Inspect -> PD scars
- Palpate for all organs
- Hepatomegaly may indicate hepatic cysts
- Percuss liver and spleen
- May hear a bruis of transplant

Legs
- Pedal oedema for fluid status

I would like a urine dip, and blood pressure

(if pressed for rest of abdo exam - hernial orifices, external genitalia and PR)

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53
Q

PKD present to examiner

A

Decide on whether they have end-stage disease

This patient has end stage disease as evidenced by Eg fistula / lines / transplant / nephrectomy scar
- This is likely due to PKD

They are currently getting renal replacement therapy via …

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54
Q

Differentials for ballotable kidney

A

Bilateral
- ADPKD
- Tuberous sclerosis
- Von Hippel lindau
- Amlyidosis
- Bilateral hydronephrosis
- Bilateral RCC

Unilateral
- ADPKD with nephrectomy
- RCC
- Unilateral hydronephrosis

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55
Q

Investigations with PKD

A

Blood pressure

Urine dip

Bloods
- U&Es
- Albumin creatinine ratio
- FBC - anaemia / polycythemia
- Bone profile
- Cholesterol
- Consider genetic testing if no family history

Imaging
- If positive family history -> US first line
- CT / MRI - lets you look at true cyst burden which helps as indicator for whether patient can be given tolvaptan

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56
Q

Management of PKD

A

Acute management of rupture / haemorrhage / infection

Conservative
Patient education
Genetic counciling
- Progression and rate of CKD
- HTN and CV risk
- Salt restriction

Medications
- Blood pressure control ACEi first line
- Statins if required
- AVOID NSAIDs
- Tolvaptan - vasopressin antagonist

Complications
- Infections / radiological drainage
- Anaemia - iron supplementation / EPO
- Aim to avoid blood transfusions to avoid sensitisation of patient
- RRT

Surgical
- Recurrent infections etc

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57
Q

Who can get tolvaptan in PKD

A

CKD 2/3
Must stop at CKD 5

Need family hisory or genetic testing

Must have rapidly progressive disease
- based on imaging cyst burden
- Or decline in renal function

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58
Q

complications of PKD

A

CKD / end stage renal disease

Cysts
- pain from growth
- Haemorrage into cysts
- UTI
- Renal calculi

Extra renal
- Head - Berry aneurisms -> SAH haemorrhage
- Cardio - Anaemia of chonic disease / polycythaemia
- HTN
- MV prolapse in 20% / Aortic regurg
- Stroke duer to CKD and HTN
- Abdominal wall hernias in 45% thought to be due to increased pressure
- Liver / pancreatic / spleen cysts - rarely more than just discomfort

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59
Q

What are the indications for nephrectomy in PKD

A

1 - Make room for transplant

2 - Recurrent sepsis / haemorrhage

3 - Occasionally pain

3 - Renal cell carcinoma

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60
Q

Abdo exam ending bits

A

ISHRUG

Inguinal lymph nodes
Stool chart
Hernial orrifices
Rectal exam
Urine analysis
Genital exam

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61
Q

Signs on exam chronic liver disease

A

End of bed
- Tattoos (hepatitis)
- Cachexia
- icterus
- Brusing
- excoriation

Hands
-Clubbing
- Leukonychia (hypoalbuminaemia)
- Dupuytren’s contracture
- Palmar erythema
- Asterixis (hepatic encephalopathy)

Face
- Xanthelasimia

Neck
- Raised JVP

Chest
- Gynaecomastia
- Reduced body hair

Abdo
- Spider naevi
- Caput medusae
- Mass in RUQ - Size, smooth / craggy
- Bruis over liver ?HCC
- Ascities / drain scars

[testicular atrophy]

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62
Q

What 3 things on exam would make you think of decompensated liver

A

Ascites - shifting dullness
Asterixis
Altered conciousness - heaptic encephalopathy

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63
Q

What are the main causes of hepatomegally

A

Cirrhosis - NAFLD
Carcinoma - either primary or secondary mets
Congestive - cardiac failure - may feel pulsatile. Or Bud chiari

Infectious - HepB/C, EBV, Leptospirosis, hyatid, abscess, malaria
Immune - PBC / PSC / AIH
Infiltrative - amyloid / myeloproliferative

64
Q

liver disease investigations

A

FBC, Clotting, U&E, LFT and glucose
- Look for evidence of anaemia, bleeding and synthetic liver funciton
- Macrocytic assoc alcohol use
- Thrombocytopenia

Investigation of cause
- Hepatitis / BBV screen
- Anti-mitochondrial antibody (PBC)
- Anti-neutrophil cytoplasmic antibody (PSC)
- Anti-smooth muscle antibody (AIH)
- Elevated immunoglobulin G (AIH)
- A1AT
- Ferritin + elevated transferrin saturatio - haemochromatosis
- caeruloplasmin - Wilsons

Ascitic tap - new diagnosis / rule out SBP

US of liver - including looking at portal flow
-> Consider MRCP / ERCP for PSC

Liver biopsy

65
Q

Bloods to assess liver synthetic function acute? Chronic?

A

Acute - INR

Chronic - albumin

66
Q

Cirrhosis main complications

A

Variceal haemorrhage - portal hypertension

Hepatic encephalopathy

Asicites - SBP

[Hepatorenal / hepatopulmonary syndome. Hepatocellular carcinoma]

67
Q

Score system for cirrhosis classification? Score is using?

A

Child pugh

AB AEI

Albumin
Bilirubin
Ascites
encephalopathy
INR

Essentially any of the signs of decompensation / synthetic dysfunction

68
Q

What is the treatment of ascities in cirrhosis? If failing?

A

Tense ascities - may need acute paracentesis if no signs of infection

Abstience from alcohol
Drainage
Salt restriction
- duretics start with spironolactone 100mg with K+ monitoring

If failing consider TIPPS procedure or
Liver transplant

Spiro>frusemide - as blocks aldosterone (which promotes water retention)

69
Q

Name 3 causes of gynaecomastia? name 3 drugs

A

Cirrhosis

kleinfelters

Kennedy

Testicular tumour / orcidectomy

Drugs - DISCO AK
(digoxin, isoniazid, spironolactone, cimmetidine, oestrogens, anti-androgen, ketoconazole)

70
Q

How to identify? What triggers

A

Spider naevi?

Triggered by Oestrogen
Press in middle to get blanching -> release and fill from centre outward

71
Q

Main causes of chronic liver disease

A

Most common is acohol Alcohol

Metabolic associated steatoic liver disease
MASLD

viral hepatitis usually

Metabolic
- haemochromatosis
- wilsons
- A1AT

Autoimmune
- Autoimmune liver disease
- Primary biliary cirrhosis
- Primary sclerosing cholangitis

Drugs
- Amiodarone
- phenytoin
- methtrexate

71
Q

Why do liver patients have hyponatraemia

A

Activated renin-angiotensin axis
Salt and water retention
Diruretic use

72
Q

LFTs
Which are biliary? Hepatocellular?

A

ALP and GGT
- predominantly cholestatic dysfunction
- PBC / PSC / Biliary obstruction

ALT / AST
- Hepatocellular
- Alcohol + hepatitis

73
Q

Why is coag prolonged in biliary obstruction

A

Dont absorb fat soluble vitamin K

74
Q

Young patient with acutely decompensated liver disease no significant pmh what 2 conditions would you worry about?

A

Bud chiari
Hepatitis

[drug induced]

75
Q

What is SAAG how does it work? high or low values mean?

A

Serum ascites albumin gradient

It’s calculated by subtracting the albumin in the ascitic fluid from the serum albumin concentration.

A SAAG > 1.1 g/dL
- portal hypertension
- CCF

SAAG < 1.1 g/dL - exudate
- SBP
- malignancies
- tuberculous peritonitis
- nephrotic syndrome

76
Q

How to assess cirrhosis using an US

A

Fibroscan

77
Q

Chronic liver disease management?
Haemochromatosis?
PBC?
PSC?
Autoimunne?

A

Conservative
- Follow up with repeat US
- Psychosocial support - alcohol abstinence
- Dietetics especially if alcohol
MASLD
- Weight management

Medical
- Hepatitis treatment
- Haemochromasis - venesection
- Autoimmune - immune supression eg steroids + azathioprine
- PBC - Ursodeoxycarbolic acid
- PSC - Not treatable with meds (transplant)

Surgical
- Transplant

78
Q

What causes hepatic encephalopathy? treatment?

A

Ammonia

Consider ICU referral for airway and perform focused A-E

Keep hydrated
Lactulose +/- enemas if needed
Consider rifaxamin

Also important to manage cause Eg SBP
Manage complications such as coagulopathy

79
Q

Haemochromatosis abdo exam findings

A

Inspect
- increased pigmentation

Hands
- Liver disease (dupertryens, palmar erythema
- Glucose finger prick marks

Arms
Venesection scars

Face
Icterus

chest
- gynaecomastia

abdo
- Hepatomegaly
- Chronic liver disease
- liver biposy scar

To finish
- Cardiac exam for CCF
- Joints for arthropathy
Hypogonad

80
Q

haemochromatosis investigations

A

Bedside
- Glucose
- ECG

Bloods
- Increased ferritin (screen)
- increased transferrin saturastions
- HBA1C
- LFTs + a fetoprotein

Imaging
- CXR / Echo - cardiomyopathy
- Liver US - HCC

Special
- Liver biopsy not usually required but can be used for diagnosis and staging
- Genotyping

81
Q

haemochromatosis inheritence? complications?

A

Ressessive HFE gene (chrom 6)

males affected earlier (mensturation)

Endocrine - bronze diabetes
- hypogonads

Hepatocellular carcinoma

Cardiac failure

Joints - pseudogout

82
Q

Management haemochromatosis

A

Conservative
Patient education
Alcohol abstinence
Follow up for HCC risk
Family screening

venesect - 1 unit / week until iron deficient
- then 1 unit per month dependent on transferrin saturations

Management of complications
- Diabetes
- Heart failure
- Arthalgia (usually improved with venesection)

83
Q

Haemochromatosis prognosis

A

without cirrhosis + effective treatment = normal

200x normal risk of HCC if cirrhotic

84
Q

Splenomegaly exam signs

A

Anaemia
Lymphadenopathy
- Axilla / cervical / inguinal
purpura

Abdo
- Mass in RUQ which moves inferomedial with inspiration
- Cannot get above it ballot
- Sometimes hepatomegaly

85
Q

signs on exam which lead to a possible cause of splenomegaly

A

Lymphadenopathy - Haematological / infection

CLD signs - cirrhosis + portal hypertension

Rheumatoid hands - > felty syndrome

Splinter haemorrhages / murmur -> bacterial endocarditis

86
Q

Causes of splenomegaly? Massive?

A

With lymphnodes
Lymphoblastic
- Lymphoma
- CLL
- AML
Infection
- EBV
- Malaria
- Leishmeniasis
- Brucella

Without lymphnodes
Myeloid (Ineffecient myelopoesis in bone marrow (-> spleen starts some myelopoesis)
- Could be due to infiltrative eg Metastatic Breast Ca
- Myelofibrosis
- CML
- Haemolytic anaemia (bone marrow unable to keep up)

Infiltration of spleen
- Amyloid
- Gaucher disease
- Sarcoid

Chronic liver disease -> portal hypertension -> congestion in spleen

Inflammatory
- Lupus
- Felty syndrome - Rheumatoid

*Massive >8cm from costal margin
- Myeloproliferative disorders (Myelofibrosis / CML)
- Malaria
- Visceral leishmaniasis
- Brucellosis

87
Q

Splenomegaly investigations

A

Bloods
- FBC - haematological issues
[Would expect a low platlet count irrespective of cause in splenomegally as they get sequestered]
- Liver function - especially Bilirubin
Haemolysis screen
- Low haptoglobin
- raised LDH
- Reticulocyte count
- DAT coombs -> helps idfentify if haemolysis is autoimmune. Ie not haemolysis through a valve

If suspicious myeloproliferative
- blood film
- Lymph node biopsy
- CT CAP

Infectious
- Inflammatory markers
- Malaria antigen / thick/thin films
- viral serology

Confirm diagnosis with US
-> look at liver
- likely to need a CT anyway

if not CT scan consider CXR for bihilar lymphadeopathy

Rarely bone marrow aspirate for myeloid issue

88
Q

What are the indications for splenectomy? What do you have to consider?

A

Acute - Rupture - trauma

Chronic
- Haematological - ITP / Hereditary spherocytosis / autoimmune haemolytic anaemia

Consider
Vaccination encapsulated bacteria
- Ideally 2/52 prior to splenectomy
- Pneumococcus, meningococcus, haemophilus

consideration prophylactic penicillin - lifelong

Medic alert bracelet

89
Q

CLL whats seen on blood film

A

Smear cells (lymphocytes)

90
Q

Causes of unilateral renal enlargement?
Bilateral?

A

Unilateral
RCC
Cysts
Ureteric obstruction
PKD (with unilateral nephrectomy)

Bilateral
PKD
Bilat RCC (5%)
hydro nephrosis
tuberous sclerosis
Amyloidosis

91
Q

Exam finding signs?

How might you take a guess at cause?

Medications?

A

Evidence of CLD

Slate grey pigmentation / venesection- haemochromatosis

Autoimmune disease eg thyroid scar - PBC

Tattoo and needle marks - HepB/C

Ciclosporin - Gum hypertrophy and hypertension

Steroids - cushingoid

92
Q

What are the top 3 causes of liver transplant?

A

Cirrhosis

Acute hepatic failure - Hep A / paracetamol overdose

Hepatic malignancy - HCC

93
Q

Liver transplant outcomes?

A

80% at 1 year
70% at 5

94
Q

Skin findings in transplant patients

A

Actinic keratosis (dysplasia)

Squamous cell carcinoma - 100x risk

Basal cell carcinoma - 10x risk
Melanoma - 10x risk

Infections
- Cellulitis
- Viral warts

95
Q

What are the 3 main things you need to try and explain in presentation of renal patient

A

Underlying reason for renal failure
- PKD
- Diabetes Eg finger prick, visual impairment, injection sites
- Rheumatoid
- Hepatosplenomegaly eg amyloid
- Calcineurin inhibitor nephrotoxicity - lung / liver transplant
- Tuberus sclerosis - ungal fibromata, adeonoma sebaceum (Small, red-pink, wart-like lesions that are usually less than 5 mm in size on face), PKD

Current treatment modality
- Haemodialysis - Has the fistula been needled recently, are there thrills / palpable pulse. Lines
- PD catheters
- Functioning transplant - no other current dialysis

Complications of past / current treatment
- Cushings from steroids
- tremor - tacrolimus
- Gum hypertrophy - ciclosporin
- hypertension - tac / ciclo
- Scars - prev access / failed transplant

Ungal fibroma

96
Q
A

Peritoneal dialysis scars

97
Q

Who would you consider had recieved a kidney-pancreas transplant

A

Younger 30-50

evidence of previous diabetes eg visual impairment

Lower midline laparotomy scar with a palpable kidney

98
Q

Complications post renal transplant

A

Rejection
- Acute / chronic

Immunosupression
- Infection - PCP / CMV etc
- Nephrotoxicity (calcineurin inhibitors

Disease recurrence
- especially FSGN

Increased risk other pathology
- Skin malignancy
- Lymphoproliferative disorders
- CV disease Hyperlipidaemia / Hypertension -> stroke / MI

99
Q

Barriers to renal transplant

A

Finding a matched donor

Malignancy
Chronic deep seated infection
Active vasculitis

Cardiopulmonary health and fitness for operation

100
Q

haemochromatosis ways of presenting

A

May be picked up in relative screening programe

Incidental with raised transferrin saturations

Lethargy / arthralgia / diabetic symptoms

CLD

101
Q

Who should be screened for haemochromatosis and how

A

First degree relatives
Measurement of ferritin and transferrrin saturations.

If positive may go onto hfe gene testing, though this has variable penetrance and does not neccessarily mean a phenotype

102
Q

Splenomegaly isolated on exam without lymphadeopathy what do you think the cause is? What additional examinations would you like to perform?

What would be the key points on history to help?

A

Possible chronic haemolysis such as heredetary spherocytosis

Rheumatoid examn looking for felty syndrome

Thyroid examination

History
- Any bleeding
- Any recent infections
- Foreign travel esp to endemic malaria
- Screen for haem malignancy - fever, night sweats, anaemia symptoms, easy brusing, regular infections

103
Q

Why do you get gynaecomastia in CLD? 2 reasons

A

Due to raised oestrogen:testosterone ratio
[Also causes the hair loss and testicular atrophy]

May also be due to Spironolactone / cimetidine / digoxin

104
Q

How do you grade liver encephalopathy

A

1 - altered mood, reduced concentration and reversal of sleep wake cycle
2 - drowsiness
3 - agitation
4 - coma

105
Q

What is dose of spironolactone in ascities?

A

100mg to start
- note much higher than in heart failure

106
Q

What is a TIPPS procedure

A

Transjugular intrahepatic portosystemic shunt

Enter through jugular
passed into hepatic vein and through into portal vein with stend inserted

This allows blood to pass from portal system to systemic venous system
-> reduces pressure in portal system and varices

107
Q

Causes of hepatosplenomegaly

A

Liver disease + portal hypotension

Myeloproliferative conditions eg CML and myelofibrosis

Lymphoproliferative - CLL and lymphoma

Infective - EBV, CMV, brucella, leptospirosis, malaria, leishmaniasis and TB

Sarcoid, amyloid and Gauchers

Basically the same as just splenomegaly

108
Q

Which signs of liver disease are specific to alcohol

A

Parotid enlargement

Withdrawal tremor

109
Q

Differentiate mass that is spleen or kidney

A
  • Unable to palpate above spleen
  • Spleen more likely to be dull to precuss as no overlying bowel / gas
  • Spleen moves down with respiration
  • Spleen not ballotable
110
Q

chronic myeloid leukaemia gene?
Presentaiton?
Found on bloods / marrow?
Treatment?

A

Associated with
-BCR ABL gene - philadelphia chromosome (tyrosine kinase activity)

Fatigue/malaise, abdominal fullness, sweating, bleeding, gout, anaemia symptoms
- Some are asymptomatic

Bloods - anaemia, thrombocytopenia and massive raised WCC
-Blood film will show raised myelocytes

Marrow would show - hypercellularity with raised myeloid:erythroid cells

Treatment - imatinib (tyrosine kinase inhibitors) often gives long term control

110
Q

Myelofibrosis aetiology?
Presentation?
Bloods / marrow?
treatment?

A

hyperplasia of megakaryocytes
-> marrow fibrosis
-> extra medullary erythropoesis -> hepatosplenomegaly

Fatigue, fevers night sweats
Abdominal symptoms from organomegaly
Anaemia symptoms

Bloods - anaemia with variable WCC. Tear drop cells
Often JAK2 positive (may progression from polycythemia)

Marrow - often ‘dry tap’ due to fibrosis with biiopsy showing fibrosis

Stem cell transplant in younger

111
Q

What would make you think of polycythaemia as diagnosis on exam? how to confirm?

A

Facial plethora
Splenomegally
brusing / excoriations

May complain of burning sensation in fingers and toes, especially after a hot bath

May have evidednce of previous thrombotic event Eg stroke

Gout - due to increased purines

Bloods
- increased HB + haematocrit
- WCC / platelets my be increased
- JAK2 confirms diagnosis

112
Q

What on exam would make you consider a diangosis of a lymphoproliferative disorder

A

Hepato/splenomegaly with lymphadenopathy

Anaemia
brusing

113
Q

What would make you think of haemolytic anaemia

A

Triad of
- Jaundice
- Anaemia
- splenomegaly

[May also occur on CLD but likely to have extra signs]

114
Q

Most common cause of inherited haemolytic anaemia? others?
Aquired causes?

A

hereditary spherocytosis

G6PD deficiency
Heretary eliptocytosis

Aquired
- Autoimmune haemolytic anaemia
- Drugs
- Microangiopathic haemolytic anaemia
- malaria
- paroxysmal nocturnal haemoglobinuria

115
Q

What are the clinical features of feltys syndrome

A

Rheumatoid arthritis
neutropenia
splenomegaly

116
Q

What is hypersplenism

A

pancytopenia due to increased sequestration in spleen

116
Q

In a patient not picked up on screening / incidental how would PKD present

A
  • work up for hypertension
  • Following haemorrhage / infection into cyst and present with acute pain
  • Stones my also be presenting feature
117
Q

Routine screening of berry aneurysms in PKD

A

MRA imaging only done in high risk patients
Eg warning symptoms or prev rupture

This is due to unclear surgical prevention of risk in asmptomatic patients

118
Q

Name 3 causes of bilateral renal cysts

A

PKD
Multiple symple cysts
Tuberous sclerosis
Von hippel lindau

119
Q

What is von hippel lindau

A

Autosomal dominant mutation of tumour supressor gene chromosome 3

  • Renal cell carinomas (bilat in 40%)
  • Phaeochromocytomas
  • Cysts in kidneys, spleen, epidydymus
  • Retinal cerebella and spinal cord haemoblastomas
120
Q

What symptoms and signs to suggest failing renal transplant

A
  • Reduced urine output / Fluid retention
  • Uraemia - flap / encephalopathy
  • Fever / tenderness over transplant
121
Q

What makes a sucsessful renal transplant

A

Living donor > cadaver
Improved HLA matching
Less transfusions prior -> antibodies

122
Q

Management post renal transplant

A

Conservative
- Regualr follow up
- Monitor renal and haematological blood profile
- Regular BP monitoring
- CV health
- Assess for signs of graft regection
- Monitor for complications - Eg skin malignancy / toxicity of immunosupression

Women - cervical screening

123
Q

Causes of a RIF mass

A

Renal transplant
Crohns disease
Caecal tumour
ovarian tumour
Abscess Eg TB

124
Q

Koilonychia vs leukonychia

A

Koilonychia - Also known as “spoon nails”, - this condition causes nails to curve inward and become thin and indented.
- It can be a sign of iron deficiency anemia, autoimmune diseases like lupus, or poor blood flow in the hands or feet.

leukonychia- white spots or streaks to appear on the nails
- drugs, disease, or occur spontaneously.
- When associated with chronic liver disease, leukonychia is usually caused by hypoalbuminemia.
- It can also occur with arsenic poisoning, heart disease, renal failure, or pneumonia.

125
Q

Decomp ALD and psoriasis main cause

A

Alcohol

126
Q

Differentials for a mass in the RIF without scar ? Key investigations

A

Malignancy
Crohns

[ilieal abscess eg TB
Ovarian cyst]

CT scan first line
Followed by biopsy / colonoscopy

I would also like bloods looking at evidence of anaemia and inflammation as well as liver kidney and bone profile tests.
I would consider CA19-9, CEA and Ca 125.
Tb testing may be required

127
Q

Differentials for mass RUQ?

A

Hepatomegally
HCC
Polycystic kidney / hydronephrosis

128
Q

Epigastric mass differential

A

Stomach Ca / pancreas - especially if virchows node
Cholangiocarcinoma - non tender palpable gallbaldder and jaundice
Pancreatic pseudocyst
AAA
Lymphoma

129
Q

LUQ mass differential

A

Splenomegally
splenic flexure tumour
L hydronephrosis / PKD

130
Q

LLQ mass differential

A

Diverticular abscess
Colon Ca
Feaces
Lymphoma
Ovarian cyst

131
Q

Present ascities

A

This patient has a distended abdomen with fullness in the flanks

The umbiliicus is inverted

There is no oragnomegally palpable

There is evidence of shifting dullness

I would like to examin the JVP and perform a rectal exam

132
Q

What are the causes of ascities

A

Most commonly portal hypertension secondary to liver cirrhosis

Congestive cardiac failure

Malignancy

Rarer causes include
- Nephrotic syndrome
- Hypoalbuminaemia
- Bud chiari
- Severe TR
- TB
- Meigs syndrome

133
Q

What findings on exam might suggest ascities from malignancy

A
  • Cachexia
  • Irregular liver - from mets
  • abdominal mass from primary - Usually GI / Ovarian
  • Virchows node
134
Q

What is bud chiari? Causes?

A

Rapid developing abdo pain
Hepatomegaly
ascities

Caused by thrombotic / non thrombotic obstruction of the hepatic blood flow

Haematological / inherited thrombotic
- Polycythemia
- Essential thrombocytosis
- Anti phospholipid syndrome
- Protein C / S deficiencies
- Factor V leiden

Chronic inflammatory
- IBD
- Bechets
- SLE / Sjorgrens

Other
- Pregnancy
- Cancer -> obstruction

135
Q

What is meigs syndrome

A

Ascites present due to ovarian fibroma
+ pleural effusion (usually on right)

136
Q

How to confirm ascites and cause? History points? what else would you do?

A

Urine dipstic
nephrotic syndrome
Patient weight

Bloods
FBC, LFTs especially heptic function INR and Albumin, Renal function tests

Ascitic tap
Albumin to calculate SAAG
C&S
WCC - polymorphs vs lymphocytes
Cytology
LDH
Glucose
?Amylase / lipase

US abdo / pelvis
- Liver small -> cirrhosis
- Impaired hepatic flow -> bud chiari
- Generalised hepatic congestion - CCF / TR
- Evidence of liver mets
- Other abdominal masses

Take a full history especially risks for
- chronic liver disease . Eg Alcohol, IVDU, tattoos.
- Malignancy - bowel habit / weight loss
- family history liver disease
- PMH IHD etc
- Drug history

137
Q

What 2 things might albumin tell you in a patient with ascities

A
  • Hepatic synthetic function
  • Whether nephrotic syndome is involved
138
Q

What is nephrotic syndrome? how to diagnose?
Other features?

A

Protein loosing state due to increased permiability of the glomerulus

Diagnosis >3.5g protien / 24hr urine protein
Can use urine sample for protein:creatinine ratio

Oedema
Hypercholesterolaemia
Hyperlipidaemia
Increased risk of blood clots

139
Q

What are the causes of nephrotic syndrome?

A

Primary - histological findings
- Minimal chnage - children
- FSGS and membranous nephropathy

Secondary - more common [A B See D]
- Amyloid
- hep B virus
- SLE
- Diabetes
- Gold

140
Q

How would you treat ?SBP

A

Full septic screen
Diagnostic tap prior to Abx if possible

If unstable
- Broad spectrum Abx
- Consider level 2 care if required

141
Q

Management of ascites

A

Treat cause
Eg CCF

  • Low salt diet
  • Diuretics - spironolactone
  • Water restiction especially if HypoNa

Ascitic drain

Hepatic transplant

142
Q

Present IBD

A

This young patient is thin with evidence of clubbing

There is an irregular pupilliary outline suggestive of previous uveitis

There are oral ulcers

On the left lower leg there is evidence of an ulcer suggestive of pyodema gangrenosum.
There is also erythema nodosum

There are multiple scars on the Abdomen relating to previous surgery as well as a stoma bag.

The stoma appears pink and healthy.

There is no organomegally or ascites

143
Q

Why is this patient with ibd anaemic

A

Anaemia of chronic disease

Malabsobsion especially B12 in terminal ileium
Dude Is Just Feeling Ill Bro

Blood loss

Immunosupression eg MTX -> folate defiiency

Ca

144
Q

Why is this patient with IBD jaundiced
Give 4 dd

A

Liver may be involved

Risk of Primary sclerosing cholangitis with ulcerative colitis [obstructive jaundice]

Other autoimmune Eg autoimmune hepatitis

Malabsorbtion -> gallstones / pancreatitis

Cholangiocarcinoma

Immunosupression -> viral infections

145
Q

Extra intestinal features IBD

A
  • Anterior uveitis / epi/scleritis
  • Arthritis seronegative usually large joints / Ank Spond
  • PSC
  • Pyoderma gangrenosum
    Necrotic ulcer
  • Erythema nodosum
    -Painful erythematous nodules
146
Q

What is a severe attack US

A

> 6 Stools / day with signs of systemic upset

Eg fever tachycardia pyrexia

147
Q

What are carcinoid tumours?
Where from?
Requirement for development of carcinoid syndrome?
Features?
Diagnosis?
Management ?
Compliations?

A

Neuroendocrine tumours which secrete serotonin and other vasoactive kinins
-> Carinoid syndrome

  • Usually mid GI jej/ileum / bronchial
  • If GI carcinoid there must be liver mets as otherwise liver will remove active peptides
  • Flushing
  • Diarrhorea
  • Telangectasia secondary to flushing
  • Wheeze
  • Heart failure secondary to valve fibrosis - usually R sided

Diagnosis
24 hr - Urinary 5-HIAA
Serum chomogranin A in liver mets

Imaging of tumours
- CT / MRI
- Ocretide PET CT

Managment
Medical - somatostatin alaouges eg Ocretide
Surgical resection of localised disease

Complications - [obstructive hearts pop]
- Intestinal obstruction
- Carinoid heart disease
- Pellegra
- carcinoid crisis - severe prolonged symptoms

148
Q

What is pellegra? symptoms

A

Vit B3 (naicin) deficiency
Dematitis
Dementia
Diarrhoea

Often caused by carcinoid syndrome due to serotonin negative feedback on B3 production

149
Q

Differentials for carcinoid syndrome?

A

IBS

Crohns

Ovarian Ca

Menopause
FSH/LH raised

Asthma
- Absence of diarrhoea / abdo pain

150
Q

Igs in liver disease

A

Raised

IgG autoimmune
IgA alcohol
IgM PBC

151
Q

Igs in liver disease

A

Raised

IgG autoimmune
IgA alcohol
IgM PBC

152
Q

Opiates in liver disease ? Drugs to avoid in liver disease

A

Don’t give codeine / DHC
Morphine is good

Avoid
- NSAIDs
- Gent (high volume distribution -> accumulates in ascites and get renal failure)
- Caution paracetamol

153
Q

IBD malignancy risk

A

There is increased risk of colonic malignancy
- Should have surveillance colonoscopy after 10 years

154
Q
A

A PACES (11 decks)

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