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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

Ciclosporin
- Gum hypertrophy
- Hypertension
- Neurotoxicity
- Headaches, insomnia, hairloss

Azathioprine
- Pancytopenia (marrow supression)
- Pancreatitis

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
More distal and confluent rather than patchy
Usually presents with bloody diarrhorrea
Flare over days to weeks

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

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24
Q

Key difference UC and crohns

A

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

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

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25
Q

Ibd exam

A

Hands
Clubbing rare in IBD
Palmer erythema rare

Arms
Picc lines

Face
Eyes Pallor and anaemia
Mouth - ulcers

Neck
Line scars

Quick look at back for scars

Abdo
Scars inc port scars especially umbilical

Stoma also check under bag

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

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26
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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27
Q

IBD investigation

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

If UC - consider sigmooroscopy

Refer to gastroenterology to consider colonoscopy

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28
Q

IBD treatment

A

Conservative
- Psych support
- Smoking cessation
- Nutritional support

Medical
- All should get Prophylaxtic clexane if inpatient

Mild crohns
- Oral budesonide (not absorbed out gut)

Mild UC
- Mesalazine eg rectal

If requires admission
- IV steroids

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

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

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29
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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30
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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31
Q

Whhy high risk of VTE in flare of IBD

A

Protein losing state

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32
Q

Crohns complications

A

Fistula / perforation / strictures

Sexual confidence / psych

Cancer

If on biologics - high risk for skin Ca

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33
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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34
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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35
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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36
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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37
Q

Risk of VTE in preg?

A

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

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38
Q

d dimer in preg

A

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

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39
Q

SOB in pregnancy

A

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

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40
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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41
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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42
Q

Can you thrombolyse in pregnancy

A

Yes

Half life is around 5-10 mins

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43
Q

Hypertension in pregnancy vs pre existing

A

If before 20 weeks = pre existing

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44
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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45
Q

How to check BP in pregnancy to confirm htn

A

Check in calm environment after 5 minutes rest

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46
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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47
Q

Hypertensive emergency in pregnancy is? Rx?

A

160/90

IV labetalol / hydralazine
Mgs04
High likelihood of delivering baby

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48
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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49
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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50
Q

Heart failure in pregnancy

A

Can use b blockers
Furosemide

Going to get echo / ECG

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51
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

52
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

53
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)

54
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 …

55
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

56
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

57
Q

Management of PKD

A

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

58
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

59
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

60
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

61
Q

Abdo exam ending bits

A

ISHRUG

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

62
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]

63
Q

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

A

Ascites - shifting dullness
Asterixis
Altered conciousness - heaptic encephalopathy

64
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

65
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

66
Q

Bloods to assess liver synthetic function acute? Chronic?

A

Acute - INR

Chronic - albumin

67
Q

Cirrhosis main complications

A

Variceal haemorrhage - portal hypertension

Hepatic encephalopathy

Asicites - SBP

[Hepatorenal / hepatopulmonary syndome. Hepatocellular carcinoma]

68
Q

Score system for cirrhosis classification? Score is using?

A

Child pugh

AB AEI

Albumin
Bilirubin
Ascites
encephalopathy
INR

69
Q

What is the treatnent 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 with K+ monitoring

If failing consider TIPPS procedure or
Liver transplant

70
Q

Name 3 causes of gynaecomastia? name 3 drugs

A

Cirrhosis

kleinfelters

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

Testicular tumour / orcidectomy

71
Q

How to identify? What triggers

A

Spider naevi?

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

72
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

72
Q

Why do liver patients have hyponatraemia

A

Activated renin-angiotensin axis
Salt and water retention
Diruretic use

73
Q

LFTs
Which are biliary? Hepatocellular?

A

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

ALT / AST
- Hepatocellular
- Alcohol + hepatitis

74
Q

Why is coag prolonged in biliary obstruction

A

Dont absorb fat soluble vitamin K

75
Q

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

A

Bud chiari
Hepatitis

[drug induced]

76
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
Nonportal hypertension
- malignancies
- tuberculous peritonitis
- nephrotic syndrome

77
Q

How to assess cirrhosis using an US

A

Fibroscan

78
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

79
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

80
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

81
Q

haemochromatosis investigations

A

Increased ferritin (screen)
increased transferrin saturastions

Check blood sugar / HBA1C - diabetes
ECG / CXR / Echo - cardiomyopathy
Liver US + a fetoprotein - HCC

Liver biopsy not usually required but can be used for diagnosis and staging
genotyping

82
Q

haemochromatosis inheritence? complications?

A

Ressessive HFE gene (chrom 6)

males affected earlier (mensturation)

Endocrine - bronze diabetes
- hypogonads

Hepatocellular carcinoma

Cardiac failure

Joints - pseudogout

83
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)

84
Q

Haemochromatosis prognosis

A

without cirrhosis + effective treatment = normal

200x normal risk of HCC if cirrhotic

85
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

86
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

87
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

88
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 chest / abdo

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

89
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

90
Q

CLL whats seen on blood film

A

Smear cells (lymphocytes)

91
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

92
Q

Exam finding signs?

How might you take a guess at cause?

Medications?

A

Evidence of CLD

Slate grey pigmentation - haemochromatosis

Autoimmune disease eg thyroid scar - PBC

Tattoo and needle marks - HepB/C

Ciclosporin - Gum hypertrophy and hypertension

Steroids - cushingoid

93
Q

What are the top 3 causes of liver transplant?

A

Cirrhosis

Acute hepatic failure - Hep A / paracetamol overdose

Hepatic malignancy - HCC

94
Q

Liver transplant outcomes?

A

80% at 1 year
70% at 5

95
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

96
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

97
Q
A

Peritoneal dialysis scars

98
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

99
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

100
Q

Barriers to renal transplant

A

Finding a matched donor

Malignancy
Chronic deep seated infection
Active vasculitis

Cardiopulmonary health and fitness for operation

101
Q

How would haemochromatosis usually present

A

May be picked up in relative screening programe

Incidental with raised transferrin saturations

Lethargy / arthralgia / diabetic symptoms

102
Q

Who should be screened for harmochomatosis 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

103
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

104
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

105
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

106
Q

What is dose of spironolactone in ascities?

A

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

107
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

108
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

109
Q

Which signs of liver disease are specific to alcohol

A

Parotid enlargement

Withdrawal tremor

110
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
111
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

111
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
Marrow - often ‘dry tap’ due to fibrosis with biiopsy showing fibrosis

Stem cell transplant in younger

112
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

113
Q

What would make you consider a diangosis of a lymphoproliferative disorder

A

Hepato/splenomegaly with lymphadenopathy

114
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]

115
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

116
Q

What are the clinical features of feltys syndrome

A

Rheumatoid arthritis
neutropenia
splenomegaly

117
Q

What is hypersplenism

A

pancytopenia due to increased sequestration in spleen

117
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
118
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

119
Q

Name 3 causes of bilateral renal cysts

A

PKD
Multiple symple cysts
Tuberous sclerosis
Von hippel lindau

120
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
121
Q

What symptoms and signs to suggest failing renal transplant

A
  • Reduced urine output / Fluid retention
  • Uraemia - flap / encephalopathy
  • Fever / tenderness over transplant
122
Q

What makes a sucsessful renal transplant

A

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

123
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

124
Q

Causes of a RIF mass

A

Renal transplant
Crohns disease
Caecal tumour
ovarian tumour
Abscess Eg TB

A PACES (9 decks)

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