Abdomina Flashcards
What is murphys sign
Hold over liver - deep breath
Pain on inspiration
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?
adrenalectomy or nephrectomy
PCKD
Young patient with bilaterally enlarged kidneys. You suspect polycystic kidney disease.
You notice that they also have a hemiparesis.
subarachnoid haemorrhage
Partial vs complete nephrectomy pros and cons
Partial
Higher risk of recurrence
Preservation of renal function
RCC gender?
age?
Type?
Male predominance
30-50
Clear cell RCC (up to 70%,
Papillary RCC (2nd most common)
Chromophobe RCC
Where do clear cell RCC come from? Gene?
originating in the proximal tubule with a 3p deletion)
Classic symptoms of a rcc
Haematuria
Flank mass
Loin tenderness
Note this triad only in 10%
Investigations for suspected RCC
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
Gold standard management of RCC?
Name another option?
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)]
RCC outcome predictors
Staging
tumour Size (</> 7cm),
Nuclear Grade
the absence/presence of tumour Necrosis)
Renal transplant exam?
To finish?
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
Indications for polycystic kidneys nephrectomy
Make room for donor kidney
Recurrent infections
Impact bowel - pressure reduces absorption
Most common reasons for renal transplant name 5
Diabetes - 50%
Young - reflux neuropathy
Hypertensive renal disease
PCKD
Glomerulonephritis
CKD of uncertain aetiology sometimes with multiple risk factors
Present renal transplant exam
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
Investigations in renal tranplant?
Extra if suspicion of Tx failure?
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
Common viruses to worry about in renal transplant
CMV especially if donor positive
BK virus
EBV
What are the principles of the management of people with CKD ?
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
Drug for PCKD
Tolvaptan
Renal tranplant drugs specific side effects
Steroids
Tacrolimus
Ciclosporin
Azathioprine
Mycophenolate
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
When refer CKD for RRT
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.
Haemodialysis and peritoneal dialysis pros and cons
“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
-
AV fistula complications
Bleeding
Failure - up to 20% need extra op to work in first 6 months
Clotting
Decreased vasular supply to hand
Running out of access
Differences UC and crohns
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
Ibd exam
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
IBD history? Differentials?
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
IBD investigation? gold standard diagnosis?
Bedside
Full gastro exam
Observations esp tachycardia / pyrexia
Stool chart
Routine
FBC
LFTs - association with IBD
Haemetinics b12/folate/ferritin
U&Es
Inflam markers
- Anti TTG for coeliac
Microbiology
- Stool cultures
- Blood cultures
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
IBD management - acute?
Chronic
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
Before starting biologics what do you need to screen for
HepB/C and HIV
If anti-TNF - TB screen eg quanteferon and CXR
Herpes zoster
Why do people over 60 tend not to get thiopurines eg azathiopurine?
Risk of Ca
-> Often moved to biologic
Whhy high risk of VTE in flare of IBD
Protein losing state
Crohns complications
Fistula / perforation / strictures
Sexual confidence / psych
Cancer - especially UC -> surveillence colonoscopy
If on biologics - high risk for skin Ca
Screening for gestational diabetes in preg
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]
Gestational diabetes key issues
Macrosomia
-> risk of shoulder dystocia
Also risk of miscarriage, preeclampsia, pregnancy hypertension
May unmask longstanding t2dm
Management for gestational diabetes
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
Post partum with GDM what do they need to do?
Usually can stop insulin and check HBA1C after 3 months
(60-70% risk of T2DM)
Risk of VTE in preg?
4x usual population and risk remains for 4-6 weeks post partum
d dimer in preg
non validated for VTE screen - usually around 2-3x baseline
SOB in pregnancy
Anaemia
Asthma (especially as reflux triggers)
PE
Pneumonia
Cardiomyopathy
Physiological breathlessness in pregnancy
What is physiological SOB in pregnancy
Often history “when I talk on the phone my friends think Im breathless”
No history orthopnea
no SOBOE up stairs
SOB in preg ix
FBC anaemia - often around 100 is normal
ECG - cardiolymopathy
CXR - pneumonia
If PE risk CTPA
Assess for asthma
Can you thrombolyse in pregnancy
Yes
Half life is around 5-10 mins
Hypertension in pregnancy vs pre existing
If before 20 weeks = pre existing
Hypertension in pregnancy issues?
Pre term delivery
Small baby
Miscarriage / stillbirth
Pre eclampsia. HELLP syndrome
Placental abruption
Longer term
CKD / HF / IHD / CVA usuals
How to check BP in pregnancy to confirm htn
Check in calm environment after 5 minutes rest
Management of hypertension in pregnancy
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
Hypertensive emergency in pregnancy is? Rx?
160/90 and hyperreflexic
IV labetalol / hydralazine
Mgs04
High likelihood of delivering baby
Asthma in pregnancy management which drugs? Whatextraa?
All drugs safe
Check peak flows (should be nomal)
Often add in omeprazole as reflux may be trigger
Antiepileptics in pregnancy
Aim to move to 1 agent
Leveteraceitam / lamotrigine
Can treat any status
Eg IV phenytoin
Give folic acid 3 months before and throughout pregnancy
Heart failure in pregnancy main drugs
Can use b blockers
Furosemide
Going to get echo / ECG
basic pathophysiology PCKD ? Genes
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
Formal diagnosis of PKD
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
PKD exam
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)
PKD present to examiner
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 …
Differentials for ballotable kidney
Bilateral
- ADPKD
- Tuberous sclerosis
- Von Hippel lindau
- Amlyidosis
- Bilateral hydronephrosis
- Bilateral RCC
Unilateral
- ADPKD with nephrectomy
- RCC
- Unilateral hydronephrosis
Investigations with PKD
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
Management of PKD
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
Who can get tolvaptan in PKD
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
complications of PKD
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
What are the indications for nephrectomy in PKD
1 - Make room for transplant
2 - Recurrent sepsis / haemorrhage
3 - Occasionally pain
3 - Renal cell carcinoma
Abdo exam ending bits
ISHRUG
Inguinal lymph nodes
Stool chart
Hernial orrifices
Rectal exam
Urine analysis
Genital exam
Signs on exam chronic liver disease
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]
What 3 things on exam would make you think of decompensated liver
Ascites - shifting dullness
Asterixis
Altered conciousness - heaptic encephalopathy
What are the main causes of hepatomegally
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
liver disease investigations
FBC, Clotting, U&E, LFT and glucose
- Look for evidence of anaemia, bleeding and synthetic liver funciton
- Macrocytic assoc alcohol use
- Thrombocytopenia
Ascitic tap - new diagnosis / rule out SBP
US of liver - including looking at portal flow
-> Consider MRCP / ERCP for PSC
Liver biopsy
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
Bloods to assess liver synthetic function acute? Chronic?
Acute - INR
Chronic - albumin
Cirrhosis main complications
Variceal haemorrhage - portal hypertension
Hepatic encephalopathy
Asicites - SBP
[Hepatorenal / hepatopulmonary syndome. Hepatocellular carcinoma]
Score system for cirrhosis classification? Score is using?
Child pugh
AB AEI
Albumin
Bilirubin
Ascites
encephalopathy
INR
Essentially any of the signs of decompensation / synthetic dysfunction
What is the treatment of ascities in cirrhosis? If failing?
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 - blocks aldosterone (usualy promotes water retention)
Name 3 causes of gynaecomastia? name 3 drugs
Cirrhosis
kleinfelters
Kennedy
Testicular tumour / orcidectomy
Drugs - DISCO AK
(digoxin, isoniazid, spironolactone, cimmetidine, oestrogens, anti-androgen, ketoconazole)
How to identify? What triggers
Spider naevi?
Triggered by Oestrogen
Press in middle to get blanching -> release and fill from centre outward
Main causes of chronic liver disease
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
Why do liver patients have hyponatraemia
- Hypervolaemic
Cirrhosis -> Release of NO -> Splanchnic (and systemic) vasodilation -> ADH release (water retention) - Hypovolaemic
Diruretic use
Note RASS (Aldosterone -> increased Na retention) activation also but outweighed by ADH
LFTs
Which are biliary? Hepatocellular?
ALP and GGT
- predominantly cholestatic dysfunction
- PBC / PSC / Biliary obstruction
ALT / AST
- Hepatocellular
- Alcohol + hepatitis
Why is coag prolonged in biliary obstruction
Dont absorb fat soluble vitamin K
Young patient with acutely decompensated liver disease no significant pmh what 2 conditions would you worry about?
Bud chiari
Hepatitis
[drug induced]
What is SAAG how does it work? high or low values mean?
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
How to assess cirrhosis using an US
Fibroscan
Chronic liver disease management general principles?
Haemochromatosis?
PBC?
PSC?
Autoimunne?
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
What causes hepatic encephalopathy? treatment?
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
Haemochromatosis abdo exam findings
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
haemochromatosis investigations
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
haemochromatosis inheritence? complications?
Ressessive HFE gene (chrom 6)
males affected earlier (mensturation)
Endocrine - bronze diabetes
- hypogonads
Hepatocellular carcinoma
Cardiac failure
Joints - pseudogout
Management haemochromatosis
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)
Haemochromatosis prognosis
without cirrhosis + effective treatment = normal
200x normal risk of HCC if cirrhotic
Splenomegaly exam signs
Anaemia
Lymphadenopathy
- Axilla / cervical / inguinal
purpura
Abdo
- Mass in RUQ which moves inferomedial with inspiration
- Cannot get above it ballot
- Sometimes hepatomegaly
signs on exam which lead to a possible cause of splenomegaly
Lymphadenopathy - Haematological / infection eg EBV
CLD signs - cirrhosis + portal hypertension
Rheumatoid hands - > felty syndrome
Splinter haemorrhages / murmur -> bacterial endocarditis
Causes of splenomegaly? Massive?
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
Splenomegaly investigations
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
- EBV serology / monospot
- 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
What are the indications for splenectomy? What do you have to consider?
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
CLL whats seen on blood film
Smear cells (lymphocytes)
Causes of unilateral renal enlargement?
Bilateral?
Unilateral
RCC
Cysts
Ureteric obstruction
PKD (with unilateral nephrectomy)
Bilateral
PKD
Bilat RCC (5%)
hydro nephrosis
tuberous sclerosis
Amyloidosis
Exam finding signs?
How might you take a guess at cause?
Medications?
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
What are the top 3 causes of liver transplant?
Cirrhosis
Acute hepatic failure - Hep A / paracetamol overdose
Hepatic malignancy - HCC
Liver transplant outcomes?
80% at 1 year
70% at 5
Skin findings in transplant patients
Actinic keratosis (dysplasia)
Squamous cell carcinoma - 100x risk
Basal cell carcinoma - 10x risk
Melanoma - 10x risk
Infections
- Cellulitis
- Viral warts
What are the 3 main things you need to try and explain in presentation of renal patient
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
Peritoneal dialysis scars
Who would you consider had recieved a kidney-pancreas transplant
Younger 30-50
evidence of previous diabetes eg visual impairment
Lower midline laparotomy scar with a palpable kidney
Complications post renal transplant
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
Barriers to renal transplant
Finding a matched donor
Malignancy
Chronic deep seated infection
Active vasculitis
Cardiopulmonary health and fitness for operation
haemochromatosis ways of presenting
May be picked up in relative screening programe
Incidental with raised transferrin saturations
Lethargy / arthralgia / diabetic symptoms
CLD
Who should be screened for haemochromatosis and how
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
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?
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
Why do you get gynaecomastia in CLD? 2 reasons
Due to raised oestrogen:testosterone ratio
[Also causes the hair loss and testicular atrophy]
May also be due to Spironolactone / cimetidine / digoxin
How do you grade liver encephalopathy
1 - altered mood, reduced concentration and reversal of sleep wake cycle
2 - drowsiness
3 - agitation
4 - coma
What is dose of spironolactone in ascities?
100mg to start
- note much higher than in heart failure
What is a TIPPS procedure
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
Causes of hepatosplenomegaly
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
Which signs of liver disease are specific to alcohol
Parotid enlargement
Withdrawal tremor
Differentiate mass that is spleen or kidney
- 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
chronic myeloid leukaemia gene?
Presentaiton?
Found on bloods / marrow?
Treatment?
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
Myelofibrosis aetiology?
Presentation?
Bloods / marrow?
treatment?
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
What would make you think of polycythaemia as diagnosis on consultation station? how to confirm?
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
What on exam would make you consider a diangosis of a lymphoproliferative disorder
Hepato/splenomegaly with lymphadenopathy
Anaemia
brusing
What would make you think of haemolytic anaemia
Triad of
- Jaundice
- Anaemia
- splenomegaly
[May also occur on CLD but likely to have extra signs]
Most common cause of inherited haemolytic anaemia? others?
Aquired causes?
hereditary spherocytosis
G6PD deficiency
Heretary eliptocytosis
Aquired
- Autoimmune haemolytic anaemia
- Drugs
- Microangiopathic haemolytic anaemia
- malaria
- paroxysmal nocturnal haemoglobinuria
What are the clinical features of feltys syndrome
Rheumatoid arthritis
neutropenia
splenomegaly
What is hypersplenism
pancytopenia due to increased sequestration in spleen
In a patient not picked up on screening / incidental how would PKD present
- work up for hypertension
- Following haemorrhage / infection into cyst and present with acute pain
- Stones my also be presenting feature
Routine screening of berry aneurysms in PKD
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
Name 3 causes of bilateral renal cysts
PKD
Multiple symple cysts
Tuberous sclerosis
Von hippel lindau
What is von hippel lindau
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
What symptoms and signs to suggest failing renal transplant
- Reduced urine output / Fluid retention
- Uraemia - flap / encephalopathy
- Fever / tenderness over transplant
What makes a sucsessful renal transplant
Living donor > cadaver
Improved HLA matching
Less transfusions prior -> antibodies
Management post renal transplant
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
Causes of a RIF mass
Renal transplant
Crohns disease
Caecal tumour
ovarian tumour
Abscess Eg TB
Koilonychia vs leukonychia
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.
Decomp ALD and psoriasis main cause
Alcohol
Differentials for a mass in the RIF without scar ? Key investigations
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
Differentials for mass RUQ?
Hepatomegally
HCC
Polycystic kidney / hydronephrosis
Epigastric mass differential
Stomach Ca / pancreas - especially if virchows node
Cholangiocarcinoma - non tender palpable gallbaldder and jaundice
Pancreatic pseudocyst
AAA
Lymphoma
LUQ mass differential
Splenomegally
splenic flexure tumour
L hydronephrosis / PKD
LLQ mass differential
Diverticular abscess
Colon Ca
Feaces
Lymphoma
Ovarian cyst
Present ascities
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
What are the causes of ascities
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
What findings on exam might suggest ascities from malignancy
- Cachexia
- Irregular liver - from mets
- abdominal mass from primary - Usually GI / Ovarian
- Virchows node
What is bud chiari? Causes?
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
What is meigs syndrome
Ascites present due to ovarian fibroma
+ pleural effusion (usually on right)
How to confirm ascites and cause? History points? what else would you do?
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
What 2 things might albumin tell you in a patient with ascities
- Hepatic synthetic function
- Whether nephrotic syndome is involved
What is nephrotic syndrome? how to diagnose?
Other features?
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
What are the causes of nephrotic syndrome?
Primary - histological findings
- Minimal chnage - children
- FSGS and membranous nephropathy
Secondary - more common [A B See D]
- Amyloid
- hep B virus
- SLE
- Diabetes
- Gold
How would you treat ?SBP
Full septic screen
Diagnostic tap prior to Abx if possible
If unstable
- Broad spectrum Abx
- Consider level 2 care if required
Management of ascites
Treat cause
Eg CCF
- Low salt diet
- Diuretics - spironolactone
- Water restiction especially if HypoNa
Ascitic drain
Hepatic transplant
Present IBD
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
Why is this patient with ibd anaemic
Anaemia of chronic disease
Malabsobsion especially B12 in terminal ileium
Dude Is Just Feeling Ill Bro
Blood loss
Immunosupression eg MTX -> folate defiiency
Ca
Why is this patient with IBD jaundiced
Give 4 dd
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
Extra intestinal features IBD
- Anterior uveitis / epi/scleritis
- Arthritis seronegative usually large joints / Ank Spond
- PSC
- Pyoderma gangrenosum
Necrotic ulcer - Erythema nodosum
-Painful erythematous nodules
What is a severe attack US
> 6 Stools / day with signs of systemic upset
Eg fever tachycardia pyrexia
What are carcinoid tumours?
Where from?
Requirement for development of carcinoid syndrome?
Features?
Diagnosis?
Management ?
Compliations?
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
What is pellegra? symptoms
What may cause it?
Vit B3 (naicin) deficiency
Dematitis
Dementia
Diarrhoea
Often caused by carcinoid syndrome due to serotonin negative feedback on B3 production
Differentials for carcinoid syndrome?
IBS
Crohns
Ovarian Ca
Menopause
FSH/LH raised
Asthma
- Absence of diarrhoea / abdo pain
Igs in liver disease
Raised
IgG autoimmune
IgA alcohol
IgM PBC
Igs in liver disease
Raised
IgG autoimmune
IgA alcohol
IgM PBC
Opiates in liver disease ? Drugs to avoid in liver disease
Don’t give codeine / DHC
Morphine is good
Avoid
- NSAIDs
- Gent (high volume distribution -> accumulates in ascites and get renal failure)
- Caution paracetamol
IBD malignancy risk
There is increased risk of colonic malignancy
- Should have surveillance colonoscopy after 10 years
Causes of pancreatitis
Most common
- Alcohol
- Gallstones
Less common
- Trauma
- Steroids / azathioprine
- ERCP
- Hypercalcaemia / Hyperlipidaemia
- Mumps
- Autoimmune
Complications of pancreatitis? management?
Acute
- SIRS -> death
- [Supportive]
Chronic
- Pain
- portal vein / splenic thrombosis
- Pancreatic cysts / pseudocysts -> obstructions
- Pancreatic insuficciency -> malabsorbtion [steatorrheoa, weight loss, vit d and magnesium defiiciency]
- Diabetes
Management
- Alcohol / smoking abstience
- Analgesia
- Anticoag as needed
- Drainage cysts
- Creon + PPI (otherwise acid breaks creon down) + Healthy balanced diet
Abx to avoid in transplant patient s
Macrolides
-> increases caleneurin inhibitor levels
