Abdominal Flashcards
Causes of hepatomegaly
Common hepatic causes
- alcoholic liver disease
- non-alcoholic liver disease
- viral hepatitis (hep B / C)
Immune
- autoimmune hepatitis: IgG, autoantibodies (ANA, anti-liver/kidney microsomal type 1, AMA, ANCA, soluble liver/kidney antigen)
- primary biliary cholangitis (AMA, IgM)
- primary sclerosing cholangitis (IgM, pANCA)
Genetic
- Wilson’s (low copper & caeruloplasmin)
- haemochromatosis (raised ferritin, TSAT)
Haematological
- CLL, CML, myelofibrosis
Congestive
- cardiac failure (right heart)
- Budd-Chiari (hepatic vein thrombosis)
Infiltrative
- amyloidosis (congo red, liver biopsy)
- sarcoidosis (non-caseating granuloma)
Causes of splenomegaly
UK common
- portal hypertension (e.g. cirrhotic liver disease)
- CML (massive)
- myelofibrosis (massive)
- other lymphoproliferative: CLL, lymphoma
Worldwide commonest = infections
- chronic malaria
- –> Ix: thick and thin films
- –> Mx: chloroquine or artesunate (severe) based therapies
- visceral leischmaniasis
- –> Ix: DAT +ve, biopsy
- –> Mx: amphotericin B
- schistosomiasis
- –> Ix: MCS egg detection urine / faeces, antigen tests
- –> Mx: praziquantel
Red blood cell clearance related
- spherocytosis
- thalassaemias
- early sickle cell
- nutritional deficiencies
Other infections
- infectious mononucleosis
- subacute bacterial infective endocarditis
Immune disorders
- Felty’s syndrome (RA + splenomegaly)
- SLE
Infiltrative
- amyloidosis
- sarcoidosis
- Gaucher’s (lipid storage disease)
Causes of hepatosplenomegaly
UK commonest
- liver disease with portal hypertension (pre-cirrhosis)
- –> alcoholic liver disease
- –> non-alcoholic liver disease
- –> viral hepatitis
- –> HCC
- haematological: CML, myelofibrosis, CLL, lymphoma
Worldwide commonest (infectious disease)
- chronic malaria
- visceral leishmaniasis
- schistosomiasis
Others
- –> congestive: heart failure, budd chiari
- –> immune: AIH, PBC, PSC
- –> genetic: haemochromatosis, Wilson’s
- –> infiltrative: sarcoid, amyloidosis
- –> infections: CMV, EBV, endocarditis
Splenectomy & post-op care
Trauma Haemolytic anaemia - spherocytosis - thalassaemia Autoimmune cytopenias - ITP Association with other organ removal in cancer operations
Mx
- prophylactic antibiotics: penicillin V
- vaccinations: pneumococcal, meningiococcal, haemophilus influenza B, influenza
Causes of cirrhosis
Commonest
- alcoholic liver disease
- non-alcoholic liver disease
- viral hepatitis
Autoimmune
- AIH (IgG, ANA, AMA, ANCA, anti-liver kidney microsomal type 1, soluble liver kidney antigen)
- PBC ( IgM, AMA)
- PSC (IgM, pANCA)
Genetic
- Wilson’s (AR)
- haemochromatosis (AR)
- alpha 1 antitrypsin (A co-D - multiple variants of allele)
- hereditary haemorrhagic telangiectasia (AD)
Drug induced e.g. methotrexate
Chronic liver disease that does not -> cirrhosis
Hereditary haemorrhagic telangiectasia
- AD
- liver AVMs
HCC
Causes of jaundice
Pre-hepatic - haemolytic anaemia - unconjugated
- hereditary
- –> spherocytosis
- –> G6PD
- haemoglobinopathy
- –> sickle
- –> thalassaemia
- Infection
- –> malaria
- Autoimmune
- –> transfusion reactions
- –> cold agglutanin (mycoplasma)
- –> warm AIHA (DAT +ve) e.g. CTD / malignancy associated
- –> paroxysmal nocturnal haemoglobinuria (cold AIHA)
Intrahepatic - mixed
- decompensated cirrhotic liver disease
- alcoholic hepatitis
- non-alcoholic steatohepatitis
- viral hepatitis
- hypoxic / ischaemic liver disease
- autoimmune hepatitis
- haemochromatosis
- wilson’s
- alpha 1 antitrypsin
Post-hepatic - unconjugated
- PBC / PSC
- cholangitis / choledocolithiasis
- pancreatic head malignancy / cholangiocarcinoma
Enzymatic defects
- Gilbert’s - unconjugated
Indications & contraindications for liver transplant
Acute liver failure
- e.g. paracetamol overdose according to King’s criteria
- –> ph <7.3 following resuscitation
- –> INR >6.5 + creatinine > 300 + grade III/IV encephalopathy
Chronic liver failure
- UKELD scoring for liver prognosis
Contraindications
- alcohol drinking <3-6months
- recreational drugs
- untreated HIV
- extrahepatic malignancy
- active extrahepatic sepsis
- relative
- –> poor clinic / medication compliance
- –> poor social support
- –> smoking
- –> BMI >40
- –> extensive previous intra-abdominal surgery
Complications of liver transplant
Acute
- surgery related (pain, bleeding, infection, neurovascular injury, VTE)
- acute graft rejection
Chronic
- immunosuppression related
- –> opportunistic infections
- –> calcineurin toxicity (renal)
- –> gum hypertrophy (ciclosporin)
- –> cushing’s
- –> (post transplant diabetes)
- –> malignancy: PTLD, skin
- graft failure
- –> rejection
- –> disease recurrence
- –> biliary stricturing
IBD features
Crohn’s
- macroscopic
- –> whole GI tract
- –> skip lesions
- –> cobblestoning
- –> fistulae (including peri-anal)
- –> stricturing
- –> rectal sparing more common
- microscopic
- –> transmural inflammation
- signs/symptoms
- –> oral ulceration
- –> perianal fistulae
- –> diarrhoea + mucus/blood
- –> weight loss / malabsorption
- –> extra-intestinal: uveitis, arthritis/arthralgia, pyoderma gangrenosum, erythema nodosum
- –> increased risk GI malignancy
Ulcerative colitis
- macroscopic
- –> rectum -> proximal without skip lesions
- –> pseudopolyps (chronic)
- –> lead pipe colon (chronic)
- –> no rectal sparing
- microscopic
- signs/symptoms
- –> diarrhoea / bleeding more significant feature
- –> no stricturing / fistulae less common
- –> no rectal sparing
- –> extra-intestinal: uveitis, arthritis/arthralgia, pyoderma gangrenosum, erythema nodosum
- –> associated PSC
- –> increased risk colonic cancer
Mx IBD
Mild-moderate induction
1) ASA (topical / oral depending on anatomic localisation)
2) prednisolone (oral)
Acute severe
1) IV hydrocortisone
2) Re-evaluate at 72 hours
- –> surgical excision
- –> ciclosporin OR infliximab
Surgery
- crohn’s —> depends on affected segment
- UC
- –> subtotal colectomy + end ileostomy -> stump surveillance +/- completion proctectomy
- –> panproctocolectomy + IPAA + defunctioning ileostomy -> ileostomy reversal
ESRF causes
UK commonest
- diabetic nephropathy
- hypertensive nephropathy
Glomerulonephritides
- ANCA vasculitis: malaise, fever, arthralgias, mononeuritis multiplex (IV methylpred, cyclophosphamide)
- –> granulomatosis with polyangiitis & microscopic polyangiitis: collapsed nasal bridge, pulmonary haemorrhage
- –> eosinophilic granulomatosis with polyangiitis: asthma / sinusitis
- non-ANCA vasculitis
- –> polyarteritis nodosa: systemic, skin, neuropathy, arthralgia
- –> cryoglobulinaemia e.g. HIV, hep C, malignancy - peripheral neuropathy, arthralgia, purpura, skin ulcers
- anti-GBM (Mx: PLEX, IV methylpred)
Obstructive uropathy
Recurrent renal infections
ADPKD
- type 1: Xsome 16
- type 2: Xsome 4 - less severe
- other features
- –> hypertension
- –> cyst haemorrhage / infection
- –> berry aneurysms
- –> PICA aneurysm: CN3 palsy
- Mx: control hypertension, fluid balance, ACEi, tolvaptan, RRT / transplant
Connective tissue disease associated
- SLE
Enlarged kidneys
ADPKD (bilateral, or unilateral including nephrectomy) Amyloidosis Tuberous sclerosis RCC Hydronephrosis Renal cyst
Nephrotic syndrome
Proteinuria >3g/24 hours
Oedema
Hypoalbuminaemia
Hyperlipidaemia
Membranous nephropathy
- primary (immunosuppression e.g. rituximab)
- secondary (cancer)
Minimal change disease
- steroids
Diabetic nephropathy
SLE
Amyloidosis
Alport’s
Nephritic syndrome
Vasculitis - steroids, immunosuppression
- ANCA associated
- polyarteritis nodosa
- cryoglobulins
Anti-GBM - PLEX, steroids
IgA nephropathy (post URTI) - steroids
Post streptococcal - supportive
HSP - supportive
TTP / HUS - PLEX
