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Abdominal Flashcards

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1
Q

What are the causes of cirrhosis?

A

Alcohol
Viral (hepatitis B, hepatitis C)
Autoimmune (primary biliary cirrhosis, primary sclerosing cholangitis, autoimmune hepatitis)
Metabolic (NAFLD, haemochromatosis, cystic fibrosis)
Drugs (methotrexate, isoniazid, amiodarone, phenytoin)

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2
Q

What are the complications of cirrhosis?

A 
Portal hypertension (varices, ascites, hypersplenism)
Liver dysfunction (coagulopathy, encephelopathy, jaundice, hypoalbuminaemia)
Hepatocellular carcinoma
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3
Q

What are the causes of decompensation in cirrhosis?

A 
Infection
Spontaneous bacterial peritonitis
Hypokalaemia
GI bleeding
Sedatives
Hepatocellular carcinoma
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4
Q

How do you classify the severity of hepatic encephalopathy?

A

Reversible neurological dysfunction or coma related to decompensated liver disease
Graded from 1 to 4 depending on degree of impairment
Asterixis may be present at any stage

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5
Q

How do you assess the severity of cirrhosis?

A

The Childs-Pugh score
Prognostic score based on bilirubin, albumin, INR, ascites and encephalopathy
Graded from A-C (A best prognosis)

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6
Q

How would you manage a patient with cirrhosis?

A

Slow or reverse liver disease (alcohol abstinence, antiviral therapy)
Preventing further liver damage (immunisations, abstinence)
Preventing complications (hepatoma surveillance, endoscopy, prophylaxis against variceal bleeds with propranolol)
Liver transplantation

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7
Q

What are the most common causes of ascites?

A

Cirrhosis
Malignancy
Heart failure

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8
Q

What initial investigations would you use to determine the cause of the ascites?

A 
Paracentesis (albumin and protein, white cell count, gram stain, culture, cytology)
Abdominal ultrasound (mass, splenomegaly, portal hypertension, thrombosis)
Blood tests (liver function, clotting, full blood count)
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9
Q

How do you classify transudative and exudative ascites?

A

Comparing the ascitic fluid albumin to the patient’s serum albumin
The serum ascites/albumin gradient (serum albumin - ascitic albumin)

A result of >11 suggests transudative, <11 suggests exudative

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10
Q

What is the pathophysiology of ascites in cirrhosis?

A

Only occurs following the development of portal hypertension

Disruption of portal blood flow due to liver fibrosis, resulting in accumulation of fluid in the peritoneal cavity

The cirrhotic liver releases vasodilatory compounds, which cause sphlanchnic vasodilation. This decreases systemic vascular resistance > lower circulating volume and blood pressure > activates the renin-angiotensin-aldosterone system, which results in sodium and water retention

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11
Q

What is the initial treatment of ascites in cirrhosis?

A

Sodium restriction
Fluid restriction
Diuretic therapy, initially with aldosterone antagonists, with loop diuretics added once naturesis is achieved
Liver transplantation

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12
Q

What are the causes of isolated hepatomegaly?

A 
Cirrhosis
Carcinoma
CCF
Infection (HBV, HCV)
Auto-immune (PBC, PSC, AIH)
Infiltration (amyloid, myeloproliferative disorders)
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13
Q

Which tumours commonly spread to the liver?

A 
Colorectal (most common)
Upper GI
Lung 
Breast
Renal
Endometrial
Bone
Sarcomas
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14
Q

What are the infective causes of acute hepatitis?

A 
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis E
Epstein-barr virus
Cytomegalovirus 
Toxoplasmosis 
Herpes simplex virus
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15
Q

What are the causes of splenomegaly?

A 
Portal hypertension 
Haematological malignancy 
Infection (HIV, endocarditis, epstein-barr)
Congestion (cardiac failure)
Primary splenic disease (splenic vein thrombosis)
Haemolysis
Thalassaemia
Glycogen storage disorders
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16
Q

How would you evaluate a patient with splenomegaly?

A

History - constitutional symptoms, risk factors for HIV, features pancytopenia, travel history, autoimmune disease, liver disease

Investigations - full blood count, blood film, liver function, LDH, autoimmune screen, imaging (ultrasound and full CT imaging if looking for disseminated malignancy), lymph node or bone marrow biopsy

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17
Q

What are the significance of b-symptoms on Hodgkin’s lymphoma?

A

Fever >38, weight loss >10% body weight in 6 months, drenching night sweats

Presence of these alters the patient’s clinical staging

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18
Q

What are the cytogenetics of chronic myeloid leukaemia?

A 
The philadelphia chromosome is present in 90-95% of patients with CML
Chromosomal translocation (fusion of c-abl oncogene of chromosome 9 with bcr on chromosome 22.

This fusion leads to increased oncogene activity through tyrosine kinase signalling

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19
Q

What are the causes of hyposplenism?

A 
Splenic infarction 
Splenic artery thrombosis
Infiltrative conditions (amyloidosis, sarcoidosis)
Coeliac disease
Autoimmune disease
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20
Q

What advice should patients with hyposplenism/post-splenectomy be given?

A

Vaccinations (pneumococcal, haemophillus influzena B and meningococcal group C
Prophylactic antibiotics
Malaria prophylaxis and travel advice
Medic alert card or bracelet

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21
Q

What is Felty’s syndrome?

A

Triad of seropositive arthritis with neutropaenia and splenomegaly

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22
Q

What is the mode of inheritance of hereditary haemochromatosis?

A

Autosomal recessive
HFE gene is located on the short arm of chromosome 6
Most caucasian patients are homozygous for the cysteine to tyrosine substitution at position 282

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23
Q

How is haemochromatosis diagnosed?

A

Iron overload suggested by iron studies
Transferrin saturation >60% in males and >50% in females
Liver biopsy to show parenchymal iron deposition

Genetic testing for C282Y and H63D
First degree relatives should undergo genetic testing

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24
Q

What is the treatment of haemochromatosis?

A

Vensection (initially twice weekly until transferrin saturation below 50%, and then maintenance every three months)
Hepatocellular carcinoma surveillance

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25
What are the clinical features of primary biliary cirrhosis?
Fatigue Pruritis Hypercholesterolaemia Liver disease occurs late
26
How is primary biliary cirrhosis diagnosed?
Serum anti-mitochondrial antibodies are present in >95% The histological lesion is a portal tract granuloma Imaging may be done to exclude extra-hepatic cholestasis
27
Which drugs can cause cholestasis?
``` Phenothiazines Sulphonamides Penicillins Rifampicin Macrolides Carbamazepine Androgenic steroids Diclofenac ```
28
What is the management of primary biliary cirrhosis?
Supplementation of fat soluble vitamins Treatment of bone disease (vitamin D, calcium, bisphosphonates) Treatment of hypercholesterolaemia Treatment of liver disease (ursodeoxycholic acid improves liver biochemistry and slows disease progression) Management of pruritis (colestyramine, rifampicin, naltrexone) Anti-histamines do not work and may worsen encephalopathy Management of fatigue (exclude co-existent anaemia and hypothyroidism) Referral for transplantation (bilirubin >50, refractory fatigue or pruritis)
29
What are the major causes of chronic renal disease in developed countries?
``` Diabetes Glomerulonephritis Hypertension Drugs Polycystic kidney disease Obstructive uropathy ```
30
What are the principles of the management of chronic renal disease?
Treatment of reversible causes (cessastion of drugs, treatment of vasculitis, exclusion of obstruction) Slowing disease progression (treatment of hypertension, treatment of cardiovascular risk factors, managing diabetes) Treatment of the complications of chronic renal disease (volume overload, high phosphate, metabolic acidosis, anaemia, renal bone disease)
31
What are the indications for renal replacement therapy?
``` Pericarditis or pleuritis due to uraemia Uraemic bleeding diathesis (platelet dysfunction) Volume overload refractory to diuretics Refractory hypertension Refractory acidosis Encephalopathy Removal of toxins (lithium, salicylates) ```
32
What are the complications of haemodialysis?
Removal of too much circulating fluid Bacteraemia Bleeding secondary to heparin use Dialysis related amyloidosis
33
What are the complications of peritoneal dialysis?
Bacterial peritonitis Solute clearance or ultrafiltration failure Diabetes (glucose in filtration fluid) Local complications (hernias, catheter site infection)
34
What are the manifestations of renal osteodystrophy?
Increased bone turnover due to secondary hyperparathyroidism, which may cause bone pain and bone cysts Osteomalacia
35
What is the definition of nephrotic syndrome?
Proteinuria >3g in 24 hours Hypoalbuminaemia Oedema
36
What are the causes of nephrotic syndrome?
In adults, approximately 30% have a systemic disorder (diabetes, SLE) The remainder are due to intrinsic renal disease Minimal change disease - idiopathic, diabetes, NSAIDs, Hodgkin’s lymphoma Focal segmental glomerulosclerosis - idiopathic, HIV, NSAIDs, obesity Membranous glomerulonephritis - infection, autoimmune disease, solid organ malignancy Mesangiocapillary glomerulonephritis - infection, autoimmune disease, cryoglobulinaemia
37
What are the complications of nephrotic syndrome?
``` Oedema Hypertension Hypercholesterolaemia Thrombosis Infection ```
38
What are the differentials of bilateral renal cysts?
Polycystic kidney disease Multiple simple cysts Tuberous sclerosis Trisomies 13 (Patau) 18 (Edward) and 21 (Down’s)
39
What is the differential diagnosis of a single palpable kidney?
Polycystic kidney disease Hydronephrosis Hypertrophy of a single functioning kidney Renal cell carcinoma
40
What is the differential diagnosis for bilateral palpable kidneys?
Polycystic kidney disease Bilateral hydronephrosis Amyloidosis Bilateral renal cell carcinoma (von Hippel lindau syndrome)
41
What are the genetics of adult Polycystic kidney disease?
Typically autosomal dominant ADPKD1 accounts for 90%, chromosome 16 Most of the remainder are ADPKD2, chromosome 4, less severe phenotype
42
What are the features of autosomal dominant Polycystic kidney disease?
Flank and abdominal pain Acute pain suggests haemorrhage, infection or torsion Nocturia due to impaired ability to concentrate urine Hypertension Recurrent UTI Haematuria
43
What are the extra renal manifestations of autosomal dominant Polycystic kidney disease?
Cerebral aneurysm Liver cysts Pancreatic cysts Valvular heart disease - mitral valve prolapse and aortic regurgitation
44
What are the principles of management of autosomal dominant Polycystic kidney Disease?
Nephrectomy for recurrent bleeds, infection, increase in size Management of renal failure (control hypertension, adequate nutrition, treat anaemia, phosphate binders, vitsmin D) Dialysis Renal transplantation Screening of relatives Genetic counselling
45
What is von Hippel lindau syndrome?
Autosomal dominant condition Chromosome 3 Cerebellar, retinal and spinal haemangioblastomas Cysts occur in the kidneys, liver, spleen and epidydymis Increased risk of renal cell carcinoma and phaeochromocytoma
46
What are the causes of a right upper quadrant mass?
Liver Right kidney Gallbladder Colon
47
What are the causes of a left upper quadrant mass?
Spleen Left kidney Pancreas Colon
48
What are the causes of a right lower quadrant mass?
Colon Small intestine Appendix Pelvic mass
49
What are the causes of a left lower quadrant mass?
Sigmoid colon | Pelvic mass
50
What inherited conditions predispose to colorectal cancer?
Hereditary non-polyposis colorectal cancer (lynch syndrome) - autosomal dominant Familial adenomatous polyposis - autosomal dominant Peutz-Jeghers syndrome - associated with pigmented lesions in the buccal mucosa and lips, autosomal dominant
51
What are the indications for kidney transplant?
Most common are glomerulonephritis, diabetic nephropathy, Polycystic kidney disease
52
What complications may occur following renal transplantation?
``` Rejection (acute or chronic) Infection secondary to immunosuppression Skin malignancy, lymphoproliferative disease, hypertension, hyperlipidaemi Recurrence of original disease Chronic graft dysfunction ```
53
What are the indications for liver transplantation?
Cirrhosis Acute hepatic failure (paracetamol overdose, hepatitis) Primary biliary cirrhosis Haemochromatosis
54
What are the side effects of organ transplantation medications?
``` Fine tremor (tacrolimus) Steroid side effects Gum hypertrophy (ciclosporin) Hypertension (ciclosporin, tacrolimus) Skin damage and malignancy ```
55
What are the indications for splenectomy?
Rupture | Haematological (ITP, hereditary shperocytosis)
56
What are the causes of massive splenomegaly?
``` Myeloproliferative disorders (CML, myelofibrosis) Tropical infection (malaria) ```
57
What are the causes of moderate splenomegaly?
Myelo/lymphoproliferative disorders | Infiltration (Gaucher’s, amyloidosis)
58
What are the causes of mild splenomegaly?
Myelo/lymphoproliferative disorders Portal hypertension Infection (EBV, infective endocarditis, infective hepatitis) Haemolytic anaemia
59
What are the complications of haemochromatosis?
Diabetes, hypogonadism, testicular atrophy Cardiac failure Pseudo-gout
60
What autoantibodies are implicated in liver disease?
Primary biliary cirrhosis - anti-mitochondrial antibodies Primary scelrosing cholangitis - Anti-nuclear antibodies, anti-smooth muscle antibodies Autoimmune hepatitis - anti-smooth muscle, anti-liver/kidney microsomal type 1
61
What are the clinical signs of decompensated liver disease?
Ascites Asterixis Encephelopathy
62
What complications may occur secondary to cirrhosis?
Variceal haemorrhage Hepatic encephalopathy Spontaneous bacterial peritonitis
63
How would you investigate a patient with suspected cirrhosis?
Liver screen - autoantibodies and immunoglobulins, hepatitis serology, ferritin, caeruloplasmin, alpha 1 antitrypsin, alphafetoprotein Hepatic function - albumin, INR Liver biopsy ERCP to exclude or diagnose primary sclerosing cholangitis
64
How would you investigate a patient with suspected IBD?
``` Stool MC&S FBC and inflammatory markers Sigmoidoscopy or colonoscopy and biopsies Bowel contrast study (look for fistulae) CT scanning ```
65
What is the treatment of Chron’s disease?
Mild/moderate: oral steroid, 5-ASA Severe: IV steroids, infliximab Maintenance: oral steroids, azathioprine, methotrexate, TNF-inhibitors (infliximab) Nutritional support Psychological support Surgery
66
What is the medical treatment of ulcerative colitis?
Mild/moderate: topical steroids, oral steroids, 5-ASA Severe: IV steroids, IV ciclosporin Maintenance: oral steroids, 5-ASA, azathioprine Nutritional support Psychological support Surgery
67
What are the indications for surgery in Chron’s?
Obstruction Complications from fistulae Failure to respond to medical therapy
68
What are the indications for surgery in ulcerative colitis?
Chronic symptomatic relief Emergency surgery for refractory colitis Colonic dysplasia/carcinoma
69
What are the causes of gynaecomastia?
``` Puberty and senility Genetic: Kleinfelter’s GI: Cirrhosis Drugs: Spironolactone, Digoxin Endocrine: Thyroid disease, Addison Testicular tumour ```

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