Abdominal Flashcards
What are the causes of cirrhosis?
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)
What are the complications of cirrhosis?
Portal hypertension (varices, ascites, hypersplenism) Liver dysfunction (coagulopathy, encephelopathy, jaundice, hypoalbuminaemia) Hepatocellular carcinoma
What are the causes of decompensation in cirrhosis?
Infection Spontaneous bacterial peritonitis Hypokalaemia GI bleeding Sedatives Hepatocellular carcinoma
How do you classify the severity of hepatic encephalopathy?
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
How do you assess the severity of cirrhosis?
The Childs-Pugh score
Prognostic score based on bilirubin, albumin, INR, ascites and encephalopathy
Graded from A-C (A best prognosis)
How would you manage a patient with cirrhosis?
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
What are the most common causes of ascites?
Cirrhosis
Malignancy
Heart failure
What initial investigations would you use to determine the cause of the ascites?
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)
How do you classify transudative and exudative ascites?
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
What is the pathophysiology of ascites in cirrhosis?
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
What is the initial treatment of ascites in cirrhosis?
Sodium restriction
Fluid restriction
Diuretic therapy, initially with aldosterone antagonists, with loop diuretics added once naturesis is achieved
Liver transplantation
What are the causes of isolated hepatomegaly?
Cirrhosis Carcinoma CCF Infection (HBV, HCV) Auto-immune (PBC, PSC, AIH) Infiltration (amyloid, myeloproliferative disorders)
Which tumours commonly spread to the liver?
Colorectal (most common) Upper GI Lung Breast Renal Endometrial Bone Sarcomas
What are the infective causes of acute hepatitis?
Hepatitis A Hepatitis B Hepatitis C Hepatitis E Epstein-barr virus Cytomegalovirus Toxoplasmosis Herpes simplex virus
What are the causes of splenomegaly?
Portal hypertension Haematological malignancy Infection (HIV, endocarditis, epstein-barr) Congestion (cardiac failure) Primary splenic disease (splenic vein thrombosis) Haemolysis Thalassaemia Glycogen storage disorders
How would you evaluate a patient with splenomegaly?
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
What are the significance of b-symptoms on Hodgkin’s lymphoma?
Fever >38, weight loss >10% body weight in 6 months, drenching night sweats
Presence of these alters the patient’s clinical staging
What are the cytogenetics of chronic myeloid leukaemia?
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
What are the causes of hyposplenism?
Splenic infarction Splenic artery thrombosis Infiltrative conditions (amyloidosis, sarcoidosis) Coeliac disease Autoimmune disease
What advice should patients with hyposplenism/post-splenectomy be given?
Vaccinations (pneumococcal, haemophillus influzena B and meningococcal group C
Prophylactic antibiotics
Malaria prophylaxis and travel advice
Medic alert card or bracelet
What is Felty’s syndrome?
Triad of seropositive arthritis with neutropaenia and splenomegaly
What is the mode of inheritance of hereditary haemochromatosis?
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
How is haemochromatosis diagnosed?
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
What is the treatment of haemochromatosis?
Vensection (initially twice weekly until transferrin saturation below 50%, and then maintenance every three months)
Hepatocellular carcinoma surveillance
What are the clinical features of primary biliary cirrhosis?
Fatigue
Pruritis
Hypercholesterolaemia
Liver disease occurs late
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
Which drugs can cause cholestasis?
Phenothiazines Sulphonamides Penicillins Rifampicin Macrolides Carbamazepine Androgenic steroids Diclofenac
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)
What are the major causes of chronic renal disease in developed countries?
Diabetes Glomerulonephritis Hypertension Drugs Polycystic kidney disease Obstructive uropathy
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)
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)
What are the complications of haemodialysis?
Removal of too much circulating fluid
Bacteraemia
Bleeding secondary to heparin use
Dialysis related amyloidosis
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)
What are the manifestations of renal osteodystrophy?
Increased bone turnover due to secondary hyperparathyroidism, which may cause bone pain and bone cysts
Osteomalacia
What is the definition of nephrotic syndrome?
Proteinuria >3g in 24 hours
Hypoalbuminaemia
Oedema
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
What are the complications of nephrotic syndrome?
Oedema Hypertension Hypercholesterolaemia Thrombosis Infection
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)
What is the differential diagnosis of a single palpable kidney?
Polycystic kidney disease
Hydronephrosis
Hypertrophy of a single functioning kidney
Renal cell carcinoma
What is the differential diagnosis for bilateral palpable kidneys?
Polycystic kidney disease
Bilateral hydronephrosis
Amyloidosis
Bilateral renal cell carcinoma (von Hippel lindau syndrome)
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
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
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
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
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
What are the causes of a right upper quadrant mass?
Liver
Right kidney
Gallbladder
Colon
What are the causes of a left upper quadrant mass?
Spleen
Left kidney
Pancreas
Colon
What are the causes of a right lower quadrant mass?
Colon
Small intestine
Appendix
Pelvic mass
What are the causes of a left lower quadrant mass?
Sigmoid colon
Pelvic mass
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
What are the indications for kidney transplant?
Most common are glomerulonephritis, diabetic nephropathy, Polycystic kidney disease
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
What are the indications for liver transplantation?
Cirrhosis
Acute hepatic failure (paracetamol overdose, hepatitis)
Primary biliary cirrhosis
Haemochromatosis
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
What are the indications for splenectomy?
Rupture
Haematological (ITP, hereditary shperocytosis)
What are the causes of massive splenomegaly?
Myeloproliferative disorders (CML, myelofibrosis) Tropical infection (malaria)
What are the causes of moderate splenomegaly?
Myelo/lymphoproliferative disorders
Infiltration (Gaucher’s, amyloidosis)
What are the causes of mild splenomegaly?
Myelo/lymphoproliferative disorders
Portal hypertension
Infection (EBV, infective endocarditis, infective hepatitis)
Haemolytic anaemia
What are the complications of haemochromatosis?
Diabetes, hypogonadism, testicular atrophy
Cardiac failure
Pseudo-gout
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
What are the clinical signs of decompensated liver disease?
Ascites
Asterixis
Encephelopathy
What complications may occur secondary to cirrhosis?
Variceal haemorrhage
Hepatic encephalopathy
Spontaneous bacterial peritonitis
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
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
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
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
What are the indications for surgery in Chron’s?
Obstruction
Complications from fistulae
Failure to respond to medical therapy
What are the indications for surgery in ulcerative colitis?
Chronic symptomatic relief
Emergency surgery for refractory colitis
Colonic dysplasia/carcinoma
What are the causes of gynaecomastia?
Puberty and senility Genetic: Kleinfelter’s GI: Cirrhosis Drugs: Spironolactone, Digoxin Endocrine: Thyroid disease, Addison Testicular tumour
