Abdominal Flashcards
Primary biliary cholangitis examination
Middle aged woman
Xanthelasma
Excoriation marks
Easy bruising
Hepatosplenomegaly
High ALP
Anti-mitochondrial antibody
Ursodeoxycholic acid to slow progression or liver transplant
Autoimmune hepatitis examination
Hepatomegaly, Jaundice
Vitiligo
Thyroidectomy scar
Steroid side-effects
ANA, AMA, anti-LKM antibodies
Steroids, immunosuppressants or liver transplant
Cause of Wilson’s disease?
Autosomal recessive, ATP7B gene
Reduced excretion of copper into the bile and therefore accumulation into organs such as brain, heart and liver
Causes low caeruloplasmin levels
Indications for urgent dialysis
AEIOU:
Acidosis <7.1
Electrolytes (refractory hyperkalaemia)
Ingestions (lithium, salicylates, alcohols)
Overload (congestive cardiac failure)
Uraemia (pericarditis or encephalopathy)
Complications of an AV fistula?
Infection
Thrombosis
Stenosis
Steal syndrome
Vascular access for RRT?
AV fistula
AV graft
Tunnelled venous catheter
Non-tunnelled venous catheter
ALWAYS present renal features of
Uraemia
Fluid overload
Features of renal replacement therapy
Causes of Nephrotic syndrome
FSGS
Minimal change disease
Membranous nephropathy
Membranoproliferative nephropathy
Symptoms of Cushing syndrome
Bruising, hypertension
Stretch marks, weight gain
Carpal tunnel
Proximal myopathy
Hirsutism, periods/erections
Causes of Cushing syndrome
ACTH-dependent:
- Pituitary microadenoma (MEN1)
- ectopic secretion by lung tumour
ACTH-independent:
- Adrenal adenoma or hyperplasia
- Iatrogenic from oral prednisolone
Investigation for Cushing syndrome
Confirming test:
Overnight dex suppression test or 24h urinary cortisol
Localising test: high dose dex suppression test
If ACTH and cortisol high —> CT thorax
If ACTH high and cortisol low —> MRI pituitary
If ACTH low —> CT adrenals
Causes of high serum-ascites albumin gradient >1.1g/l (transudate)
Liver cirrhosis
Congestive cardiac failure
Nephrotic syndrome
Meig’s syndrome
Causes of low serum-ascites albumin gradient <11.1g/l (exudate)
Hepatocellular carcinoma
Pancreatitis
Tuberculosis
Appendicectomy scar
McBurney’s incision
Liver transplant scar
Mercedes Benz or modified rooftop incision
Kidney transplant scar
Rutherford-Morrison incision
Management of Polycystic kidney disease
BP and lipid control
ACE inhibitor
Low salt diet
Active monitoring for kidney failure
Extra renal manifestations of Polycystic kidney disease
Hypertension
Cysts in liver/pancreas
Berry intracranial aneurysm
Mitral valve prolapse
Blood liver screen
ANA
AMA - PBC
ASMA - autoimmune hepatitis
LKM antibody - autoimmune / drug-induced hepatitis
Electrophoresis
Caeruloplasmin
Ferritin/transferrin - Haemochromatosis
AFP tumour marker
US abdomen and portal vein
Ascitic taped
Treatment for PBC
Ursodeoxycholic acid
Statins for high lipids
Oral vitamins
Calcium and biphosphonates for osteoporosis
Liver transplant
Cholestyramine or naltrexone for pruritus relief
Liver patient - what do you present
- Peripheral signs:
Dupuytren’s & palmar erythema
Spider naevi, gynaecomastia
Liver size
Nutritional status - Signs of portal hypertension: splénomégalique, caput medusa
- Evidence of décompensation: Astérixis, ascites, jaundice
Causes of Jaundice
Pre-hepatic:
- congenital red cell pathology (SCD, G6PD deficiency)
- autoimmune haemolytic anaemia
- malaria
Hepatic:
- Gilbert syndrome
- cirrhosis, cancer
- viral hepatitis
- drugs
Post-hepatic:
- biliary tree obstruction
- PBC
- PSC
King’s criteria for liver transplant in NON-paracetamol-induced liver failure
INR > 6.5
Or
Any three of the following 6:
- age >40
- not hepatitis related
- encephalopathy lasting over 7 days
- INR >3.5
- bilirubin >300
Symptoms of Uraemia
Fatigue, weight loss
Nausea, vomiting
Itching
Cognitive slowing, confusion
Frequent shallow breathing, metabolic acidosis
Causes of CKD
Diabetes
Hypertension
Glomerulonephritis
Polycystic kidney disease
Alport syndrome
ADPKD mutations
ADPKD1 on chrom 16
ADPKD2 on chrom 4
Differentials for unilateral palpable kidney
ADPKD
Renal cell carcinoma
Obstructive uropathy
Differentials for bilateral palpable kidney
ADPKD
Von Hippel-Lindau syndrome
Tuberous sclerosis
Causes of chronic liver disease
Alcohol
Non-alcoholic fatty liver disease
Infectious: Viral hepatitis, Malaria, CMV, EBV
Autoimmune: PBC, PSC
Metabolic: Haemochromatosis, Wilson’s disease
Cardiovascular: portal vein thrombus, congestive cardiac failure
Signs of décompensation liver disease
Asterixis
Bruising
Jaundice
Distended abdomen (ascites)
Evidence of portal hypertension (splenomegaly)
Score for severity of chronic liver disease
Child-Pugh score:
Bilirubin
Albumin
INR
Ascites
Encephalopathy
Causes of hepatomegaly
Cancer
Cirrhosis
Cardiac failure
Infection
Immunological
Infiltrative
Causes of Splenomegaly
Massive: CML, myelofibrosis, malaria, visceral leishmaniasis
Moderate: CLL, portal hypertension, Gaucher disease, Felty’s, PRV
Causes of MASSIVE Splenomegaly
CML (Philadelphia chromosome)
Myelofibrosis
Malaria
Causes of ESRF
Hypertension
Diabetes
Glomerulonephritides (FSGS, minimal change, membranous glomerulonephropathy)
Causes of Adrenal insufficiency
Primary:
- Addison’s disease
- adrenal adenoma
- TB
Secondary:
- exogenous steroids
- pituitary adenoma
Symptoms of Addison’s disease
Fatigue
Weight loss
Postural BP
Nausea/Vomiting, abdo pain, diarrhoea
Hyperpigmentation, vitiligo
Investigations for adrenal insufficiency
- Bloods (normocytic anaemia, low Na, high K, abnormal TFTs)
- 9am cortisol (<100 indicative of adrenal insufficiency, >400 suggests fine, otherwise borderline so order short synacthen test)
- ACTH (high if primary, low if secondary)
- Short synacthen test (if rise to >500 after 30 mins then suggestive)
- low aldosterone, high renin
Management of adrenal crisis
Admission for:
- IV fluids
- hyperkalaemia management
- IV hydrocortisone 100mg QDS
- IV antibiotics if infection is the precipitant
Autoimmune syndromes of which Addison’s disease can be part of?
Autoimmune polyglandular syndrome types 1 and 2
Autoimmune polyglandular syndromes
- type 1: chronic candidaisis, hypoparathyroidism, Addison’s, T1DM, thyroid disease
- type 2: Addison’s, T1DM, thyroid disease
Counselling patient on Addison’s disease
- sick day rules (double dose of oral steroids if infection, emergency hydrocortisone if vomiting)
- if strenuous exercise then ensure team mate knows to administer emergency hydrocortisone
Tests to do on ascitic fluid
Microscopy, gram stain & culture
Cytology & cell count
Albumin, glucose, LDH, amylase
Polycystic kidney disease genes
PKD1
PKD2
Spleen exam
Can’t palpate above
Medial notch
Kidney exam
Palpable upper border
Ballotable
Moves inferiority with respiration
NO NOTCH
Management of Wilson’s disease
Low copper diet
Chelating agents (penicillamine)
Zinc supplements
Complications: liver failure, HCC, CKD
Management of hereditary Haemochromatosis
Venesections
Monitor diabetes and cardiomyopathy
Definition of Nephrotic syndrome
Proteinuria >3.5g/24h
Low albumin
High lipids
Peripheral oedema
Management of nephrotic syndrome
Low sodium diet
Fluid restriction
BP control and reduce cardiovascular risk
Anticoagulation due to risk of VTE
Complications of nephrotic syndrome
Increased risk of infection
VTE
CKD
increased cardiovascular risk
Tumours in Von Hippep-Lindsay syndrome
Renal/Cerebellar/Spinal haemangioblastomas
Renal cell carcinoma
Phaechromocytoma
Pancreatic cancer
Cause of abdominal pain in PKD?
Cyst rupture or haemorrhage
Renal stones
UTIs
Causes of papillary necrosis
Pyelonephritis
Obstruction
Sickle cell disease
Tuberculosis
Cirrhosis
Aspirin nephropathy
Renal vein thrombosis
Diabetes
Examination findings for failed transplant
Fluid overload
Hypertension
Tenderness over graft
Uraemic symptoms
Recently used fistula/tunnelled line
Opportunistic infections in transplants
HSV (shingles)
CMV pneumonitis or retinitis
Pneumocystis jiroveci pneumonia
Malignancies after transplant
Skin SCC
Lymphoma
Post transplant lymphoproliferative disease
Management of ascites
Therapeutic paracentesis
Salt restricted diet
Fluid restriction
Spironolactone
Liver transplant vs TIPSS vs serial paracentesis
Management of varices haemorrhage
IV fluids
IV terlipressin
IV antibiotics
Urgent OGD for banding
Extra-hepatic manifestations of Haemochromatosis
Skin hyperpigmentation
Diabetes
Cardiomyopathy —> ICD and CCF
Arthritis
Hypogonadism
Management of Haemochromatosis
Venesection once to twice a week
Regular US liver and AFP level due to increased risk of HCC
Extra-hepatic manifestations of hepatitis B
Polyarteritis modo sa
Glomerulonephritis with nephrotic syndrome
Palpable purpura
Management of Hepatitis B
Entecavir, Tenofovir
Alpha-interferon therapy
Extra-hepatic manifestations of hepatitis C (5)
Diabetes
Peripheral neuropathy
Glomerulonephritis
Lymphoma
Cryoglobulinaemia
Polycythaemia Rubra Vera management
Venesection to haematocrit <45%
Hydroxycarbide
Complications of Polycythaemia Rubra Vera
Budd-Chiari syndrome
Strokes
Myelofibrosis
Leukaemia
