Abdominal Flashcards
How might patients with PKD present?
(FIVE)
More recently genetic screening of relatives of PKD patients
Hypertension
Renal failure
Haematuria
Abdominal pain from bleeding into cyst/infection
Inheritance of PKD
Autosomal dominant
ADPKD 1 - 80% chromosome 16
ADPKD 2 - Chromosome 4
Autosomal recessive in childhood
Difference between the types of PKD
ADPKD 2 associated with less severe, with later onset and later progression to renal failure
Treatment of PKD
(FIVE)
Control of hypertension
Control of hyperlipidaemia
High fluid, low salt diet
Renal replacement therapy
Transplant
Extra-renal manifestations of PKD
(FOUR)
Hypertension
Hepatic cysts
Pancreatic cysts
Cerebral aneurysms
Indications for nephrectomy in PKD
(FIVE)
Avoided if possible
To make room for transplant
Progression to renal cell carcinoma
Bleeding - haematuria
Recurrent/chronic infections
Chronic pain
Is nephrectomy always necessary for transplant in PKD?
No, but sometimes necessary to make room for transplant.
What would indicate a mass is kidney rather than liver or spleen?
(THREE)
Get above it
Moves with inspiration
Ballottable
Differentials for unilateral enlarged kidney
(FOUR)
PKD with one nephrectomy
Renal cell carcinoma
Simple kidney cysts
Hydronephrosis
Differentials for bilateral enlarged kidneys
(FIVE)
PKD
Bilateral renal cell carcinoma
Bilateral hydronephrosis
Tuberous sclerosis
Amyloidosis
Investigations for enlarged kidneys
(FIVE)
Blood pressure
U+E
Urine dip protein/blood
USS abdomen +/- biopsy
Genetic studies for ADPKD
Causes of end stage renal failure
(FOUR)
Hypertension
Diabetes
PKD
Glomerulonephritis
When should renal transplantation work up start?
When approaching ESRF but before requiring dialysis - best outcomes
Define end stage renal failure
GFR of less than 15 ml/min
Barriers to renal transplant
(FIVE)
Availability of matched donor kidney
Malignancy
Ongoing infection
Ongoing vasculitis
Severe obesity due to technical difficulty
Side effects of long term immunosuppression
(EIGHT)
Increased risk of infection - bacterial/viral/fungal
Malignancy - particularly skin cancer
Thin skin - steroids
Easy bruising - steroids
Cushingoid appearance - steroids
Hirsutism - ciclosporin
Gum hyperplasia - ciclosporin
Tremor - tacrolimus
Things to look for in renal transplant patient
(SEVEN)
Fluid status
Evidence of HD - tunneled lines/needled fistula
Evidence of PD - catheter
Side effects of immunosuppression
Cause of renal failure:
Diabetes - fingerprick/injection site
Enlarged kidneys - PKD
Hepatosplenomegaly - amyloidosis
Complications following renal transplant
(SEVEN)
Acute rejection
Chronic rejection
Infection with immunosuppression - CMV/PCP
Skin malignancy
Ciclosporin nephrotoxicity
Recurrence of original disease
Post transplant lymphoproliferation
Signs of chronic liver disease
(NINE)
Hepatomegaly
Jaundice
Leuconychia
Clubbing
Dupuytren’s contracture
Xanthelasma
Spiner naevi
Caput medusa
Gynaecomastia
Signs of decompensated liver disease
(FOUR)
Ascites
Asterixis
Altered consciousness - encephalopathy
Jaundice
Causes of chronic liver disease
(NINE)
Alcoholic liver disease
Non-alcoholic fatty liver disease
Viral hepatitis
Autoimmune hepatitis
Primary biliary cholangitis
Primary sclerosing cholangitis
Haemochromatosis
Alpha-1-antitrypsin deficiency
Wilson’s disease
Investigations for chronic liver disease
(ELEVEN)
Full history
Alcohol history
Basic bloods - FBC, U+E, LFT, clotting
HBV, HCV, HIV tests
Ferritin and iron studies
Caeruloplasmin
Autoantibody screen
AFP
Ascitic tap
USS abdomen
CT +/- biopsy
Autoantibodies for chronic liver disease
(FOUR)
ANA - PSC
Smooth muscle antibody - PSC, AIH
Anti mitochondrial antibody - PBC
Anti LKM antibody - AIH
Presentation of primary biliary cirrhosis
(THREE)
Fatigue
Pruritus
Chronic liver disease
Complications of primary biliary cirrhosis
(THREE)
Chronic liver disease
Cirrhosis
Hepatocellular carcinoma
Treatment of primary biliary cirrhosis
(TWO)
Ursodeoxycholic acid
Transplant
Signs of underlying cause of chronic liver disease
(FIVE)
Tattoos - viral hepatitis
Injection marks - viral hepatitis
Signs of diabetes - NAFLD
Slate grey pigmentation - haemochromatosis
Venesection - haemochromatosis
Causes of jaundice
(THIRTEEN)
Pre-hepatic:
Gilbert’s syndrome
Haemolytic anaemia
Thalassaemia
Intra-hepatic hepatocellular:
Viral hepatitis
Alcoholic hepatitis
Autoimmune hepatitis
Decompensated cirrhosis
Intra-hepatic cholestasis:
PBC
PSC
Post-hepatic:
Gallstones
Pancreatic cancer
Cholangiocarcinoma
Pancreatitis
Complications of cirrhosis
(FOUR)
Portal hypertension
Variceal haemorrhage
Hepatic encephalopathy
Spontaneous bacterial peritonitis
What to look for on ascitic tap?
(FIVE)
Albumin for SAAG
Amylase for pancreatitis
Cytology for cancer
Microscopy and culture for infection
WCC for SBP (>250 neut)
What does a high SAAG indicate?
(TWO)
Low protein - cirrhosis
High protein - heart failure
What does a low SAAG indicate?
(FIVE)
Low protein - nephrotic syndrome, TB peritonitis
High protein - cancer, pancreatitis, TB
Causes of ascites
(SEVEN)
Cirrhosis
Cancer
Congestive heart failure
Infection - viral hepatitis
Immune - PBC, PSC, AIH
Infiltrative - amyloidosis
Iron - haemochromatosis
Treatment of cirrhotic ascites
(FOUR)
Stop alcohol
Low salt diet
Diuretics
Transplant
Indications for liver transplant
(THREE)
Cirrhosis (ALD, NAFLD, viral hepatitis, autoimmune, haemochromatosis)
Acute hepatic failure (paracetamol)
Hepatocellular carcinoma
Selection of patients for liver transplant
MDT approach
Significant liver dysfunction
UK end stage liver disease score
Signs of portal hypertension
(TWO)
Caput medusae
Splenomegaly
Contraindications to liver transplant
(FOUR)
IV drug abuse
Ongoing alcohol excess
Significant medical comorbidities (cardio/ceberbrovascular disease)
Metastases in malignancy
Complications of haemochromatosis
(FIVE)
Diabetes
Cirrhosis
Testicular atrophy
CCF
Pseudogout
Inheritance of haemochromatosis
Autosomal recessive
HFE mutation
Chromosome 6
Treatment of haemochromatosis
(FIVE)
Venesection
Alcohol avoidance
Screen for HCC
Monitor cardiac function
HbA1c monitoring
Signs to look for in splenomegaly
(THREE)
Anaemia
Lymphadenopathy
Purpura
Signs of causes of splenomegaly
(FOUR)
Lymphadenopathy - haem/infective
Chronic liver disease signs - portal hypertension
Rheumatoid hands - Felty’s syndrome
Thyroid exam - hyperthyroid
Causes of mild-moderate splenomegaly
(FIVE)
Portal hypertension
Myeloproliferative disorders
EBV
Infective endocarditis
Haemolytic anaemia
Causes of massive splenomegaly
(THREE)
CML
Myelofibrosis
Chronic malaria
Investigations for splenomegaly
(SIX)
FBC and blood film
USS abdomen
Autoimmune screen
CT if concern for malignancy
Thick and thin blood films
Consider bone marrow aspirate
Indications for splenectomy
(TWO)
Rupture
Haematological (ITP/hereditary spherocytosis)
Splenectomy work up
(FOUR)
Pneumococcal vaccine
Meningococcal vaccine
Haemophilus influenzae type B vaccine
Lifelong prophylactic abx
Presentation of haemochromatosis
(SEVEN)
Family screening
Asymptomatic with elevated ferritin
Fatigue
Arthralgia
Diabetes
Bronze pigmentation
Cardiomyopathy
Screening for haemochromatosis
First degree relatives with haemochromatosis
Baseline ferritin and transferrin saturation
Genetic HFE screening
Tests in haemochromatosis
(FOUR)
HbA1c
Liver USS
AFP
Echo
Hereditary spherocytosis inheritance
Autosomal dominant
Hereditary spherocytosis presentation
(FOUR)
Anaemia
Jaundice
Splenomegaly
Screening programmes of first degree relative
Complications of hereditary spherocytosis
(THREE)
Aplastic crisis (due to infection)
Anaemia
Gallstones
Investigations for hereditary spherocytosis
(SEVEN)
FBC
Reticulocyte count
Blood film
LDH
Haptoglobin
Coomb’s test
EMA binding test/osmotic fragility test
Treatment of hereditary spherocytosis
(THREE)
Folic acid
Treat complications
Consider splenectomy
Types of renal transplant
Live relative
Live altruistic
Cadaveric neuro death
Cadaveric circulatory death
Causes of gynaecomastia
(SIX)
Puberty
Increasing age
Kleinfelter’s syndrome
Cirrhosis
Drugs (spironolactone)
Orchidectomy
Investigations for inflammatory bowel disease
(SIX)
FBC, U+E, LFT, CRP
Folate, B12
Stool cultures
Faecal calprotectin
AXR
Endoscopy and biopsy
Differences between Crohn’s and UC
(FOUR)
UC - large bowel (particularly sigmoid and rectum), crohn’s -anywhere
UC - only mucosa, Crohn’s - transmural
UC - no fistulae, Crohn’s - fistulae
UC - fibrosis (lead pipe), Crohn’s not
Management of acute IBD
IV fluids
IV steroids
Surgical referral for IBD
(THREE)
If dilatation on AXR
If fistulating or obstructive disease
If flare is refractory to medical management
What is coeliac disease
Autoimmune disorder
Hypersensitivity to gluten containing products
Results in villous atrophy and malabsorption
What is dermatitis herpetiformis
Associated with coeliac disease
Blistering itchy rash
On extensor surfaces
Investigations for coeliac disease
(SIX)
Bloods:
- FBC
- Ferritin, B12, folate
- U+E, LFT
- IgA ttg
- Immunoglobulins
Endoscopy and biopsy
Management of coeliac disease
(THREE)
Gluten avoidance
Dietician to support with gluten avoidance
Correct nutritional deficiencies