Abdominal Flashcards
What are the hand signs of chronic liver disease
Leuconychia, clubbing, dupuytren’s contracture, palmar erythema
What are the causes of hepatomegaly
Cirrhosis (alcoholic)
Carcinoma (secondaries)
Congestive cardiac failure
Infectious (HBV, HCV)
Immune (PBC, PSC, AIH)
Infiltrative (amyloid, myeloproliferative disorders)
Iron (HH)
What are the causes of palmar erythema
Cirrhosis, hyperthyroidism, pregnancy, polycythaemia, rheumatoid arthritis
What are the causes of gynaecomastia
Physiological (puberty)
Klienfelter’s
Drugs (spironolactone)
Cirrhosis
Testicular tumour/orchidectomy
Endocrine (hypo/hyperthyroid, addisons)
What is the Child-Pugh score based on
Bilirubin
Albumin
INR
Ascites
Encephalopathy
Which scoring system is used for assessing liver transplant
MELD score
What is the Milan criteria
Transplant criteria for HCC + cirrhosis:
(1) single tumor diameter less than 5 cm; (2) not more than three foci of tumor, each one not exceeding 3 cm; (3) no angioinvasion; (4) no extrahepatic involvement.
What are the causes of massive splenomegaly (>8cm)
- haem malignancies (CML, myelofibrosis)
- tropical infections (malaria, visceral leishmaniasis)
What are the causes of moderate splenomegaly (4-8cm)
- myelo/lymphoproliferative disorders
- infiltration (Gaucher’s, amyloid)
What are the causes of small splenomegaly (tip <4cm)
- myeloproliferative
- portal hypertension
- infections (EBV, endocarditis, hepatitis)
- haemolytic anaemia
What are the indications for splenectomy
- trauma
- haematological (ITP, hereditary spherocytosis)
What is important in splenectomy work up
- vaccination against encapsulated bacteria (pneumococcus, meningococcus, H. Influenzae)
- prophylactic penicillin lifelong
What are the causes of unilateral kidney enlargement
- PKD (other kidney not palpable or contralateral nephrectomy)
- Renal cell carcinoma
- simple cysts
- hydronephrosis
What are the causes of bilateral kidney enlargement
- PKD
- bilateral renal cell carcinoma
- bilateral hydronephrosis
- tuberous sclerosis
- amyloidosis
What other organs are involved in ADPKD
- liver (hepatic cysts)
- intracranial berry aneurysms
- mitral valve prolapse
What are the causes of gum hypertrophy
- drugs: cyclosporin, phenytoin, nifedipine
- scurvy
- AML
- pregnancy
- familial
What skin signs may be present in transplant patients
- Malignancy
- dysplastic changes (actinic keratosis)
- SCC (100x increase)
- BCC and melanoma (10x increase) - Infection
- viral warts
- cellulitis
How can you assess if an AV fistula is currently working
Thrill
Dressings, needle marks
Which scar indicates renal transplant
Iliac fossa scar (j shaped scar)
What could an iliac fossa scar and a midline laparotomy scar indicate
Pancreas and kidney transplant (usually younger patients - may just have laparotomy and palpable transplanted kidney with no IF scar!)
What are the complications of steroids in transplant patients
- cushingoid appearance
- thin skin
- abdominal striae
- easy bruising
- proximal myopathy
- cataracts
What are the complications of cyclosporin in transplant patients
- tremor
- gingival hyperplasia
- hypertrichosis
- nephrotoxicity
What are the top 3 causes of renal transplant
- Glomerulonephritis
- Diabetes
- ADPKD
What is the difference between ADPKD type 1 and 2
Type 1: Ch 16, more severe
Type 2: Ch 4, less severe, slower progression to ESRD
What is the non-surgical management of ADPKD
Antihypertensives
Statins
Tolvaptan (V2 receptor antagonist)
High fluid, low salt diet
What are the indications for nephrectomy in PKD
Avoid if possible but indications include:
1. Make room for transplanted kidney
2. Progression to renal cell carcinoma
3. Chronic pain
4. Chronic infection
5. Large volume haematuria
What is the difference between corneal arcus and kayser-fleischer rings
- Corneal arcus: white-grey ring from lipid deposits
- KF rings: dark rings from copper deposits
What are the complications of haemochromatosis
- endocrine: diabetes, testicular atrophy
- cardiac: heart failure
- joints: arthropathy (pseudo-gout)
- liver: hepatomegaly, CLD
- skin: slate-grey/bronzed appearance
What is the inheritance of haemochromatosis
AR, HFE gene on Chr 6
What investigations should be requested in haemochromatosis
Diagnosis: raised ferritin, raised transferrin sats, liver biopsy, genotyping
Complications: blood glucose, ECG/CXR/echo, Liver USS + AFP
What is the treatment of haemochromatosis
- Venesect 1unit/week until iron deficient, then 1 unit 3-4 times/year
- Avoid alcohol
- Surveillance for HCC
How do you screen for haemochromatosis in relatives
Iron studies (ferritin + transferrin sats) - if positive then liver biopsy and genotyping
What is the prognosis of haemochromatosis
- If cirrhotic, reduced life expectancy and 200x risk of HCC
- if not cirrhotic, normal life expectancy
What will cause hand deformities and splenomegaly
Felty’s disease
How can ADPKD present
- Hypertension
- recurrent UTIs
- Abdo pain (bleeding/infected cyst)
- haematuria
- CKD
What are the top 3 indications for liver transplant
- Cirrhosis
- Acute hepatic failure (Hep A, Hep B, paracetamol overdose)
- Hepatic malignancy (HCC)
What is the definition of ESRF
GFR <15ml/min
What are the barriers to renal transplantation
- donor matching (not available)
- malignancy
- deep seated infection
- ongoing vasculitis
- severe obesity
Which immunosuppressant causes gum hypertrophy
Ciclosporin
Which immunosuppression causes tremor
Tacrolimus
What tests are used to assess the livers synthetic function
- INR (short term)
- albumin (long term)
Which liver blood test is characteristic of ALD
AST/ALT ratio > 2:1
What should be considered in alcoholics with chronic abdo pain
Chronic pancreatitis (faecal elastase can be used to aid diagnosis)
Which gene is affected in PKD
PKD1 gene (AD) - Chr 16 (85%)
PKD2 gene (AD) - Chr 4 (15%)
Infantile PKD (AR) - much less common
Which mode of dialysis is preferred in PKD
HD (PD can cause discomfort and increases risk of infected cyst)
What do most patients with PKD die from
Cardiac causes
What is the management of PKD
Non-pharma: low salt diet, dietary protein restriction
Pharma: BP control (ACEi), statins, tolvaptan, haemodialysis
Surgical: transplant, nephrectomy if indicated
How many spider naevi are needed to be classed as abnormal
> 5
How do you examine an AV fistula
- Thrill/bruit to see if it’s functioning
- look for needling to see if it’s in use
Which scars can indicate liver transplant
- Mercedes Benz incision
- reverse J incision
What signs indicate portal hypertension
Caput medusae, splenomegaly, ascites
What is the UK end stage liver disease score based on
Sodium
Creatinine
Bilirubin
INR
What UK ELD score indicates transplant in CLD
> = 49
What are the criteria for super urgent liver transplant in paracetamol overdose
- pH <7.25 24hrs after OD
- PT >100s / INR >6.5
- Cr >300 / aneuria
- grade 3-4 encephalopathy
How often should AFP and liver USS be repeated in cirrhosis due to haemochromatosis
6 monthly
What will joint X rays show in haemochromatosis
Chondrocalcinosis, squared off bone ends, hook-like osteophytes (particularly 2nd and 3rd MCP joints)
Until when should haemochromatosis pts receive weekly transfusions
Until ferritin levels 20-30 and transferrin sats <50%
How does hereditary spherocytosis usually present
- Triad of anaemia, jaundice and splenomegaly
- screening
- neonatal jaundice
What are the complications of hereditary spherocytosis
- aplastic crisis
- anaemia
- gallstones
What are the diagnostic tests for hereditary spherocytosis
EMA (eosine-5-maleimide) binding test (osmotic fragility test if this is not available)
What is the management of hereditary spherocytosis
- folic acid
- transfusions
- splenectomy (need vaccines and prophylactic antibiotics)
Which is the most common chromosome affected in hereditary spherocytosis
Chromosome 8
What are the commonest causes of cirrhosis in the UK
- Alcoholic liver disease
- Chronic Hep C infection
- NAFLD
What criteria is used to assess severity of UC
Truelove Witts criteria
What are the types of haemodialysis
- AVF
- Temporary CVC
- Tunnelled CVC
What are the complications of an AVF
- Bleeding
- Failure of fistula (higher risk of synthetic)
- Heart failure (increased CO)
- Ischaemic distal limb
What can be used to help guide which patients with ESRF need dialysis
The kidney failure risk equation
What complications can occur after renal transplant
- Rejection (acute vs chronic)
- Infection - CMV, PCP
- Malignancy (skin, lymph)
- Immunosuppression toxicity
- Recurrence of original disease
- Chronic graft dysfunction
When should a patient be worked up for renal transplant
As they approach ESRD (eGFR <15) but before they require dialysis
Which scoring system can be used to guide need for future RRT in patients approaching ESRD
The kidney failure risk equation
Which autoantibodies are positive in autoimmune hepatitis
- Anti-smooth muscle
- Anti-LKM1
- ANA
What UKELD score is indicative of liver transplant
UKELD >49
What are the contraindications to liver transplant
IVDU, ongoing alcohol excess, significant co-morbidities, extensive malignancy
How would you investigate splenomegaly
Diagnosis - USS abdomen
- Haem cause - FBC and blood film, JAK2, Philadelphia chromosome, CTTAP, BM biopsy, LN biopsy
- Infectious cause - thick and thin films, viral serology, HIV test
- Autoimmune cause - RF, ANA
- Haemolysis cause - LDH, haptoglobin, coombe’s test, bilirubin
What are the complications of liver transplant
- Graft rejection (acute vs chronic)
- Side effects of immunosuppression
- Recurrence of underlying disease
Which vein is affected in budd-chiari syndrome
Hepatic vein thrombosis
What are the possible indications for a rooftop scar
- liver transplant
- liver resection
- pancreatic surgery
- gastric surgery
What are the causes of liver transplant + diabetes
- NAFLD
- Haemochromatosis
- Side effects of steroids/immunosuppression
Which joints are most commonly affected in hereditary haemochromatosis
2nd and 3rd MCP and PIP joints
What are the causes of a high SAAG gradient
Transudate - portal HTN
- cirrhosis/liver failure
- hepatic venous obstruction
- constrictive pericarditis/CCF
- liver metastases
What are the causes of a low SAAG (<1.1 g/dL)
Exudate:
- malignancy eg peritoneal mets
- infection eg TB
- pancreatitis
- nephrotic syndrome
- bowel obstruction/infarction
What can cause a falsely low TTG level
IgA deficiency
Gluten free diet
What is seen on jejunal biopsy in coeliac disease
Villous atrophy
What are the types of kidney transplant
Live donor - relation/altruistic
Deceased - circulatory/neurological
What are the advantages of simultaneous pancreas kidney transplants
- better 10 year survival vs kidney transplant alone
- no need for continuous CBG monitoring and insulin
- glucose and lipid metabolism improved
(But unclear if long term vascular complications of diabetes improved)
