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PACES > Abdominal > Flashcards

Abdominal Flashcards

1
Q

ADPKD presentation

A

Renal:
- Hypertension
- Abdo pain (rupture, stones, infection)
- Haematuria
- ESRF
Extrarenal
- SAH
- Mitral valve prolapse
- Liver/pancreas cysts

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2
Q

PKD inheritance/chromosomes

A

AD - Chromosome 16 or 4
10% de novo
(AR also exists)
4 slower course

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3
Q

ADPKD management

A

Lifestyle
- High fluid, low salt
Medical
- BP control (RAAS blockade)
- Vasopressin analogues (tolvaptan) reduces cyst formation
- Later - RRT/transplant
- Avoid nephrectomy if possible

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4
Q

ADPKD nephrectomy indications

A
  • Frequent/chronic infection
  • Mass effect
  • Space for transplant
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5
Q

Causes of bilateral kidney enlargement

A

PKD
Bilateral renal carcinoma
Bilateral hydronephrosis (e.g. HPCR)
Tuberous sclerosis

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6
Q

Extrarenal ADPKD

A
  • HTN
  • Liver/pancreas/seminal vesical cyst
  • Cerebral aneurysm - ICH/SAH
  • MR/AR
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7
Q

Clinical signs of portal hypertension

A

Caput medusae
Splenomegaly
JVP, oedema less so

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8
Q

Clinical signs hepatic decomensation

A

Ascites/oedema
Asterixis
Altered consciousness (encephalopathy)
Coagulopathy

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9
Q

Causes of hepatomegaly

A

3Cs, 4Is
- Cirrhosis (alcoholic)
- Carcinoma
- Congestive (CCF, Budd Chiari)
- Infection (HBV/HCV)
- Immune (PBC, PSC, AIH)
- Infiltrative (myeloproliferation, amyloid)
- Iron (haemochromatosis)

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10
Q

Liver screen bloods

A
  • Autoantibodies (PBC (antimitochondrial), PSC, AIH (ANA, anti-smooth muscle, ALKM1))
  • HBV, HCV serology
  • Ferritin (haemochromatosis)
  • Caeruloplasmin (Wilson’s)
  • Alpha-1 antitrypsin
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11
Q

Causes of palmar erythema

A

Cirrhosis
Hyperthyroidism
RA
Pregnancy
Polycythaemia

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12
Q

Conjugated vs unconjugated bilirubin

A

Prehepatic - unconjugated
Intrahepatic - conjugated ->therefore pale stools/dark urine

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13
Q

Urine dip to distinguish site of jaundice

A

Prehepatic - no urinary bilirubin
Post-hepatic - no urobilinogen

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14
Q

Prehepatic jaundice causes

A

Haemolysis
Hereditary:
- Membrane defects (spherocytosis etc)
- Enzyme deficiencies (G6PD, pyruvate kinase)
- Abnormal Hb (SCC, thalassaemia)

Acquired:
- Autoimmune haemolytic anaemia (SLE, RA, scleroderma)
- Alloimune e.g. ABO incompat
- Infection (CMV, EBV, toxo, leishmania)
- MAHA (DIC, TTP, HUS)

Non-haemolytic
- Conjugation - Gilbert’s

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15
Q

Intrahepatic jaundice causes

A

NAFLD - now called MASH (metabolic associated steatohepatosis)

Infectious
- HAV, HBV (ac/ch), HCV (ch), HDV+BV, HEV (ac)
- HIV
- Parasites (e.g. ascaris, entamoeba)
- Leptospirosis
Toxic
- Alcohol
- DILI (paracetamol, antibiotics, anti-inflammatories)

Neoplasia
- HCC
- Lymphoma - mass or infiltration
- Metastases (CRC, breast, lung, etc)

Autoimmune
- AIH
- PBC
- PSC (initially cholestatic)

Genetic
- Haemochromatosis
- Wilson’s
- Alpha-1 antitrypsin

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16
Q

Post-hepatic jaundice causes

A

Benign
- Gallstones
- Cholangitis
- Strongyloides

Malignant
- Pancreatic cancer
- Cholangiocarcinoma
- Metastases
- Lymphoma

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17
Q

Courvoisier’s law

A

Palpable gallbladder with jaundice is cancer, not stone - in impacted stone, chronic infection leads to GB atrophy

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18
Q

Autoimmune hepatitis antibodies

A

ANA, anti-smooth muscle, ALKM1

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19
Q

PBC antibodies

A

Anti-mitochondrial

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20
Q

Haemolysis blood tests

A

Haptoglobin
LDH
Reticulocytes
Smear
Direct/indirect antiglobulin test

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21
Q

Cirrhosis complications

A
  • Portal hypertension -> varices
  • Hepatic encephalopathy
  • SBP
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22
Q

Conditions most likely to recur in renal transplant

A

Glomerular sclerosis
Amyloidosis
IgA nephropathy
HUS

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23
Q

Renal transplant rejection presentation

A

Hyperacute - within minutes. Swelling, discolouration of graft
Acute - 2/52-6/12. Cell or Ab mediated. Pain, dysfunction
Chronic - Proteinuria and HTN most common

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24
Q

Most common causes ESRF

A

Hypertension
Diabetes
Glomerulonephritis
(PKD, reflux/obstructive)

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25
Q

Renal transplant workup tests

A

ABO, HLA
Viral screen - CMV (don & rec), Hep B, C
Urinalysis & culture
Optimise comorbidities
Cardio ax - ECG, echo, ?stress test
Psychological

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26
Q

Calcineurin inhibitors

A

Tacrolimus, cyclosporin

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27
Q

Antiproliferative angents

A

Mycophenolate
Cyclophosphamide

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28
Q

Liver function best tests

A

PT/INR (+ coag)
Albumin

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29
Q

Alcoholic liver disease LFTs

A

AST:ALT >2:1
(>50 if ischaemic)

30
Q

sBP ascites WCC

A

> 250/mm3

31
Q

Ascitic fluid tests

A
  • Cell count
  • Albumin / SAAG
  • Amylase/lipase
  • MC&S
  • Cytology
  • Glucose
32
Q

Utility of ascites glucose measurement

A

Low - increases likelihood of infection or malignancy
Low sens/spec

33
Q

Grading of liver disease

A

MELD score -Labs only: Bili, PT, Na, Cr, Dialysis
Child-Pugh - Bili, Alb, PT + Ascites, Encephalopathy

34
Q

SAAG

A

Serum ascites albumin gradient
- SAAG >1.1 g/dL = Transudate = Hydrostatic/Oncotic pressure problem = CCF/Renal failure/Liver failure/Budd Chiari etc
- SAAG <1.1g/dL = Exudate = Capillary permeability = Malignant, Infection (inc. TB), Inflammatory (e.g. RA)

35
Q

Extra-intestinal IBD signs

A

Mouth: Aphthous ulcers

Skin: Erythema nodosum, pyoderma gangrenosum

Joints: Clubbing, seronegative arthritis (e.g. AS)

Eye: Uveitis, episcleritis, iritis

Liver: PSC with UC

Amyloidosis

36
Q

IBD severity

A

Truelove & Witt
- Frequency >6/day
- Stool blood vol
- Temp >37.8
- Pulse >90
- Hb <105
- ESR >30
ECCO (European Crohn’s & Colitis Org)

37
Q

UC vs CD endoscopy

A

UC:
- rectal/colon only
- Continuous
- Mucosa/submucosa
CD:
- Whole bowel
- Skip lesions
- Full depth, may include granulomas
- Structures, fistulae
- Cobblestoning

38
Q

IBD investigations

A

Bedside:
- T, HR
Labs:
- Stool culture
- Faecal calpro
- FBC, U&E, CRP, LFT, extended electrolytes, B12/fol, iron studies
- Consider TPMT level if considering thiopurines
Imaging:
- AXR - dilatation
- CT - fistulae etc
- Sigmoidoscopy in acute /colonoscopy

39
Q

Management acute severe UC

A
  • Admit, resus (IVF)
  • LMWH
  • IV corticosteroid
  • Ciclosporin (calcineurin inhib)/Infliximab (anti TNF) if failure to respond in 72h
  • Surgery if failure to respond
40
Q

Mild acute UC management

A

Topical 5-ASA or steroid (e.g. rectal mesalazine or budesonide)
5-ASAs better

41
Q

Maintenance of remission UC & monitoring

A

Depends on what induced remission. Options include:
- Topical/oral 5-ASAs (mesalazine/sulfasalazine)
If 2 flares/year - immunomodulation:
- Thiopurines (azathioprine)
- Infliximab (anti TNF)
- Tofacitinib (JAK2 inhibitor)

Vaccinations (flu, pneumococcal, HBV, VZV)
Scope 10 years post Dx + ongoing depending on findings/Hx
Vit D/Ca supplements
Dietician input

42
Q

IBD and smoking

A

CD - increased risk 3x
UC - lower risk

43
Q

Mild crohns flare treatment

A

Oral steroid (budesonide/pred) OD, reduce over 7/52

44
Q

TPMT level relevance

A

Prior to starting thiopurines (azathioprine/mercaptopurine) measure thiopurine S-methyltransferase.

45
Q

Aminosalicilates in IBD

A

Good evidence in UC
Poor evidence in CD
e.g. Mesalazine, sulfasalazine

46
Q

Maintenance of remission CD

A
  • Thiopurines (e.g. azathioprine)
  • Can use MTX if failure
  • Or consider infliximab
  • Anti-integrin mabs also - reduce lymphocyte trafficking in bowel
  • Aim to avoid surgery, and if using minimise
47
Q

IBD surgery indications

A
  • Obstruction
  • Fistulation
  • Toxic megacolon/severe colitis
  • Intractable symptoms
    Relapse rate high in CD
48
Q

Ileum absorption

A

B12
Bile salts (which absorb fat soluble vitamins ADEK)

49
Q

Coeliac endoscopy findings

A

Villous atrophy
Crypt hypertrophy
Lymphocytes in epithelium and lamina propria

50
Q

Coeliac most common deficiencies

A

B12, Folate, D (Iron)

51
Q

Coeliac complications

A

Malabsorptive:
- Anaemia
- Osteopenia/porosis
- Neuropathy / SACDC

Other:
- Dermatitis herpetiformis
- Hyposplenism
- T cell lymphoma

52
Q

Causes splenomegaly

A

Infiltrative:
- Myeloproliferation
- Lymphoproliferation
- Lymphoma
- Amyloid/sarcoid
- Thyrotoxicosis
- Gauchers (lipid breakdown disorder)

Increased function:
- Red cell sequestration: spherocytosis, thalassaemia, early sickle cell disease
- Infection - malaria, leishmaniasis, glandular fever (EBV), brucella
- Disordered immunoregulation: Felty’s (in rheumatoid), SLE, Sarcoid

Abnormal flow:
- Cirrhosis
- Hepatic/portal vein obstruction

53
Q

Causes massive splenomegaly

A
  • CML
  • Myelofibrosis
  • Gaucher’s disease
  • Chronic malaria
  • Kala-azar (leishmaniasis)
54
Q

Splenomegaly investigations

A
  • FBC & film
  • Thin/thick films for sickle & malaria
  • CTCAP for ?malignancy
  • Bone marrow aspirate/trephine
  • Lymph node biopsy if present
55
Q

Complications of splenomegaly

A

Pancytopenia -> anaemia, infection, bleeding

56
Q
A
57
Q

Indications for splenectomy

A
  • Trauma usually
  • Hypersplenism
  • Autoimmune haemolysis

Leads to Howell-Jolly and Pappenheimer bodies, and target cells

58
Q

Splenectomy follow up

A

Risk of encapsulated organism infections: S. pneumoniae, N meningitides, H influenzae.

  • Immunisations: pneumococcal, meningitis, Hib
  • Penicillin V lifelong
  • Alert cards
  • Broad spectrum Abx if infected
  • Meticulous malaria prophylaxis if travelling
59
Q

Indications for liver transplant

A

Chronic liver failure:
- Cirrhosis - alcoholic, MASH, autoimmune, haemochromatosis, Wilson’s, a1 antitrypsin etc.
- HCC

Acute liver failure (within 8/52 of onset):
- Paracetamol most common
- Hep A, B

Variant:
- Diuretic-resistant ascites
- Intractable pruritis
- Intractable encephalopathy
- Hepatopulmonary syndrome

60
Q

Liver transplant contraindications

A

IVDU
Ongoing alcohol excess
Significant med/psych comorbidities
Extrahepatic spread of HCC

61
Q

Liver transplant complications

A
  • Operative risk
  • Immunosuppression - infection, cancers
  • Post transplant lymphoproliferation
  • Metabolic syndrome
  • Rejection
  • Recurrence of indicative disease
62
Q

Haemochromatosis gene

A

HFE chromosome 6. Autosomal recessive
Variable penetrance

Leads to defective hepcidin, which would normally control negative feedback in duodenal iron absorption

(Other genes exist including transferrin receptor, juvenile

63
Q

Haemochromatosis presentation

A
  • 1st degree relative screening commonly
  • Incidental with raised ferritin
    OR
  • Lethargy
  • Loss of libido & sexual dysfunction
  • Arthralgia (often 2-3 CP, PIPs - pseudogout)
    LATER
  • Hepatomegaly, cirrhosis
  • Diabetes
  • Cardiomyopathy
  • Bronze/”slate-grey” skin
    Tends to present earlier in males due to menstruation

Examination:
- Bronze diabetes
- Venesection scars
- CCF
- Arthropathy

64
Q

Haemochromatosis investigations

A
  • Transferrin sats and ferritin both high
  • HFE gene
  • LFTs - though haemochromatosis does not often cause transaminitis
  • Glucose/HbA1c regularly
  • Consider AFP

Imaging:
- Liver US - 6/12ly if cirrhosis
- Echocardiogram
- Consider DEXA - association with osteoporosis
- Joint XRs - chondrocalcinosis

Liver biopsy can be considered for severity assessment

65
Q

Haemochromatosis screening

A

1st degree relatives of patients
Ferritin - 200 in F, 300 in M
+ T sats >45% F, >50% M

Then HFE gene

66
Q

Haemochromatosis management

A
  • Avoid dietary iron
  • Avoid alcohol
  • Avoid vitamin C
  • Phlebotomy until iron deficient, then reduce frequency
  • Iron chelation only when above not feasible
  • HCC surveillance - 6 monthly if cirrhosis
  • Family screening
67
Q

Liver transplant eligibility score

A

Chronic: United Kingdom Model for End-Stage Liver Disease (UKELD). INR, Creatinine, Bilirubin, Sodium

Acute - various, inc Kings criteria for paracetamol

68
Q

PBC antibodies

A

Antimitochondrial

69
Q

PSC antibodies

A

ANA, Anti-smooth muscle sometimes

70
Q

Autoimmune hepatitis antibodies

A

Anti smooth muscle
Anti liver/kidney microsomal (LKM1)

PACES (5 decks)

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