Abdominal Flashcards
ADPKD presentation
Renal:
- Hypertension
- Abdo pain (rupture, stones, infection)
- Haematuria
- ESRF
Extrarenal
- SAH
- Mitral valve prolapse
- Liver/pancreas cysts
PKD inheritance/chromosomes
AD - Chromosome 16 or 4
10% de novo
(AR also exists)
4 slower course
ADPKD management
Lifestyle
- High fluid, low salt
Medical
- BP control (RAAS blockade)
- Vasopressin analogues (tolvaptan) reduces cyst formation
- Later - RRT/transplant
- Avoid nephrectomy if possible
ADPKD nephrectomy indications
- Frequent/chronic infection
- Mass effect
- Space for transplant
Causes of bilateral kidney enlargement
PKD
Bilateral renal carcinoma
Bilateral hydronephrosis (e.g. HPCR)
Tuberous sclerosis
Extrarenal ADPKD
- HTN
- Liver/pancreas/seminal vesical cyst
- Cerebral aneurysm - ICH/SAH
- MR/AR
Clinical signs of portal hypertension
Caput medusae
Splenomegaly
JVP, oedema less so
Clinical signs hepatic decomensation
Ascites/oedema
Asterixis
Altered consciousness (encephalopathy)
Coagulopathy
Causes of hepatomegaly
3Cs, 4Is
- Cirrhosis (alcoholic)
- Carcinoma
- Congestive (CCF, Budd Chiari)
- Infection (HBV/HCV)
- Immune (PBC, PSC, AIH)
- Infiltrative (myeloproliferation, amyloid)
- Iron (haemochromatosis)
Liver screen bloods
- Autoantibodies (PBC (antimitochondrial), PSC, AIH (ANA, anti-smooth muscle, ALKM1))
- HBV, HCV serology
- Ferritin (haemochromatosis)
- Caeruloplasmin (Wilson’s)
- Alpha-1 antitrypsin
Causes of palmar erythema
Cirrhosis
Hyperthyroidism
RA
Pregnancy
Polycythaemia
Conjugated vs unconjugated bilirubin
Prehepatic - unconjugated
Intrahepatic - conjugated ->therefore pale stools/dark urine
Urine dip to distinguish site of jaundice
Prehepatic - no urinary bilirubin
Post-hepatic - no urobilinogen
Prehepatic jaundice causes
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
Intrahepatic jaundice causes
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
Post-hepatic jaundice causes
Benign
- Gallstones
- Cholangitis
- Strongyloides
Malignant
- Pancreatic cancer
- Cholangiocarcinoma
- Metastases
- Lymphoma
Courvoisier’s law
Palpable gallbladder with jaundice is cancer, not stone - in impacted stone, chronic infection leads to GB atrophy
Autoimmune hepatitis antibodies
ANA, anti-smooth muscle, ALKM1
PBC antibodies
Anti-mitochondrial
Haemolysis blood tests
Haptoglobin
LDH
Reticulocytes
Smear
Direct/indirect antiglobulin test
Cirrhosis complications
- Portal hypertension -> varices
- Hepatic encephalopathy
- SBP
Conditions most likely to recur in renal transplant
Glomerular sclerosis
Amyloidosis
IgA nephropathy
HUS
Renal transplant rejection presentation
Hyperacute - within minutes. Swelling, discolouration of graft
Acute - 2/52-6/12. Cell or Ab mediated. Pain, dysfunction
Chronic - Proteinuria and HTN most common
Most common causes ESRF
Hypertension
Diabetes
Glomerulonephritis
(PKD, reflux/obstructive)
Renal transplant workup tests
ABO, HLA
Viral screen - CMV (don & rec), Hep B, C
Urinalysis & culture
Optimise comorbidities
Cardio ax - ECG, echo, ?stress test
Psychological
Calcineurin inhibitors
Tacrolimus, cyclosporin
Antiproliferative angents
Mycophenolate
Cyclophosphamide
Liver function best tests
PT/INR (+ coag)
Albumin
Alcoholic liver disease LFTs
AST:ALT >2:1
(>50 if ischaemic)
sBP ascites WCC
> 250/mm3
Ascitic fluid tests
- Cell count
- Albumin / SAAG
- Amylase/lipase
- MC&S
- Cytology
- Glucose
Utility of ascites glucose measurement
Low - increases likelihood of infection or malignancy
Low sens/spec
Grading of liver disease
MELD score -Labs only: Bili, PT, Na, Cr, Dialysis
Child-Pugh - Bili, Alb, PT + Ascites, Encephalopathy
SAAG
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)
Extra-intestinal IBD signs
Mouth: Aphthous ulcers
Skin: Erythema nodosum, pyoderma gangrenosum
Joints: Clubbing, seronegative arthritis (e.g. AS)
Eye: Uveitis, episcleritis, iritis
Liver: PSC with UC
Amyloidosis
IBD severity
Truelove & Witt
- Frequency >6/day
- Stool blood vol
- Temp >37.8
- Pulse >90
- Hb <105
- ESR >30
ECCO (European Crohn’s & Colitis Org)
UC vs CD endoscopy
UC:
- rectal/colon only
- Continuous
- Mucosa/submucosa
CD:
- Whole bowel
- Skip lesions
- Full depth, may include granulomas
- Structures, fistulae
- Cobblestoning
IBD investigations
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
Management acute severe UC
- Admit, resus (IVF)
- LMWH
- IV corticosteroid
- Ciclosporin (calcineurin inhib)/Infliximab (anti TNF) if failure to respond in 72h
- Surgery if failure to respond
Mild acute UC management
Topical 5-ASA or steroid (e.g. rectal mesalazine or budesonide)
5-ASAs better
Maintenance of remission UC & monitoring
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
IBD and smoking
CD - increased risk 3x
UC - lower risk
Mild crohns flare treatment
Oral steroid (budesonide/pred) OD, reduce over 7/52
TPMT level relevance
Prior to starting thiopurines (azathioprine/mercaptopurine) measure thiopurine S-methyltransferase.
Aminosalicilates in IBD
Good evidence in UC
Poor evidence in CD
e.g. Mesalazine, sulfasalazine
Maintenance of remission CD
- 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
IBD surgery indications
- Obstruction
- Fistulation
- Toxic megacolon/severe colitis
- Intractable symptoms
Relapse rate high in CD
Ileum absorption
B12
Bile salts (which absorb fat soluble vitamins ADEK)
Coeliac endoscopy findings
Villous atrophy
Crypt hypertrophy
Lymphocytes in epithelium and lamina propria
Coeliac most common deficiencies
B12, Folate, D (Iron)
Coeliac complications
Malabsorptive:
- Anaemia
- Osteopenia/porosis
- Neuropathy / SACDC
Other:
- Dermatitis herpetiformis
- Hyposplenism
- T cell lymphoma
Causes splenomegaly
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
Causes massive splenomegaly
- CML
- Myelofibrosis
- Gaucher’s disease
- Chronic malaria
- Kala-azar (leishmaniasis)
Splenomegaly investigations
- FBC & film
- Thin/thick films for sickle & malaria
- CTCAP for ?malignancy
- Bone marrow aspirate/trephine
- Lymph node biopsy if present
Complications of splenomegaly
Pancytopenia -> anaemia, infection, bleeding
Indications for splenectomy
- Trauma usually
- Hypersplenism
- Autoimmune haemolysis
Leads to Howell-Jolly and Pappenheimer bodies, and target cells
Splenectomy follow up
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
Indications for liver transplant
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
Liver transplant contraindications
IVDU
Ongoing alcohol excess
Significant med/psych comorbidities
Extrahepatic spread of HCC
Liver transplant complications
- Operative risk
- Immunosuppression - infection, cancers
- Post transplant lymphoproliferation
- Metabolic syndrome
- Rejection
- Recurrence of indicative disease
Haemochromatosis gene
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
Haemochromatosis presentation
- 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
Haemochromatosis investigations
- 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
Haemochromatosis screening
1st degree relatives of patients
Ferritin - 200 in F, 300 in M
+ T sats >45% F, >50% M
Then HFE gene
Haemochromatosis management
- 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
Liver transplant eligibility score
Chronic: United Kingdom Model for End-Stage Liver Disease (UKELD). INR, Creatinine, Bilirubin, Sodium
Acute - various, inc Kings criteria for paracetamol
PBC antibodies
Antimitochondrial
PSC antibodies
ANA, Anti-smooth muscle sometimes
Autoimmune hepatitis antibodies
Anti smooth muscle
Anti liver/kidney microsomal (LKM1)
Massive splenomegaly
Haem
- Myelofibrosis
- CML
INFECTION
- malaria
- leishmaniasis
