Abdominal Station Flashcards
Causes of splenomegaly
- Work hypertrophy
- RBC sequestration (haemaglobinopathies, membranopathies)
- Immune-mediated (malaria, HIV, EBV, infective endocarditis, visceral leishmaniasis, RA, sarcoidosis, thyrotoxicosis)
- Extra-medullary haematopoiesis (ET, PV, MF) - Infiltration
- Neoplasms (lymphoma, leukaemia, metastasis)
- Metabolic (Gaucher’s, amyloidosis)
- Cysts/abscesses - Congestion (PHT, CCF)
Myeloproliferative disorders
Chronic myeloid leukaemia
Essential thrombocytosis
Polycythaemia rubra vera
Primary myelofibrosis
Splenomegaly vs Renal Mass on Clinical Exam
Splenic notch
Getting above the mass
Percussion
Ballot
Movement with inspiration
Direction of enlargement
Felty’s syndrome
Rheumatoid arthritis
Splenomegaly
Neutropaenia (recurrent infections)
Causes of massive splenomegaly
Myeloproliferative disorders (CML and myelofibrosis)
Visceral leishmaniasis
Chronic malaria
Causes of hepatomegaly
Cirrhosis
Congestive cardiac failure
Carcinoma (HCC, metastasis)
Infections (Hep B + C)
Autoimmune (AIH, PBC, PSC)
Infiltrative (myeloproliferative disorders, sarcoidosis, amyloidosis)
Causes of cirrhosis
Alcohol-related liver disease
Non-alcoholic fatty liver disease
Chronic viral hepatitis (Hep B & C)
Autoimmune (AIH, PBC, PSC)
Haemachromatosis
Wilson’s disease
Alpha-1 antitrypsin deficiency
Drug-induced (methotrexate)
Indications for liver transplant
Cirrhosis
Hepatocellular carcinoma
Acute liver failure (i.e. paracetamol overdose)
Complications of immunosuppression
Infection (CMV, VZV, PCP)
Malignancy (skin cancer - SCC and BCC)
Post-transplant diabetes mellitus
Hypertension
Dyslipidaemia
Weight gain
IHD
CVA
Criteria used in selecting patients for liver transplants
Chronic: UKELD score (49+)
Acute: KCH (paracetamol-induced vs non-paracetamol-induced)
Immunosuppressive agents used in organ transplants and their side effects
Calcineurin inhibitors: tacrolimus (tremor, paraesthesia, nephrotixicity), ciclosporin (gingival hypertrophy, hypertrichosis , nephrotoxicity)
Antiproliferative agents: MMF (nausea, diarrhoea, bone marrow suppression), azathioprine (alopecia, seborrheic keratosis, bone marrow suppression)
Haemochromatosis symptom triad
Fatigue
Arthralgia
Sexual dysfunction
Complications of haemochromatosis
Cirrhosis
T1DM
Skin discolouration (bronze or slate-grey)
Anterior pituitary dysfunction
Arthropathy (chondrocalcinosis)
Cardiomyopathy
Hepatocellular carcinoma
Investigations for haemochromatosis
Blood glucose and HbA1c
Iron studies: ferritin (>300 in men, >200 in women) and transferrin >45%
Alpha-fetoprotein
Liver ultrasound, fibroscan
ECG
CXR
Echo
Genotyping
Treatment of haemochromatosis
Regular venesection
- 1 unit/week until ferritin 20-30, transferrin saturation <50%, then 1 unit 3-4 times per year
Avoid alcohol
Monitor for HCC
Genetics of haemochromatosis
Autosomal recessive
HFE gene on chromosome 6
Most common mutation C282Y
Causes of a high SAAG (>1.1 mg/dL)
Cirrhosis
CCF
Alcoholic hepatitis
Fulminant hepatic failure
Portal vein thrombosis
Budd-Chiari syndrome
Meig’s syndrome
Causes of a low SAAG (<1.1 mg/dL)
TB
Pancreatitis
GI or ovarian malignancy
Peritoneal carcinomatosis
Nephrotic syndrome
Triad of hereditary spherocytosis
Pallor
Jaundice
Splenomegaly
Pathophysiology of hereditary spherocytosis
Autosomal dominant condition
Mutation in one of 5 membrane proteins
Biconcave -> spherocyte
Sequestration in the spleen
Haemolysis
Investigations for hereditary spherocytosis
Hb
Blood film
Bilirubin
LDH
Haptoglobin
Reticulocyte count
DAT
EM binding test
Osmotic fragility testing
Flow cytometry
Management of hereditary spherocytosis
Mild: supportive
Moderate: supportive + consider splenectomy
Severe: splenectomy
Also consider cholecystectomy as these patients may have gallstones
Preoperative vaccination before splenectomy
Pneumococcal vaccine
Meningococcal vaccine
Haemophilis influenza vaccine
Postoperative splenectomy Mx
Prophylactic antibiotics (for at least 3 years)
Keep vaccines up to date
Complications of liver cirrhosis
Portal hypertension
Ascites
Spontaneous bacterial peritonitis
Hepatic encephalopathy
Variceal haemorrhage
Hepatorenal syndrome
Hepatopulmonary syndrome
Management of ascites in CLD
Low salt diet (<5.2 g/day)
Spironolactone
Furosemide
Repeated ascitic taps
TIPS
Common causes of ascites
Cirrhosis with PHT
Congestive cardiac failure
Nephrotic syndrome
Malignancy
Causes of pancreatitis
G - Gallstones
E - Ethanol
T - Trauma
S - Steroids
M - Mumps or malignancy
A - Autoimmune
S - Scorpion sting
H - Hypertriglyceridaemia or hypercalcaemia
E - ERCP
D - Drugs: Azathioprine, HCTZ, co-trimoxazole
Genetic causes: PRSS1, CFTR, Spink1
Features of pancreatic insufficiency
Weight loss
Diarrhoea
Steatorrhoea
Low Vit D
Low Mg
Low faecal elastase
Causes of palmar erythema
Cirrhosis
Polycythaemia
Pregnancy
Hyperthyroidism
Rheumatoid arthritis
Features: Crohn’s disease vs. Ulcerative Colitis
UC: colon and rectum only, continues lesions, mucosal or submucosal, crypt abscesses
Crohn’s disease: anywhere in the alimentary canal, skip lesions, transmural, granulomas
Treatment of IBD
Therapy to induce remission
Maintenance therapy
Medical:
Mesalazine (oral or topical)
Steroids (oral or topical)
Immunosuppressive agents (ciclosporin, azathioprine)
Biologicals (inflixamab, vedolizumab, ustekinumab)
Surgery
Other: dietician, TPN, stoma nurse, VTE, stop smoking
Indications for surgery in IBD
Poor response to medical therapy
Toxic megacolon
Perforation
Haemorrhage
Indications for splenectomy
Chronic ITP
Trauma
Hereditary spherocytosis
Sickle-cell disease
Primary splenic malignancy
Genetics of ADPKD
PKD1 mutation in chromosome 16 (85%)
PKD2 mutation on chromosome 4 (15%)
Ultrasound criteria for ADPKD
< 40: 3 cysts total on one or both kidneys
40 - 60: 2 cysts on both kidneys
> 60: 4 cysts on both kidneys
Extra-renal manifestations of ADPKD
Cysts elsewhere (liver, pancreas, arachnoid)
Berry aneurysms
Mitral valve prolapse
