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PACES > Abdominal Station > Flashcards

Abdominal Station Flashcards

1
Q

Differential Diagnosis for CLD

A
  • Alcoholic liver disease
  • Hepatitis B/C – tattoos, track marks
  • Autoimmune – vitiligo, thyroidectomy scar,
    Primary biliary cirrhosis – middle aged female, xanthelasma, excoriation marks, easy bruising, hepatosplenomegaly
    Autoimmune hepatitis
    Primary Sclerosing cholangitis
    Sarcoidosis
  • Drugs: Methotrexate, Amiodarone, Isoniazid, Antibiotics
  • Metabolic: NASH- xanthelasma, finger prick
  • Congestions: CCF, Budd Chiari
  • Hereditary – Hereditary haemochromatosis, Alpha-1 antitrypsin deficiency, Wilsons
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2
Q

Features of decompensated CLD

A

Jaundice, Ascites, Encephalopathy

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3
Q

Signs of CLD

A

Palmar erythema, Dupytrenes contracture, Leukonychia, Spider naevia, Gynacomastia, Reduced axillary hair, Testicular atrophy, Caput medusa, Splenomegaly, Easy bleeding, Scratching, Jaundice

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4
Q

Features to suggest Wilsons disease

A

Kayser-Fleishcer rings,
Tremor
Chorea
Jaundice

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5
Q

Investigations for CLD

A

Urine Dip

Bloods - FBC, U&Es, LFTs, Clotting, CPR, Glucose, Gamma GT

Hep B, Hep C, EBV, CMV

Ferritin

Autoantibodies – ANA, anti-Mitrochondrial, anti-LKM, Anti-Smoothmusclr

Serum caeruloplasmin/Copper/24hr urinary copper

Alpha-1-antitrypsin

AFP

Abdo USS/Firbroscan, Ascitic tap

Liver biopsy

MRCP/ERCP

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6
Q

Management of CLD

A

Alcohol abstinence
Vitamint & thiamine replacement
Dietician
Salt restriction
Avoid hepatotoxic medication
Regular laxatives - air 3 soft stools/day

Carvedilol of variceas

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7
Q

Management of Ascites

A

Spironolatone - aim 1kg/weight loss/day
Add in furosemide if needed

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8
Q

SAAG >11g/L

A

Liver disorders,
Cardiac
Budd-Chiari, Porta vein thrombosis, Myoxeodema

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9
Q

SAAG < 11g/L

A

Hypoalbuminaemia - nephrotic, severe malnutrition
Malignancy - Peritoneal caricnoma
Infection
Pancreatitis, bowel obstruction

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10
Q

Scoring system used for prognosis in CLD & composition of each

A
  • Child-Pugh = albumin, bilirubin, PT, encephalopathy, ascites –> predicts survival
    - Score >7 = decompensated
  • MELD = bilirubin, creatinine and INR to predict survival
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11
Q

Indication for liver transplant

A

Cirrhosis
Acute hepatic failure - viral or paracetamol OD
Hepatic malignancy

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12
Q

Pre liver transplant work up

A

Full liver screen
Up to date bloods
Viral serology
G&S
Tissue typing
ECG
CXR
Echo
PFTs
Cervical smear
Dental check up

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13
Q

Scoring system used to indicate need for transplant

A

UKLED (UK end-stage liver disease) score >49 or <49 + drug resistant and TIPS resistant ascites
(Na, Creatinine, Bilirubin, INR)

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14
Q

Scoring system used in acute liver disease

A

Maddrey score = prognosis >50% @ 5 years

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15
Q

Scoring system used in acute liver failure

A

Kings criteria (low pH <7.25, raised PT >100 or INR >6.5, raised Cr >300, anuria, Grade 3+ encephalopathy)

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16
Q

What are common precipitant of decompensated liver disease?

A

Infection, Increased alcohol intake, GI Bleed, Underlying malignancy, Constipation, Dehydration or increased salt intake, Hepatotoxic mediation

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17
Q

What are the complications of CLD?

A

Portal hypertension and varicese  GI haemorrhage, AScited, Juandice, Encephalopathy, SPB, Hepatorenal syndrome, Hepatopulmonary syndrome, HCC

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18
Q

What are the commonest causes of palmar erythema?

A

Chronic liver disease, Rheumatoid arthritis, Thyrotoxicosis, Pregnancy, Polycythaemia

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19
Q

What are the abdominal causes of finger clubbing?

A

IBD, Cirrhosis, Coeliac disease, HCC

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20
Q

How do you diagnose SPB?

A

Ascitic tap –> Neutrophils >250 per ml

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21
Q

Commonest cause of SPB?

A

E.coli

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22
Q

What features in an individual with chronic liver disease would warrant consideration of transplantation?

A

Progressive jaundice, Diuretic resistant ascites, HCC

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23
Q

Causes of splenomegaly

A

Haemolytic –> Lymphoma, Myelodysplastic syndromes (CML & Myelofirbosis), Haemolytic anaemia, Polycythaemia rubra vera
Pressure –> Portal hypertension secondary to liver disease or splenic vein thrombosis
Infection –> Malaria, Viscera leishmaniasis, EBV, Bacterial endocarditis
Infiltration –> Gauchers, Amyloidosis, Sarcoidosis,
Thyrotoxicosis

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24
Q

Post splenectomy complications

A

Increased risk from encapsulated organisms (S.Pneumonia, H Influenza), Thrombocytosis, Howell jolly bodies on smear

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25
Q

IBD Signs

A
  • Young, Pale, Cachectic
  • TPN line may be visible
  • Clubbing
  • Erythema nodosum, Pyoderma Gangrenosum (around stoma site)
  • Abdo – Scars, RIF Mass, Stoma (contents, surround skin),
  • Immunosuppression side effects signs
  • Aphthous ulcers, Enteropathic arthropathy, Conjunctivitis/episcleritis/anterior uveitis
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26
Q

Extraintestinal complications

A

Arthropathy, Eye Involvement, Anaemia, Aphthous Ulcers, Skins changes, Primary sclerosing cholangitis (UC), Cholangiocarcinoma, Renal stones

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27
Q

Crohns management - induce remission

A

Inducing remission = Steroids
* 2nd line = 5-ASA drugs eg mesalazine
* Add on drugs = azathioprine/mercaptopurine (check TPMT activity first to assess for risk of toxicity) or methotrexate
* Alternative = elemental diet
* Infliximab in refractory disease  if severe disease e.g intra-abdominal abscess
* Metronidazole for peri-anal disease

28
Q

Crohn’s maintenance

A
  • 1st line = azathioprine or mercaptopurine
  • 2nd line = methotrexate
29
Q

UC induce remission

A

mild-to-moderate ulcerative colitis
* topical (rectal) aminosalicylate eg mesalazine for 4 weeks
* no benefit (or if disease extends beyond descending colon) –> add oral aminosalicylate
* no remission –> add topical or oral corticosteroid

Severe colitis
* IV steroids eg 100mg hydrocortisone QDS
o IV ciclosporin if steroids are contraindicated
* no improvement after 72 hours –> add IV ciclosporin to IV corticosteroids
o at this point if >8 stools per day or CRP >45  surgical review (85% need colectomy)
* Pain worsens suddenly despite treatment  CT abdomen ?perforation
* Severe IBD flare is a prothrombotic state – requires prophylactic LMWH

30
Q

UC maintain remission

A
  • topical (rectal) aminosalicylate +/- oral aminosalicylate eg mesalazine
  • In patients taking mesalazine, check U+E before starting, at 3 months, then annually, and also FBC (as 5-ASAs can cause interstitial nephritis and agranulocytosis)

Following a severe relapse or >=2 exacerbations in the past year
* oral azathioprine or oral mercaptopurine

31
Q

What are side effects of steroids?

A

Weight gain, Acne, Fluid retention, Sleep disturbance, Alteration of mood, Hypoglycaemia, Dyspepsia
Osteoporosis, Myopathy, Infections, Cataracts

32
Q

What test is performed before administering thiopurines?

A

TPMT activity test or genotype to identify those at risk of leukopaenia.

33
Q

Poor Prognostic factors in Crohns?

A

Onset <40, Female, Perianal, Fistulating, Stricturing, perforating disease, Steroids required at first flare, Upper GI lesions

34
Q

What investigations are require prior to starting immunotherapy?

A

Check Heb B, Immunity to Varicella Zoster, Screen for latent TB, Consider outstanding live vaccinations

35
Q

What is the scoring tool used for IBD Severity?

A

Truelove & Witt’s scoring

36
Q

Causes of ESRD and features seen

A
  • Diabetes –> Finger prick marks, Insulin injection sites (lipatrophy & lipohypertrophy)
  • Hypertension
  • Autosomal dominant polycystic kidney disease  Balotable flank masses, Nephrectomy scar
  • SLE –> reducible arthropathy of hands (Jaccouds), photosensitivity, scarring alopecia,
  • Alports syndrome –> Hearing aids
  • Tuberous sclerosis –> Subungal fibromas, adenoma sebaceum, shagreen patches, ash lead macules
  • MPGN type 2: Lipdystrophy
37
Q

Hoe might patients with ADPKD present?

A

Hypertension
Signs & Symptoms of Renal Failure
Proteinura
Haematuria
Extra-renal manifestations - liver cysts, pancreas, spleen or thyroid
Loin pain, calculi or infection

38
Q

Inheritance of PKD?

A
  • It is an autosomal dominant condition.
  • There are two main genetic mutations that are associated.
  • Around 80% of patients have a mutational chromosome 16.
  • About 15% having a mutational chromosome 4.
  • There remainder of patients have no detectable genetic abnormality.
39
Q

differences between each inherited type?

A
  • Polycystic kidney disease type 2 is associated with a mutated chromosome 4.
  • Tends to be less severe with later onset.
  • Fewer cysts.
  • Later progression to renal failure.
40
Q

How would you treat someone with PKD?

A
  • Good control of blood pressure ideally with ACE inhibitors is very important.
  • There should also be aggressive control of hyperlipidaemia.
  • CKD is a major risk factor for ischaemic heart disease.
  • Patients should be on a high-fluid low-salt diet.
  • CKD stage 1–3 of the disease vasopressin receptor antagonist, eg tolvaptan, may
    be of use.
  • Later in the disease, the patient may require renal replacement therapy and/or
    transplant.
41
Q

Complications of Tacrolimus

A
  • Diabetogenic, Tremor
42
Q

Ciclosporin – Calcineurin inhibition, decreases IL2
Side effects

A
  • Nephrotoxic, Hepatic dysfunction, Gum hypertrophy & hypetrichosis, HTN, High lipids & glucose
43
Q

Azathioprine side effects

A
  • BM suppression (Test for TMPT), Hepatotoxic
44
Q

Mycophenolate side effects

A
  • Pale palmar creases, conjunctival pallor, oral ulcers
45
Q

Nephritic glomerulonephritis features

A
  • Haematuria, Proteinuira, HTN, Clots,
46
Q

Causes of Nephritic glomerulonephritis

A

Post Infective (IgA Nephropathy),
Rapidly progressive (Vasculitis),
Alports, Post streptococcal (anti-streptolysin O titre),
HSP

47
Q

Nephrotic features

A

Proteinuria >35g/day, PCR >3.5 + Hypoalbuminaemia <30 + Oedema

48
Q

Causes of nephrotic

A

Diabetes, Minimal change, Membranous, Autoimmune – RA, PAN, SLE, Infection - Heb B/C, HIV, Amyloidosis, Malignancy, Pregnancy,

49
Q

What genetic abnormalities are seen in PKD?

A

Mutation in PKD-1 on chromosome 16 (ESRF at younger age), smaller number have mutation in PKD-2 on chromosome 4 (later onset, less cysts, less progressive)

50
Q

What are the extrarenal features?

A

Hepatic cysts, Intracranial berry aneurysms, Mitral valve prolapse

51
Q

Which renal cystic conditions are at high risk of neoplastic transformation?

A

Von hippel Lindau & Tuberous sclerosis

52
Q

What is Von Hipple-Lindau

A

AD inherited disorder causing multiple tumours – benign and malignant in CNS & Viscera
* Retinal haeangioblastomas, CNS haemangioblastomas, RCC, Renal cysts, Phaeochromocytomas (Type 2 > Type1)

53
Q

What is Tuberous Sclerosis

A

Multisystem Disorder. Formation of hamartomas in many organs – brain, skin & kidneys.

Kidneys –> PKD, Angiomyolipoma, Simple cysts, RCC.

54
Q

How would you test to see if the graft is working?

A

Examination – tender, bruit, uraemic encephalopathy
Urine Output
Urinary protein on dip/collection
Renal function on bloods
Consider biopsy under specialist opinion

55
Q

What are the complications of renal transplant?

A

Graft rejection
Disease recurrent
Renal artery stenosis
Opportunistic infection
Immunosuppressant Side Effects
IHD
HTN
Skin cancer & Lymphoma

56
Q

Causes of gum hypertrophy?

A

Scurvy, Leukaemia, Ciclosporin, Phenytoin, Nifedipine

57
Q

Indications for urgent dialysis

A
  • Uraemia – pericarditis/peluritis
  • Encephalopathy/Neuropathy
  • Resistant fluid overload
  • Resistant electrolyte abnormalities
  • Resistant malignant hypertension
58
Q

Complications of dialysis:
Haemodialysis

A
  • Dialysis Washout  Volume losss, Dizziness, Light headed, Chest pain, Nausea
  • Bleeding
  • Infection
  • Fistula thrombosis/Infection
  • Amyloidosis – accumulation of B2-microglobulin
59
Q

Complications of dialysis: Peritoneal

A
  • Infection – Peritonitis
  • Diabetes
  • Local complications – hernia, catheter site infections
60
Q

Complications of chronic renal failure

A
  • CVS – HTN, Volume overload, Increased IHD, Decreased Hb
  • Metabolic – uraemia, Hyperkalaemia, Metabolic acidosis
  • Bones – Hyperphosphataemia, Hypocalcaemia (lack of Vit D hydroxylation), Hypercalcaemia – secondary  tertiary hyperparathyroidism, Renal osteodystrophy
61
Q

When start work up for transplant:

A

As they approach end stage CKD (eGFR <15), before dialysis

62
Q

Contraindication to transplant

A
  • Predicted survival <5 years
  • Predicted risk of graft loss >50% @ 1yr
  • Unable to comply with immunosuppressant therapy
  • Risk of life-threatening complications of immunosuppression (chronic viral illness, malignancy)
63
Q

Workup for transplant:

A
  • Renal screen – assess cause
  • Blood tests, Virology, G&S
  • ECG, Echo, PFT, CXR
  • Up to date cervical smear
  • Dental check up
64
Q

Superiority of AV fistula over alternative HD access

A

Lower risk of infection
Lower risk of thrombosis
Greater longevity & long term accessibility
Greater blood flow volume
Shorter duration of dialysis
Most cost effectice

65
Q

Advice for pts with new AV fistula

A

Protect against direct trauma in first few days
Avoid overuse of arm
Do not drive or lift heavy objects for first 2 weks
Carry out strengthening exercises (squeeze rubber ball) 2-3 times hourly in first few weeks

66
Q
A

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