Abdominal Station Flashcards
Differential Diagnosis for CLD
- 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
Features of decompensated CLD
Jaundice, Ascites, Encephalopathy
Signs of CLD
Palmar erythema, Dupytrenes contracture, Leukonychia, Spider naevia, Gynacomastia, Reduced axillary hair, Testicular atrophy, Caput medusa, Splenomegaly, Easy bleeding, Scratching, Jaundice
Features to suggest Wilsons disease
Kayser-Fleishcer rings,
Tremor
Chorea
Jaundice
Investigations for CLD
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
Management of CLD
Alcohol abstinence
Vitamint & thiamine replacement
Dietician
Salt restriction
Avoid hepatotoxic medication
Regular laxatives - air 3 soft stools/day
Carvedilol of variceas
Management of Ascites
Spironolatone - aim 1kg/weight loss/day
Add in furosemide if needed
SAAG >11g/L
Liver disorders,
Cardiac
Budd-Chiari, Porta vein thrombosis, Myoxeodema
SAAG < 11g/L
Hypoalbuminaemia - nephrotic, severe malnutrition
Malignancy - Peritoneal caricnoma
Infection
Pancreatitis, bowel obstruction
Scoring system used for prognosis in CLD & composition of each
- Child-Pugh = albumin, bilirubin, PT, encephalopathy, ascites –> predicts survival
- Score >7 = decompensated - MELD = bilirubin, creatinine and INR to predict survival
Indication for liver transplant
Cirrhosis
Acute hepatic failure - viral or paracetamol OD
Hepatic malignancy
Pre liver transplant work up
Full liver screen
Up to date bloods
Viral serology
G&S
Tissue typing
ECG
CXR
Echo
PFTs
Cervical smear
Dental check up
Scoring system used to indicate need for transplant
UKLED (UK end-stage liver disease) score >49 or <49 + drug resistant and TIPS resistant ascites
(Na, Creatinine, Bilirubin, INR)
Scoring system used in acute liver disease
Maddrey score = prognosis >50% @ 5 years
Scoring system used in acute liver failure
Kings criteria (low pH <7.25, raised PT >100 or INR >6.5, raised Cr >300, anuria, Grade 3+ encephalopathy)
What are common precipitant of decompensated liver disease?
Infection, Increased alcohol intake, GI Bleed, Underlying malignancy, Constipation, Dehydration or increased salt intake, Hepatotoxic mediation
What are the complications of CLD?
Portal hypertension and varicese GI haemorrhage, AScited, Juandice, Encephalopathy, SPB, Hepatorenal syndrome, Hepatopulmonary syndrome, HCC
What are the commonest causes of palmar erythema?
Chronic liver disease, Rheumatoid arthritis, Thyrotoxicosis, Pregnancy, Polycythaemia
What are the abdominal causes of finger clubbing?
IBD, Cirrhosis, Coeliac disease, HCC
How do you diagnose SPB?
Ascitic tap –> Neutrophils >250 per ml
Commonest cause of SPB?
E.coli
What features in an individual with chronic liver disease would warrant consideration of transplantation?
Progressive jaundice, Diuretic resistant ascites, HCC
Causes of splenomegaly
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
Post splenectomy complications
Increased risk from encapsulated organisms (S.Pneumonia, H Influenza), Thrombocytosis, Howell jolly bodies on smear
IBD Signs
- 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
Extraintestinal complications
Arthropathy, Eye Involvement, Anaemia, Aphthous Ulcers, Skins changes, Primary sclerosing cholangitis (UC), Cholangiocarcinoma, Renal stones
Crohns management - induce remission
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
Crohn’s maintenance
- 1st line = azathioprine or mercaptopurine
- 2nd line = methotrexate
UC induce remission
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
UC maintain remission
- 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
What are side effects of steroids?
Weight gain, Acne, Fluid retention, Sleep disturbance, Alteration of mood, Hypoglycaemia, Dyspepsia
Osteoporosis, Myopathy, Infections, Cataracts
What test is performed before administering thiopurines?
TPMT activity test or genotype to identify those at risk of leukopaenia.
Poor Prognostic factors in Crohns?
Onset <40, Female, Perianal, Fistulating, Stricturing, perforating disease, Steroids required at first flare, Upper GI lesions
What investigations are require prior to starting immunotherapy?
Check Heb B, Immunity to Varicella Zoster, Screen for latent TB, Consider outstanding live vaccinations
What is the scoring tool used for IBD Severity?
Truelove & Witt’s scoring
Causes of ESRD and features seen
- 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
Hoe might patients with ADPKD present?
Hypertension
Signs & Symptoms of Renal Failure
Proteinura
Haematuria
Extra-renal manifestations - liver cysts, pancreas, spleen or thyroid
Loin pain, calculi or infection
Inheritance of PKD?
- 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.
differences between each inherited type?
- 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.
How would you treat someone with PKD?
- 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.
Complications of Tacrolimus
- Diabetogenic, Tremor
Ciclosporin – Calcineurin inhibition, decreases IL2
Side effects
- Nephrotoxic, Hepatic dysfunction, Gum hypertrophy & hypetrichosis, HTN, High lipids & glucose
Azathioprine side effects
- BM suppression (Test for TMPT), Hepatotoxic
Mycophenolate side effects
- Pale palmar creases, conjunctival pallor, oral ulcers
Nephritic glomerulonephritis features
- Haematuria, Proteinuira, HTN, Clots,
Causes of Nephritic glomerulonephritis
Post Infective (IgA Nephropathy),
Rapidly progressive (Vasculitis),
Alports, Post streptococcal (anti-streptolysin O titre),
HSP
Nephrotic features
Proteinuria >35g/day, PCR >3.5 + Hypoalbuminaemia <30 + Oedema
Causes of nephrotic
Diabetes, Minimal change, Membranous, Autoimmune – RA, PAN, SLE, Infection - Heb B/C, HIV, Amyloidosis, Malignancy, Pregnancy,
What genetic abnormalities are seen in PKD?
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)
What are the extrarenal features?
Hepatic cysts, Intracranial berry aneurysms, Mitral valve prolapse
Which renal cystic conditions are at high risk of neoplastic transformation?
Von hippel Lindau & Tuberous sclerosis
What is Von Hipple-Lindau
AD inherited disorder causing multiple tumours – benign and malignant in CNS & Viscera
* Retinal haeangioblastomas, CNS haemangioblastomas, RCC, Renal cysts, Phaeochromocytomas (Type 2 > Type1)
What is Tuberous Sclerosis
Multisystem Disorder. Formation of hamartomas in many organs – brain, skin & kidneys.
Kidneys –> PKD, Angiomyolipoma, Simple cysts, RCC.
How would you test to see if the graft is working?
Examination – tender, bruit, uraemic encephalopathy
Urine Output
Urinary protein on dip/collection
Renal function on bloods
Consider biopsy under specialist opinion
What are the complications of renal transplant?
Graft rejection
Disease recurrent
Renal artery stenosis
Opportunistic infection
Immunosuppressant Side Effects
IHD
HTN
Skin cancer & Lymphoma
Causes of gum hypertrophy?
Scurvy, Leukaemia, Ciclosporin, Phenytoin, Nifedipine
Indications for urgent dialysis
- Uraemia – pericarditis/peluritis
- Encephalopathy/Neuropathy
- Resistant fluid overload
- Resistant electrolyte abnormalities
- Resistant malignant hypertension
Complications of dialysis:
Haemodialysis
- Dialysis Washout Volume losss, Dizziness, Light headed, Chest pain, Nausea
- Bleeding
- Infection
- Fistula thrombosis/Infection
- Amyloidosis – accumulation of B2-microglobulin
Complications of dialysis: Peritoneal
- Infection – Peritonitis
- Diabetes
- Local complications – hernia, catheter site infections
Complications of chronic renal failure
- 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
When start work up for transplant:
As they approach end stage CKD (eGFR <15), before dialysis
Contraindication to transplant
- 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)
Workup for transplant:
- Renal screen – assess cause
- Blood tests, Virology, G&S
- ECG, Echo, PFT, CXR
- Up to date cervical smear
- Dental check up
Superiority of AV fistula over alternative HD access
Lower risk of infection
Lower risk of thrombosis
Greater longevity & long term accessibility
Greater blood flow volume
Shorter duration of dialysis
Most cost effectice
Advice for pts with new AV fistula
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
