Abdominal Vivas Flashcards
What causes ascites with a SAAG >11?
Liver: Cirrhosis, alcoholic hepatitis, acute liver failure, liver mets
Cardiac: Right HF, constrictive pericarditis
Budd-chiari syndrome, portal vein thrombosis
What is indicated by a high SAAG >11?
Transudate
Portal HTN
What causes ascites with a SAAG <11?
Hypoalbuminaemia: nephrotic syndrome
Malignancy: peritoneal carcinoma
Tuberculous peritonitis
Pancreatitis
Bowel obstruction
What is indicated by a low SAAG <11?
Ascitic fluid is an exudate
5 complications of ascites
SBP
Hepatorenal syndrome
Malnutrition
Pleural effusion
GI bleed
What is SBP? How is it diagnosed? What is the most common organism involved?
Bacterial infection of ascitic fluid
Paracentesis: neutrophils >250 cells/ul
E.coli
Management of SBP
IV Cefotaxime
SBP prophylaxis
Ciprofloxacin PO for those with cirrhosis + ascites with ascitic protein ,<15
or if have had an episode of SBP
Management of ascites
Reduce dietary sodium
Fluid restrict
Aldosterone antagonists: Spironolactone
Therapeutic abdominal paracentesis (requires albumin cover)
Transjugular intrahepatic portosystemic shunt (TIPS)
What is a transjugular intrahepatic portosystemic shunt?
Procedure creates internal ‘bypass’ between portal vein + hepatic vein
List 4 indications for a TIPS procedure?
Acute variceal bleeding where other interventions have failed
Recurrent variceal bleeding
Refractory ascites
Hepatorenal syndrome
What is hepatorenal syndrome?
‘Functional’ kidney impairment due to severe renal vasoconstriction in patients with cirrhosis
Reduction in renal blood flow + GFR
4 absolute CI to laparoscopic surgery
Haemodynamic instability/ shock
Raised ICP
Acute intestinal obstruction with dilated bowel loops (> 4 cm)
Uncorrected coagulopathy
Indications for laparoscopic surgery
Diagnostic: appendicitis, PID, endometriosis
Therapeutic: Appendicectomy, cholecystectomy, hernia repair, hysterectomy, fibroidectomy
4 Benefits of laparoscopy
Faster recovery time + shorter stay
Less pain
Less risk of infection
Smaller scars
5 Complications of laparoscopy
Risks of anaesthetic
Vasovagal bradycardia in response to abdominal distension
Extra-peritoneal gas insufflation: surgical emphysema
Injury to GIT
Injury to blood vessels e.g. common iliacs, deep inferior epigastric artery
Which patient should be assessed for renal transplant?
All with end stage renal failure (GFR <15) or CKD stage 4 with progressive disease (GFR 15-29)
List 5 absolute contraindications to renal transplant
Untreated malignancy
Active infection
Untreated HIV/ AIDS
Condition with life expectancy <2y
Malignant melanoma within past 5y
Renal transplant immunosuppression regime
Initial: ciclosporin/ tacrolimus with a monoclonal antibody (Basilximab)
Maintenance: ciclosporin/ tacrolimus with MMF or Sirolimus
Add steroids if >1 steroid responsive acute rejection episode
Graft survival for renal transplants
Cadaveric: 1y= 90%, 10y = 60%
Living-donor: 1y= 95%, 10y= 70%
5 post-op problems of renal transplant
ATN of graft
Vascular thrombosis
Ureteric leaks
UTI
Delayed graft function (need for dialysis within 1st week)
Describe hyper acute rejection of a renal transplant
Mins- hours
Due to pre-existing Abs to ABO/ HLA
Widespread thrombosis of graft vessels + ischaemia + necrosis
Graft MUST be removed
Describe acute graft failure
<6 months
Due to mismatched HLA/ CMV
Asymptomatic rise in creatinine + proteinuria
May be reversible with CS + immunosuppression
Describe chronic graft failure
> 6 months
Ab + cell mediated mechanisms causing fibrosis of kidney
Recurrence of original disease
What do patients on long term immunosuppression for organ transplant require monitoring for?
CVS disease: tacrolimus + ciclosporin can cause HTN + hyperglycaemia. Tacrolimus can also cause hyperlipidaemia.
Renal failure: due to nephrotoxic effects of tacrolimus + ciclosporin/ graft rejection/ recurrence of original disease
Malignancy: educate on minimising sun exposure to reduce risk of squamous + basal cell carcinomas
RIF Mass ddx
Appendix: abscess, neoplasms
Caecal carcinoma
Ovarian tumour/ cyst
Crohn’s disease
Psoas abscess
Iliac lymphadenopathy
Transplanted/ ectopic kidney
Ileocecal tuberculosis
LIF Mass ddx
Faeces (indentable) – loaded sigmoid
Sigmoid or descending colon cancer
Diverticular disease
Ovarian tumour/ cyst
Psoas abscess
Crohn’s disease
Transplanted pelvic kidney
Iliac lymphadenopathy
Suprapubic mass ddx
Enlarged bladder
Uterine mass e.g. fibroids
Pregnant uterus
Ovarian mass e.g. cyst
Inguinal mass ddx
Herniae (inguinal, femoral)
Lymphadenopathy
Vascular: aneurysm, pseudoaneurysm, hematoma
Psoas abscess
Ectopic or undescended testis
Lipoma of the cord
Hydrocoele of the cord
Left hypochondrium mass ddx
Splenomegaly
Pancreatic CA
Colon CA
Kidney mass
Right hypochondrium mass ddx
Hepatomegaly
Enlarged gallbladder: empyema, mucocoele, CBD obstruction (pancreatic CA)
Kidney mass
Colon CA
Epigastric mass ddx
Retroperitoneal lymphadenopathy (e.g. lymphoma, teratoma)
AAA
Gastric CA
Pancreatic pseudocyst or tumour
Transverse colon CA
What is this? What is it used for?
Tesio line
Inserted into IJV (or can do subclavian)
Emergency haemodialysis
Haemodialysis where fistula unsuitable
3 types of renal replacement therapy
Haemodialysis
Peritoneal dialysis
Renal transplant
Describe haemodialysis
3x per week
3-5h
At least 8w before commencement of Tx, patient must undergo surgery to create an arteriovenous fistula, which provides site for haemodialysis
Describe peritoneal dialysis
Dialysis solution injected into abdominal cavity through a permanent catheter.
High dextrose conc. of solution draws waste products from blood into the abdominal cavity across the peritoneum.
After several hours of dwell time, dialysis solution drained, removing waste products from the body, + exchanged for new dialysis solution
What are the 2 types of peritoneal dialysis?
Continuous ambulatory peritoneal dialysis (CAPD): each exchange 30-40 mins, each dwell time 4-8h. Patient may go about their normal activities with dialysis solution in their abdomen
Automated peritoneal dialysis (APD): a dialysis machine fills + drains the abdomen while the patient is sleeping, performing 3-5 exchanges over 8-10h each night
Describe renal transplantation
Average wait: 3y
Donor kidney transplanted into groin, with the renal vessels connected to external iliac vessels.
Failing kidneys are not removed
Need lifelong immunosuppression
List 7 complications of haemodialysis
Infection
Endocarditis
Stenosis at site
Hypotension
Cardiac arrhythmia
Air embolus
Disequilibration syndrome
List 10 complications of peritoneal dialysis
Peritonitis
Catheter infection
Catheter blockage
Constipation
Fluid retention
Hyperglycaemia
Hernias
Back pain
Malnutrition
Symptoms of renal failure not being adequately managed by RRT
SOB
Fatigue + insomnia
Pruritus
Poor appetite
Swelling
Weakness
Weight gain/ loss
Abdominal cramps
Nausea
Muscle cramps
Headaches
Cognitive impairment
Anxiety, Depression
sexual dysfunction
Describe AV fistula
Surgical connection made between an artery + vein
Strengthens + enlarges vein
Allows higher rate of blood flow between vein + dialysis machine
List 3 disadvantages of AV fistula
Requires another temporary type of access during the healing + maturation phase
Maturation may be delayed/ may fail to mature
Needles are required to access the AV fistula for hemodialysis
2 elective indications for surgery in UC
Disease requiring maximal therapy
Prolonged courses of steroids.
Absolute indication for proctocolectomy in UC
Dysplastic transformation of colonic epithelium with associated mass lesions
Surgery for emergency presentations of poorly controlled UC that fails to respond to medical therapy
Sub-total colectomy
Excision of rectum has higher morbidity + is not performed in emergency setting.
An end ileostomy is created
Rectum stapled off + left in situ, or, if bowel very oedematous, brought to surface as a mucous fistula.
Proctocolectomy in UC and Crohn’s
Removes colon + rectum
Crohns: end ileostomy
UC: Ileoanal pouch anastomosis (internal J pouch)
Proctectomy
Removes rectum
Colectomy
Removes colon
Can form ileoanal pouch
3 Complications of ileoanal pouch
Anastomotic dehiscence
Pouchitis
Poor physiological function with seepage + soiling.
3 indications for surgery in crohns disease
Fistulae
Abscess formation
Strictures
Surgery for terminal ileal crohn’s
Limited ileocaecal resections
Surgery for severe perianal/ rectal Crohns
Proctectomy
Why is ileoanal pouch formation not recommended in Crohns?
High risk fistula formation + pouch failure
Recurrence of disease in internal pouch
What is a loop ileostomy used for?
Defunctioning of colon e.g. following rectal cancer surgery
Does not decompress colon (if ileocaecal valve competent)
What is a loop colostomy used for?
To defunction a distal segment of colon
Since both lumens are present the distal lumen acts as a vent
