AS PACES Abdo Flashcards
Child Pugh grading cirrhosis
A, B, C
ABCDE = albumin, bilirubin, clotting, distension (ascites), encephalopathy
Correlates with mortality: A (score 5-6); C (score 10-15) 1 yr mort 50%
Decompensated LD - precipitants
HEPATICS
Haemorrhage, electrolytes, poisons (diuretics, sedatives), alcohol, tumour, infection (SBP, pneumonia, UTI), Constipation (commonest), Hypoglycaemia (malnutrition)
Hepatic encephalopathy - presentation
Asterixes, ataxia Confusion Dysarthria Constitutional apraxia Seizures
Hepatic encephalopathy - Mx
Nurse in well lit, calm environment
Correct precipitants
Avoid sedatives
Lactulose - decrease nitrogen forming bowel bacteria
Hepatorenal syndrome
Cirrhosis = splanchnic vasodilation = reduction in ECV = RAS activation = renal arterial vasoconstriction = failure Type 1 (rapidly progressing) - survival 2wks Type 2 (steady decline) - survival 6mo IV albumin + terlipressin ± haemodyalisis ± liver transplant
SBP
Ascitis and peritonitis abdomen Complicated by HRS in 30% E. Coli, Klebsiella, Strep Ascitic tap = PMN >250mm3 + MC&S Possible for ciprofloxacin to be given as prophylaxis against SBP
Causes of ascites
80% cirrhosis with portal HTN
CCF
Carcinomatosis
SAAG = Se albumin - Ascites albumin; >1.1g/dL = portal HTN (if <1.1 Ca, pancreatitis, nephrotic syndrome
Diagnosing Portal HTN
Serum Ascites Albumin Gradient >1.1g/dL
TE
Portal presure >10mmHg (norm 5-10)
Causes of Portal HTN
Pre hepatic - Portal vein thrombosis
Hepatis - Cirrhosis
Post hepatic - Bubb-Chiari syndrome, RHF, TR
Ascites Tx
Conservative - no ETOH, fluid monitoring (aim 0.5kg/d reduction), fluid restrict <1.5L/d, low Na diet
Spironolactone
Therapeutic paracentesis
Refractory - TIPSS or transplant
DDx jaundice
Pre hepatic - Unconjugated. AIHA, HS, SCD, PNH, MAHA, malaria, G6PDD
Hepatic - CLD, paracetamol, statins, Ca
Post hepatic - conjugated, GA, Ca Panc, PBC, PSC, cholangiocarcinoma, OCP, augmentin
Immunosupression signs on peripheral examination
Cushingoid
Skin tumours - SCC, BCC, MM, AKs
Gingival hypertrophy
Ddx Rooftop scar
Liver transplant
Segmental resection
Whipples pancreatoduodenectomy
Liver transplant - causes, success rates, immunosupression regimen
Cirrhosis, acute liver failure, malignancy
80% 1 yr survival; 70% 5 yr survival
Tacrolimus / ciclosporin, azathioprine ± prednisolone
Causes of hepatomegaly
Hepatitis - ETOH, viral, NAFLD
Congestion - RHF, TR, budd chiari
Malignancy
Anatomical - Riedel’s lobe, hyperexpanded chest
Haem - leukaemia, lymphoma, myeloproliferative, SCD
Sarcoid, Amyloid, ADPKD
Splenomegaly DDx
Massive –> Myeloproliferative (CML, MF); Lymphoproliferative (CLL, lymphoma); Infiltrative (amyloid); Infectious (malaria, visceral leishmaniasis)
Small –> Haem proliferative, portal HTN, EBV, IE, malaria, RA, SLE, Sjorgen’s
Blood film: Myelofibrosis, CLL, Haemolysis
MF –> leukoerythroblastic, teartrop poikilocytes (Jak2 mutation in 50%)
CLL –> Smudge cells (Ph chr t9;22)
Haemolysis –> spherocytes, reticulocytosis
CML
Clonal proliferation of myeloid cells, 15% leukaemia
B symptoms, massive HSM, platelet dysfunction, gout, hyperviscosity
Ph Chr t(9;22) in >80% –> resulting BCR-ABL gene = tyrosine kinase activity
Imatinib or allogenic SCT (if blast crisis or TKi refractory)
Primary myelofibrosis
Clonal expansion of megakaryocytes, ++ PDGF
B symptoms, massive HSM, BM failure
Leukoerythroblastic teardrop poikilocytes on film
Cytopenias, BM often dry tap
50% Jak2 + ve
Splenectomy ± allogenic BMT, other than that treatment supportive with blood products
Hypersplenism
Pancytopenia due to pooling and destruction in large spleen (anaemia, bruising, infections)
Hyposplenism
Ddx splenectomy, coeliac disease, IBD, SCD
Howell Jolly bodies, pappenheimer bodies, target cells
Mx –> immunisation (HiB, pneumovax, Men C, flu)
Abx –> Pen V or erythromycin
Warning alert card / bracelet
Splenectomy - indications and complications
Trauma, rupture, AIHA, ITP, HS Early VTE - need post op aspirin Transient ileus - post op NG tube Atelectasis Pancreatitis Susceptibility to infections by encapsulated bacteria (haemophilus, pneumo, meningo)
Mx APDKD
1:1000, PKD1 chr 16 85%; PKD2 chr 4 15%
Conservative - ensure good hydration, less caffeine, genetic counselling
Monitor U&E & BP, MRI for Berri aneurysms
Medical –> HTN (aggressively, target <130/80)
Surgical –> nephrectomy if recurrent bleeds / infections / abdo discomfort
Prognosis –> ESRF 70% by 70 yrs
ARPDK
1:400000, perinatal presentation with oligohydramnios
ESRF 20 yrs, need Tx
Tuberous sclerosis
AD, hamartomas in skin brain eye kidney
Skin –> nasolabial adenoma sebaceum, ash-leaf macules, peri ungal fibromas
Neuro –> Low IQ, epilepsy, astrocytoma
Renal –> cysts, angiomyolipomas
RCC
90% renal Ca, median 55yrs, m:f 2:1
RF: smoking, obesity, HTN, dialysis (15% pts), 4% heritable (VHL)
AC from proximal renal tubular epithelium
Clear cell (glycogen) subtype: 70-80%
50% incidental finding, haematuria, loin pain, loin mass
Cannonball mets –> SOB
Paraneoplastic –> EPO, PTHrP, renin, ACTH
Spread: renal vein, lymph, haematogenous bone liver lung
VHL syndrome
AD, renal and pancreatic cysts B/L RCC Haemangioblastomas (often cerebellum) Phaeochromocytoma Islet cell tumours
RCC Mx
Medical - for poor prognosis, temsirolimus (mTOR)
Surgical - radical nephrectomy
45% 5yr survival
Commonest indications for renal Tx
DM
GN
PKD
HTN
Assessment for renal Tx
Virology: CMV, HIV, VZV, HBV, HCV Co-morbidities ABO anti-HLA Abs Haplotype: HLA DR, A, B XM CI --> infection, Ca, co-morbidityies, failed pre implantation XM
Immunosupression for renal Tx
Pre-op –> campath (anti CD52)
Post-op –> Steroids short term; tacrolimus/ciclosporin long term
Transplant rejection
Hyperacute –> ABO incompatibility, thrombosis and SIRS
Acute –> <6mo; fever and graft pain, reduce UO, high Cr, immunosupression
Chronic –> >6mo; gradual increase in Cr, interstitial fibrosis, Rx supportive
Immunospuression drug toxicity
Ciclosporin –> Calcineurin inhibitor (IL2 blocker). Nephrotoxic, hingival hypertrophy
Tacrolimus –> calcineurin inhibitor. DM, crdiomyopathy, neurotoxicity
Steroids
Steel syndrome
Distal tissue ischaemia due to fistula
Classifying CRF
>90 60-89 30-59 16-29 <15
Renal osteodystrophy: features
OP, OM, 2/3 HPT (subperiosteal bone resorption, acral osteolysis, pepperpot skull)
Osteosclerosis of the spine (Rugger Jersey spine)
Extraskeletal calcification
Renal bone disease - Mx
Phosphate binders - calichew
Vit D analogues - alfacalciferol
Ca supplements
UC Mx
MDT
Conservative: ADEK, high fibre, dietician review
Induction: 5ASA, pred (oral and PR), infliximab
Maintenance: 5ASA azathioprine, biologics
Surgical: Obstruction, megacolon, perforation, failure to respond to medical therapy
CD Mx
Conservative: ADEK, high fibre, dietician review
Induction: budesonide/sulfasalazine; pred; methotrexate, biologics
Maintenance: azathioprine, methotrexate, biologics
Surgical: Obstruction, perforation, failure to respond to medical therapy
