ASSCC 5

Question 1

Which enzyme would you expect to raise MOST in obstructive jaundice?

Answer 1

Alkaline phosphatase

Question 2

How do bile salts cause the emulsification of fat?

Answer 2

• Bile salts have a hydrophobic and hydrophilic side
• Hydrophobic side aggregates around fat droplet
• Forms micelle
• Hydrophilic side faces outwards, preventing fat droplets from re-aggregating into larger fat particles

Question 3

Which enzyme conjugates bilirubin?

Answer 3

Glucuronyl transferase

Question 4

Explain the enterohepatic circulation:

Answer 4

Bile salts are reabsorbed in the terminal ileum and return them back to the liver
= high rate of production, low rate of secretion

Question 5

How much bile is secreted in 24hrs?

Answer 5

500-1000ml

Question 6

4 Causes of pre-hepatic jaundice:

Answer 6

1) Autoimmune haemolytic anaemia
2) Congenital: SCA / hereditary spherocytosis
3) Transfusion reactions
4) Drug toxicity

Question 7

4 Causes hepatic jaundice:

Answer 7

1) Viral hepatitis
2) Alcohol-related liver disease
3) Fatty liver disease
4) Metastatic disease
5) Congenital unconjugated hyperbilirubinaemia
= Crigler-Najjar, Gilbert’s

Question 8

3 causes post-hepatic jaundice:

Answer 8

1) Intraluminal - CBD stone
2) Mural abnormalities - Biliary stricture / PSC
3) External compression - Mirizzi’s syndrome, cancer of head of pancreas

Question 9

5 Physical findings of pt with pulmonary oedema:

Answer 9

1) Extended neck veins
2) Puffiness of face
3) Anxiety, confusion
4) Widespread crepitations
5) Tachycardia, tachypnoea

Question 10

Initial mx of pt with pulmonary oedema:

Answer 10

1) ABCDE
2) Sit pt up
3) Stop IV infusions
4) Commence high flow O2 aiming sats >94%
5) Consider:
- Morphine for anxiolytic
- IV GTN if sBP >100
- IV Furosemide
- Higher level of support if signs of fatigue/acidosis/resp failure
6) Re-review

Question 11

CXR findings pulmonary oedema:

Answer 11

1) Alveolar oedema - bat wing
2) Kerley B lines
3) Cardiomegaly
4) Dilated prominent upper lobe vessels

Question 12

Why is pt with pulmonary oedema at high risk of MI?

Answer 12

• Tachycardia
• Reduced time for filling of coronary vessels during diastole
• Increased oxygen demand to myocardium

Question 13

Sodium content in 0.9% saline:

Answer 13

154 mmol/L

Question 14

Sodium content in Hartmann’s:

Answer 14

131 mmol/L

Question 15

Define enterocutaneous fistula:

Answer 15

Abnormal tract lined by granulation tissue between gastrointestinal tract and the skin

Question 16

7 causes of enterocutaneous fistula:

Answer 16

FRIENDS:

1) Foreign body
2) Radiation enteritis
3) Inflammatory bowel disease
4) Epithelialized fistula tract
5) Neoplasm
6) Distal obstruction
7) Sepsis

Question 17

3 complications of enterocutaneous fistula:

Answer 17

1) Sepsis
2) Malnutrition
3) Fluid and electrolyte imbalance

Question 18

Mx of enterocutaneous fistula:

Answer 18

1) ABCDE
2) Sepsis control
3) Nutritional support - TPN + dietician
4) Adequate fluid and electrolyte replacement
5) Anatomical assessment - MRI/CT/USS exclude abscess/collection
6) Protect skin from excoriation
7) MDT approach

Question 19

What percentage of fistula will close spontaneously with conservative management?

Answer 19

60%

Question 20

How would you perform an anatomical assessment of an enterocutaneous fistula?

Answer 20

USS/CT AP to exclude underlying collection/abscess/distal obstruction
MRI fistulogram - locate fistula, delineate length, distal obstruction

Question 21

7 factors which will prevent spontaneous healing of enterocutaneous fistula:

Answer 21

1) Malnutrition
2) Distal obstruction
3) High output
4) Infection
5) Malignancy
6) Radiation
7) Crohn’s disease

Question 22

5 causes of confusion, hypoxia and hypotension post TURP:

Answer 22

1) TURP syndrome
2) Effect of sedation + analgesia
3) Hyponatraemia
4) Blood loss
5) Cerebrovascular disease

Question 23

Define TURP syndrome:

Answer 23

Dilutional hypotonic hyponatraemia

Due to Glycine rich hypotonic irrigation solution absorbed

Question 24

Why is Glycine used as irrigation fluid in TURP?

Answer 24

As saline fluid limits diathermy use due to electrical conduction properties

Question 25

6 signs/symptoms of TURP syndrome:

Answer 25

1) Restlessness
2) Confusion
3) Initial HTN followed by hypotension
4) Blurred vision
5) Heart failure
6) Pulmonary oedema

Question 26

2 causes of confusion in TURP syndrome:

Answer 26

1) Hyponatraemia due to glycine irrigation fluid being absorbed
2) High ammonia - glycine is broken down to ammonia in the liver

Question 27

What causes hypoxia in TURP syndrome?

Answer 27

Pulmonary oedema

Question 28

If hyponatraemic, aim to increase by how much per day?

Answer 28

9-10mmol/day

Question 29

If hyponatraemia corrected too fast, what complication?

Answer 29

Central pontine demyelination

Question 30

When would you consider hypertonic saline to treat hyponatraemia? How would you give?

Answer 30

If Na+ < 110,

Give 250-500ml 3% saline via central line

Question 31

Name an osmotic diuretic + MoA:

Answer 31

Mannitol
Acts at PCT, LoH, CD
Inhibits water and sodium reabsorption

Question 32

Name a Loop diuretic + MoA:

Answer 32

Furosemide
Thick asc LoH
Inhibits Na+/K+/Cl- cotransporter

Question 33

MoA of thiazide diuretic:

Answer 33

DCT

Inhibits Na+/Cl- cotransport

Question 34

Name a K+ sparing diuretic + MoA:

Answer 34

Spironolactone
Aldosterone antagonist
DCT, CD
Inhibits sodium reabsorption + potassium secretion

Question 35

Blood changes in rhabdomyolysis:

Answer 35

• CK 5 times higher than normal
• high lactate
• high creatinine
• hyperkalaemia
• hypocalcaemia
• hyperphoshataemia
• hyperuricaemia

Question 36

Normal pressure of muscle compartments:

Answer 36

0-15mmHg

Question 37

At which compartment pressure is fasciotomy indicated?

Answer 37

> 30mmHg

Question 38

Why does rhabdomyolysis cause acute renal injury?

Answer 38

Myoglobin is oxygen binding protein found in muscle
Rhabdomyolysis = Muscle cell destruction
Release of myoglobin
Myoglobin is nephrotoxic causing acute tubular necrosis