CCC - Liver and Renal Flashcards
What can comes up is OSCE abdo?
- Chronic Liver Disease
- Chronic Kidney Disease
- Haematology clinic
What is the ABCDEFGHIJ for abdo?
Asterixs (flap) Brusing (clotting factors made in liver) Clubbing Dupytrens Erythhema (palmar) Fetor hepaticus Gyanecomastia Hair loss I Jaundice
What features do you look for in the hands?
- Asterixs (flap)
- Brusing (clotting factors made in liver)
- Clubbing
- Dupytrens
- Erythhema (palmar)
- Leuconychia
What features do you look for in the forearms?
- av fistulae
2. current or previous renal replacement therapy
What features do you look for in the head and neck?
- anaemia
- jaundice
- Skin: jaundice, excoriation marks or spider naevi
- Oral examination: pigementation, gum hypertrophy
Why might there be gum hypertrophy?
on ciclosporine after renal transplant
What do you look for on chest inspection?
- Gynaecomastia
- Hair loss
- Excoriation marks
- Spider naevi
What do you look for on abdominal inspection?
- Abdominal distension?
- Caput medusae?
- distended superficial abdominal veins
- direction of flow in the veins below the umbilicus is towards the legs - Scars?
What would a right subcostal scar suggest?
biliary surgery
What would a mercedes-benz incision suggest?
liver transplant
What would a midline laparomotmy scar suggest?
GI or any major abdominal surgery
What would a McBurney’s incision suggest?
appendicetomy
What would a J shaped incision suggest?
renal transplant
What would a low transverse incision suggest?
gynae procesdure
What would an inguinal incision suggest?
hernia repair, vascular access
What would a loin incision suggest?
nephroectomy
What are the causes of hepatomegaly?
- Cancer: primary or secondary deposits
- Cirrhosis (early, usually alcoholic)
- Cardiac:
- congestive cardiac failure
- constrictive pericarditis - Infiltration
What are the infiltration causes of hepatomegaly?
- fatty infilatration
- haemochromatosis
- amyloidosis
- sarcoidosis
- lymphoproliferative diseases
What are the causes of liver disease?
- alcohol
- autoimmune
- drugs
- viral
- biliary disease
What are the causes of splenomegaly?
- H (portal Hypertension) - chronic liver disease
- H (haematological) - haemolytic anaemia
- Infection: infectious mononucleosis, TB, IE, malaria
- Inflammation:
If abdominal pain is constant what does it suggest?
inflammation
If abdominal pain is colicky what does it suggest?
obstruction
What are epigastric pain DDx?
- Stomach:
1. peptic ulcer (NSAID use?)
2. GORD (better with antacids)
3. Gastritis (retosteronal, alcohol)
4. Malignancy - Pancreas
1. acute pancreatitis (Hx of gallstones? high amylase?)
What are surrounding epigastric pain DDx?
- Above: (heart) MI
- Below: (aorta) ruptured aortic aneurysm
- Right: (liver/gallbladder) cholecystitis, hepatitis
What is acute pancreatitis associated with?
- pain
2. v high amylase
What is chronic pancreatitis associated with?
- chronic pain
- weight loss
- loss of exocrine function (malabsoprtion)
- loss of endocrine function (diabetes)
- normal amylase
- faecal elastase (in stool sample)
What are the RUQ pain DDx?
- Gallbladder:
1. cholecystitis
2. cholangitis
3. gallstones - Liver:
1. hepatitis
2. abscess
What are the surrounding RUQ pain DDx?
- Above: (lungs) basal pneumonia
- Below: (appendix) appendicitis
- Left: (stomach, pancreas) peptic ulcer, pancreatitis
- Right: (kidney) pyelonephritis
What are RIF pain DDx?
- GI:
1. Appedicitis
2. Mesenteric adenitis (common in children)
3. Colitis (IBD)
4. Malignancy - Gynae:
1. Ectopic pregnancy
2. Ovarian cyst rupture, twist, bleed
What are suprapubic pain DDx?
- cystitis
2. urinary retention
What is LIF pain DDx?
- GI:
1. Diverticulitis
2. Colitis (IBD)
3. Malignancy - Gyanecological:
1. ovarian cyst rupture, twist, bleed
2. ectopic pregnancy
What are diffuse abdominal pain DDx?
- obstruction
- infection: peritonitis, gastroenteritis
- inflammation: IBD
- ischaemic: mesenteric ischaemia
What are medical causes of diffuse abdominal pain?
- DKA
- Addison’s
- Hypercalacemia
- Porphyria
- Lead poisoning
What does the celiac artery supply?
- Stomach
- Spleen
- Liver
- gallbladder
- Dudoenum
What does the superior mesenteric artery supply?
- small intestine
2. right colon
What does the inferior mesenteric artery supply?
left colon
What do the iliac arteries supply?
rectum
When is amylase high?
in any acute abdominal pathology - esp high in acute pancreatitis
When is lactate high?
problem with perfusion (ischaemia)
When is bicarbonate low?
metabolic acidosis
What is SBP?
spontaneous bacterial peritonitis - complication of liver disease
What is the ascites neutrophil count like in SBP?
> 250cells/mm^3 (need antibtioics)
What are causes of abdominal distension?
- Fluid
- Flatus
- Fat
- Feaces
- Fetus
- F big tumour
What may cause fluid abdominal distention?
Ascites:
- shifting dullness
- features of liver disease
What may cause flatus abdominal distension?
Obstruction:
- nause and vomiting
- not opened bowel
- high pitched tinkling bs
- previous surgery (adhesions) ?
- tender irreducible femoral hernia in groin ?
What are transudate causes of ascites?
- cirrhosis
- cardiac failure
- nephrotic syndrome
What are the exudate causes of ascites?
- malignancy (abdominal, pelvic, peritoneal mesothelioma)
- infection e.g. TB, pyogenic
- Budd-Chiari syndrome (hepatic vein thrombosis), portal vein thrombosis
What are three causes of jaundice and examples?
- prehepatic: haemolysis, defective conjugation
- hepatic: hepatitis
- post-hepatic: CBD obstruction
What are causes of pre-hepatic jaundice?
- haemolysis
2. gilbert’s syndrome
What is the mechanism of pre-hepatic jaundice?
decreased glucuronidation so increased unconjugated bilirubin
What is the mechanism of hepatocellular jaundice?
conjugated bilirubin leaks out of hepatocytes and loose in urine so dark urine
What is the mechanism of post-hepatic jaundice?
conjugated bilirubin leaks out hepatocytes giving dark urine
not getting to large bowel have decreased stercobilinogen so pale stool
What does dark urine and pale stool suggest?
post-hepatic jaundice
