Gastro/renal Flashcards by Yasmin Hazemi

Acute pancreatitis management

Fluid resuscitation and analgesia

aggressive early hydration with crystalloids
pain may be severe - key priority of care. use ladder but may need IV opioids

NICE states do not offer prophylactic antimicrobials to people with acute pancreatitis

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What are the outcomes/actions for screening for AAA

Aorta width
<3cm - normal, no further action
3-4.4cm - small aneurysm, rescan every 12 months
4.5-5.4cm - medium aneurysm, rescan every 3 months
>/= 5.5.cm - large aneurysm. refer within 2 weeks to vascular surgery for probably intervention

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Which AAAs have a low rupture risk?

asymptomatic, aortic diameter <5.5cm (i.e. small and medium aneurysms)
- abdominal US surveillance, and optimise cardiovascular risk factors (e.g. stop smoking)

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Which AAAs have high rupture risk

SYMPTOMATIC (ie pain), aortic diameter >/=5.5cm or rapidly enlarging (>1cm/year)

Refer within 2 weeks to vascular surgery for probable intervention

Treat with elective endovascular repair (EVAR) or open repair if unsuitable.

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What is an inguinal hernia?

What is a strangulated inguinal hernia?

Protrusion of viscera or abdominal contents through the superficial inguinal ring.

Hernia should be reducible. If it cannot be reduced it is referred to as an incarcerated hernia, these are at risk of strangulation.

Strangulation - surgical emergency where blood supply to the herniated tissue is compromised - leads to ischaemia or necrosis.
- pain, fever, increase in hernia size or erythema of the overlying skin. peritonitic features, bowel obstruction, bowel ischaemia .

Repair involves immediate surgery either form an open or laparoscopic approach with a mesh technique.

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Causes of hydronephrosis (unilateral and bilateral)?

Unilsteral (PACT)

Pelvic ureteric obstruction (congenital or acquired)
Aberrant renal vessels
Calculi
Tumours of renal pelvis

Bilateral (SUPER)

Stenosis of the urethra
Urethral valve
Prostatic enlargement
Extensive bladder tumour
Retro-peritoneal fibrosis

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Hydronephrosis investigations and management?

Ix - ultrasound (1st line)

IVU assess position of obstruction
antegrade/retrigrade pyelography- allows treatment
if suspect renal colic - CT scan

Management

Remove the obstruction and drainage of urine
Acute upper urinary tract obstruction: nephrostomy tube
Chronic upper urinary tract obstruction: ureteric stent or a pyeloplasty

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Which stomas are spouted and why?

Ileostomy is spouted to prevent the skin from coming into contact with the enzymes in the small intestine.

They are usually on the right side of the abdomen but not always.

Colonic stomas don’t need to be spouted as their contents are less irritant

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What do you see on imaging in bowel obstruction?

Small bowel obstruction

maximum normal diameter - 35mm
valvulae conniventes extend all the way across

Large bowel

maximum normal diameter - 55mm
haustra extend about a third of the way across

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Acute management of renal colic?

IM diclofenac

IV paracetamol if NSAIDs contraindicated or ineffective

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Management of renal stones

<5mm will usually pass spontaneously
Lithotripsy/nephrolithotomy if severe cases

Stone burden of less than 2cm in aggregate - Lithotripsy
Stone burden of less than 2cm in pregnant females
- Ureteroscopy
Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy
Ureteric calculi less than 5mm
- Manage expectantly

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How to prevent renal stones?

Calcium stones

may be due to hypercalciuria
high fluid intake
low animal protein, low salt diet
thiazide diuretic (increases distal tubular calcium resorption)

Oxalate stones

cholestyramine reduces urinary oxalate secretion
pyridoxine reduces urinary oxalate secretion

Uric acid stones

allopurinol
urinary alkalinisation e.g. oral bicarb

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Classic triad of intestinal angina?

Severe, colicky, post-prandial abdominal pain
Weight loss
Abdominal bruit

(Intestinal angina is also known as chronic mesenteric ischaemia)
- by far the most common cause is atherosclerotic disease in arteries supplying the GI tract

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What are the differences between acute mesenteric ischaemia, chronic mesenteric ischaemia?

Acute - typically caused by an embolism resulting in the occlusion of an artery which supplies the small bowel e.g. the superior mesenteric artery. Pts usually have a history of Atrial fibrillation

abdominal pain is typically severe, of sudden onset and out-of-keeping with physical exam findings.
management: urgent surgery is usually required. poor prognosis, esp if surgery delayed

Chronic - relatively rare clinical diagnosis due to it’s non-specific features and may be thought of as ‘intestinal angina’. Colickly, intermittent abdominal pain occurs.

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What is ischaemic colitis and how to manage?

Acute but transient compromise in the blood flow to the large bowel. This may lead to inflammation, ulceration and haemorrhage. It is more likely to occur in ‘watershed’ areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries.

Ix: ‘thumbprinting’ may be seen on AXR due to mucosal oedema/haemorrhage

Mx: usually supportive, surgery may be required if eg peritonitis, perforation or ongoing haemorrhage

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Management of coeliac disease

Gluten free diet
Patients with coeliac disease often have a degree of functional hyposplenism
For this reason, all patients with coeliac disease are offered the pneumococcal vaccine

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UTI tx

Non pregnant women
pregnant women
men

Non pregnant women

local guidelines
trimethoprim or nitrofurantoin for three days
send a culture if aged >65
or if visible or non visible haematuria

Pregnant women

if symptomatic:
urine culture
first-line: nitrofurantoin (should be avoided near term)
second-line: amoxicillin or cefalexin
if asymptomatic - immediate 7 day course of nitrofurantoin, amoxicillin or cefalexin

Men
- 7 day course of trimethoprim or nitrofurantoin (unless prostatitis suspected)

Catherised patients

do not tx asymptomatic
if symptomatic they should get 7 days abx

What scores are used for risk assessment of acute upper GI bleeds

Blatchford score at first assessment

Full Rockall score after endoscopy

What are the components of the Blatchford score?

Urea (mmol/l)
6·5 - 8 = 2
8 - 10 = 3
10 - 25 = 4
> 25 = 6

Haemoglobin
Men
12 - 13 = 1
10 - 12 = 3
< 10 = 6

Women
10 - 12 = 1
< 10 = 6

Systolic BP
100 - 109 = 1
90 - 99 = 2
< 90 = 3

Others

Pulse >=100/min = 1
Presentation with melaena = 1
Presentation with syncope = 2
Hepatic disease = 2
Cardiac failure = 2

Management of an upper GI Bleed

Resuscitation

ABC, wide-bore intravenous access * 2
Platelet transfusion if actively bleeding platelet count of less than 50 x 10*9/litre
fresh frozen plasma to pt w/ fibrinogen level of less than 1 g/litre, or PT/APTT greater than 1.5 times normal
prothrombin complex concentrate to patients who are taking warfarin and actively bleeding

Endoscopy

offer immediately after resuscitation in patients with severe bleed
all patients should have endoscopy within 24 hours

Management of non-variceal bleeding

NO PPIs before endoscopy to pt with suspected non-variceal upper GI bleeding although PPIs should be given to patients with non-variceal upper GI bleeding and stigmata of recent haemorrhage shown at endoscopy
if further bleeding then options include repeat endoscopy, interventional radiology and surgery

Management of variceal bleeding

terlipressin and prophylactic abc should be given to patients at presentation (i.e. before endoscopy)
band ligation for oesophageal varices and injections of N-butyl-2-cyanoacrylate for pt with gastric varices
transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

What is primary sclerosing cholangitis, features, and associations

Biliary disease of unknown aetiology characterised by inflammation and fibrosis of intra and extra hepatic bile ducts.

Associated with UC - 4% with UC have PSC, 80% with PSC have UC
(also crohns and HIV)

Features

cholestasis - pruritis, jaundice, raised bili and ALP
RUQ pain
fatigue

MRCP or ERCP
pANCA might be positive
(liver biopsy - onion skin)

Crohn’s disease investigations

Bloods - CRP
Colonoscopy. Features suggestive of Crohn’s include deep ulcers and skip lesions

Histology - inflammation in all layers from mucosa to serosa, goblet cells, granulomas

Small bowel enema - high sensitivity and specificity for examination of the terminal ileum
- Strictures: 'Kantor's string sign'
- proximal bowel dilation
- 'rose thorn' ulcers
fistulae

Primary biliary cholangitis?

Chronic liver disorder typically seen in middle aged females, thought to be autoimmune. Chronic inflammation can damage interlobular bile ducts cauing progressive cholestasis which may eventually lead to cirrhosis.

Classic presentation - itching in a middle-aged woman
Associations
- sjogren's
- rheum arthritis
- systemic sclerosis
- thyroid disease

Dx - AMA M2 abs are present in 98% of patients and are highly specific

smooth muscle antibodies in 30% of patients
raised serum IgM

Mx - urseodeoxycholic acid

cholestyramine for pruritis
fat soluble vitamin supplementation

M rule

IgM
anti-mitochondrial antibodies, M2 subtype
Middle aged females

Crohn’s disease management for inducing remission and mantaining remission?

Stop smoking

Inducing remission

glucocorticoids (oral, topical or IV) are first line +/- elemental diet
5-ASA e.g. mesalazine is second line
can add azathioprine or mercaptopurine as sadd on but not as monotherapy. or methotrexate alternative to aza

Maintaining remission

azathioprine/mercaptopurine first line for maintaining remission
methotrexate second line
consider 5-ASA if patients has had previous surgery

80% of pts with crohns will end up having surgery

Common surgical interventions for crohn’s?

Most common disease pattern is stricturing terminal ileal disease, often culminating in ileocaecal resection.

Colonic involvement in Crohn’s patients is not common, and if found is often segmental. Segmental resections of colon are not advocated because of recurrence rate in remaining colon. So options are sub total colectomy, panproctocolectomy and staged sub total colectomy and proctectomy.

CD is notorious for intestinal fistulae. Need to control sepsis, optimise nutrition, image and plan definitive surgical mx.

How to manage acute variceal bleeding?

A to E, initial resus
Terlipressin (reduces portal blood flow)
Endoscopy (if unstable asap, all patients with upper GI haemorrhage should undergo endoscopy within 24h)

How to manage variceal haemorrhage (after initial resus, terlipressin, endoscopy etc)

Prophylaxis

propranolol/non-cardioselective b blocker (reduces rebleeding)
endoscopic variceal band ligation

Features of carcinoid syndrome?

Carcinoid syndrome usually occurs when metastases are present in the liver and release serotonin into the systemic circulation. May also occur with lung carcinoid. 
Features:
- flushing
- diarrhoea
- bronchospasm
- hypotension
- right heart valvular stenosis
- other molecules such as ACTH and GHRH may also be secreted resulting in e.g. cushing's

urinary 5-HIAA
plasma chromogranin A y

somatostatin analogues e.g. octreotide
diarrhoea: cyproheptadine may help

Risk factors and features for HCC?

Main risk factor is liver cirrhosis e.g. secondary to hep B and C, alcohol, haemochromatosis, PBC.
others - male sex, alpha-1 antitrypsin deficiency

Features - tends to present late

liver cirrhosis or failure features may be seen - jaundice, ascites, RUQ pain, hepatomegaly, pruritis, splenomegaly
raised AFP

can consider screening with US for high risk groups such as pt with liver cirrhosis secondary to hep b/c, or men with liver cirrhosis secondary to alcohol

early disease: surgical resection
transplant
radiofrequency ablation

Which screen is for malnutrition?

MUST (Malnutrition Universal Screen Tool)

Investigations for coeliac disease?

tissue transglutaminase antibodies
endomyseal antibody (needed to check for IgA deficiency, which would give a false negative coeliac results)
duodenal biopsy - villous atrophy, crypt hyperplasia, increase in intraepithelial lymphocytes, lamina propria infiltration with lymphocytes)

TTG level must be interpreted along with IgA level

Tx of c diff infection

Oral metronidazole for 10-14 days
iI severe or not responding to metronidazole - oral vanc

Life threatening - combo of ORAL vancomycin and IV metronidazole

Which dyspepsia patients should be urgently referred

Dysphagia
Upper abdo mass (consistent with stomach cancer)
Aged >55 who have weight loss and any of the following:
- upper abdo pain
- reflux
- dyspepsia

Managing dyspepsia patients who don’t meet referral criteria

review meds for causes of dyspepsia
lifestyle advice
trial of full dose PPI for one month or a ‘test and treat’ approach for H pylori

What do the following presentations of hepatomegaly indicate

Non tender firm liver
Hard, irregular liver edge
firm, smooth, tender liver edge that may be pulsatile

Cirrhosis
Malignancy (metastatic spread or primary hepatoma)
Right heart failure

Criteria to diagnose AKI in adults

↑ creatinine > 26µmol/L in 48 hours
↑ creatinine > 50% in 7 days
↓ urine output < 0.5ml/kg/hr for more than 6 hours

Triad of nephrotic syndrome?

Triad of:

Proteinuria (> 3g/24hr) causing
Hypoalbuminaemia (< 30g/L) and
Oedema

Symptoms of ADPKD

Hypertension, recurrent UTIs, haematuria
Abdominal pain and early satiety as the kidneys occupy a large volume of the abdomen

Extra renal features

liver cysts (commonest)
berry aneurysms
CVS: mitral valve prolapse/mitral or tricuspid incompetence

What’s the commonest cause of acute interstitial nephritis?

Symptoms?

drugs - penicillin, rifampicin, NSAIDs, allopurinol, furosemide

also systemic disease (SLE, sarcoidosis, Sjogren’s), infection

Fever, rash, arthralgia, eosinophilia, mild renal impairment, HTN

sterile pyuria, white cell casts

What to STOP in AKI

NSAIDS (except cardiac dose), aminoglycosides, ACEi, ARBs, diuretics

What is minimal change disease/how does it present

Nephrotic syndrome (75% in children, 25% in adults) 
Normotension, highly selective proteinuria (intermediate sized proteins such as albumin and transferrin can leak through)

T cell and cytokine mediated damage to the glomerular basement membrane
- renal biopsy: normal glomeruli on light microscopy, electron microscopy shows fusion of podocytes and effacement of foot processes

Mx - steroids

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Gastro/renal Flashcards

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