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Final year recaps/management > Gastro/renal > Flashcards

Gastro/renal Flashcards

1
Q

Acute pancreatitis management

A

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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2
Q

What are the outcomes/actions for screening for AAA

A

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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3
Q

Which AAAs have a low rupture risk?

A

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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4
Q

Which AAAs have high rupture risk

A

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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5
Q

What is an inguinal hernia?

What is a strangulated inguinal hernia?

A

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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6
Q

Causes of hydronephrosis (unilateral and bilateral)?

A

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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7
Q

Hydronephrosis investigations and management?

A

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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8
Q

Which stomas are spouted and why?

A

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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9
Q

What do you see on imaging in bowel obstruction?

A

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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10
Q

Acute management of renal colic?

A

IM diclofenac

IV paracetamol if NSAIDs contraindicated or ineffective

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11
Q

Management of renal stones

A

<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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12
Q

How to prevent renal stones?

A

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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13
Q

Classic triad of intestinal angina?

A

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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14
Q

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

A

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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15
Q

What is ischaemic colitis and how to manage?

A

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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16
Q

Management of coeliac disease

A

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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17
Q

UTI tx

  • Non pregnant women
  • pregnant women
  • men
A

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
18
Q

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

A

Blatchford score at first assessment

Full Rockall score after endoscopy

19
Q

What are the components of the Blatchford score?

A 
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
20
Q

Management of an upper GI Bleed

A

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
21
Q

What is primary sclerosing cholangitis, features, and associations

A

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

Ix

  • MRCP or ERCP
  • pANCA might be positive
  • (liver biopsy - onion skin)
22
Q

Crohn’s disease investigations

A

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
23
Q

Primary biliary cholangitis?

A

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
24
Q

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

A

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

25
Q

Common surgical interventions for crohn’s?

A

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.

26
Q

How to manage acute variceal bleeding?

A

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)

27
Q

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

A

Prophylaxis

  • propranolol/non-cardioselective b blocker (reduces rebleeding)
  • endoscopic variceal band ligation
28
Q

Features of carcinoid syndrome?

A 
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

Ix

  • urinary 5-HIAA
  • plasma chromogranin A y

Mx

  • somatostatin analogues e.g. octreotide
  • diarrhoea: cyproheptadine may help
29
Q

Risk factors and features for HCC?

A

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

Mx

  • early disease: surgical resection
  • transplant
  • radiofrequency ablation
30
Q

Which screen is for malnutrition?

A

MUST (Malnutrition Universal Screen Tool)

31
Q

Investigations for coeliac disease?

A
  • 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

32
Q

Tx of c diff infection

A

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

Life threatening - combo of ORAL vancomycin and IV metronidazole

33
Q

Which dyspepsia patients should be urgently referred

A

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

34
Q

Managing dyspepsia patients who don’t meet referral criteria

A
  1. review meds for causes of dyspepsia
  2. lifestyle advice
  3. trial of full dose PPI for one month or a ‘test and treat’ approach for H pylori
35
Q

What do the following presentations of hepatomegaly indicate

  1. Non tender firm liver
  2. Hard, irregular liver edge
  3. firm, smooth, tender liver edge that may be pulsatile
A
  1. Cirrhosis
  2. Malignancy (metastatic spread or primary hepatoma)
  3. Right heart failure
36
Q

Criteria to diagnose AKI in adults

A

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

37
Q

Triad of nephrotic syndrome?

A

Triad of:

  1. Proteinuria (> 3g/24hr) causing
  2. Hypoalbuminaemia (< 30g/L) and
  3. Oedema
38
Q

Symptoms of ADPKD

A

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
39
Q

What’s the commonest cause of acute interstitial nephritis?

Symptoms?

A

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

40
Q

What to STOP in AKI

A

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

41
Q

What is minimal change disease/how does it present

A 
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

Final year recaps/management (7 decks)

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