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Gastroenterology Flashcards

1
Q

What are the causes of bloody diarrhoea?

A

Vascular: Ischaemic colitis
Infective: Campy, shigella, salmonella, E. coli,
Inflamm: UC/Crohns
Neoplastic

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2
Q

What is the most concerning complication of C. dif diarrhoea, and what are its further complications?

A

Pseudomembranous colitis (abdo pain, bloody diarrhoea, fever)

May lead to paralytic ileus, toxic megacolon and multi organ failure

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3
Q

What are the causes of constipation?

A

OPENED IT

Obstruction (mechanical or pseudo obstruction (post op ileus))
Pain - fissure
Endocrine(T4)/Electrolytes (low Ca/K)
Neuro - MS, Cauda Equina
Elderly
Diet/Dehydration
IBS
Toxins - Opiates, anti mACh
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4
Q

Give two osmotic laxatives

A

Lactulose

MgSO4 (fast acting)

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5
Q

Give four stimulant laxatives

A

Bisacodyl
Senna
Docusate
Sodium picosulphate (rapid)

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6
Q

What are the ROME criteria and what are they used for?

A

Diagnostic criteria for IBS

Abdo discomfort for >12 weeks + 2 of:

Urgency
Tenesmus
Bloating
PR mucous
Worse after food
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7
Q

What are the ROME criteria exclusion criteria?

A 
Weight loss
Bloody stool
Anorexia
>40 years old
Diarrhoea at night
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8
Q

What are the causes of dysphagia?

A

Inflammatory, mechanical, motility

Inflamm: Tonsil/oseophagitis, candidiasis, aphthous ulcers

Mechanical: May be:
Luminal: FB
Mural: Benign web, oseophagitis, malignancy, pharyngeal pouch
Extramural: Lung Ca, hiatus, LNs, retrosternal goitre

Motility: May be:
Local: Achalasia, oesophageal spasm, (pseudo)bulbar palsy
Systemic: CREST, MG

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9
Q

Dx Dysphagisa for solids and liquids at the start

A

Motility disorder, commonly achalasia

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10
Q

Dx Dysphagia solids>liquids at start

A

Stricture

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11
Q

Dx Dysphagia difficulty making swallowing movement

A

(Pseudo)bulbar palsy

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12
Q

Dx Odynophagia

A

Ca, ulcer, spasm

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13
Q

Dx intermittent dysphagia

A

Oesophageal spasm

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14
Q

Dx constant worsening dysphagia

A

Malignant stricture

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15
Q

Dx dysphagia with neck bulging/gurgling on drinking

A

Pharyngeal pouch

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16
Q

What investigations might you do for dysphagia/

A 
Bloods - FBC, UnE
CXR
OGD
Barium swallow +- video fluoroscopy
Oesophageal manometry
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17
Q

What are some secondary causes of achalasia?

A

Oesophageal cancer

Chagas disease - Trypanosoma cruzii

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18
Q

What is the management of achalasia?

A

Medical: CCBs, nitrates
Interventional: Endoscopic ballooning, botulinum
Surgical: Heller’s cardiomyotomy

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19
Q

What is Killian’s dehiscence?

A

The defect in the oesophagus which causes a pharyngeal pouch

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20
Q

What are the alarm symptoms associated with dyspepsia?

A

ALARMS

Anorexia
Loss of weight
Anaemia
Recent onset progression
Melaena/haematemesis
Swallowing difficulty
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21
Q

What is the management of new onset dyspepsia?

A 
OGD if >55 or ALARMS
Conservative measures for 4 weeks
H. pyori test if no improvement
If +ve then eradication therapy (PPI, Amox, Clari for 7 days)
If -ve then 4 week PPI trial
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22
Q

What are some distinguishing features between gastric and duodenal ulcers?

A

Gastric ulcer pain is worsened on eating, and may also cause weight loss

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23
Q

What are some potential complications of peptic ulcer disease?

A

Haemorrhage
Perforation
Gastric outflow obstruction
Malignancy

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24
Q

What is the management approach to PUD?

A

Conservative: Wt loss, stop smoking, less EtOH, dietary stuff, stop NSAIDs, OTC antacids

Medical: PPIs, H pylori eradication, H2 antagonists

Surgical: Vagotomy/antrectomy

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25
What is the cellular progression from GORD to cancer?
GORD -> Barrets oesophagus (squamous metaplasia to columnar epithelium) -> dysplasia -> adenocarcinoma
26
What is the surgical management for GORD?
Nissen fundoplication
27
Which type of hiatus hernia is more common?
Sliding (80%)
28
What are the differentials for haematemesis?
VINTAGE ``` Varices Inflammation - PUD Neoplasia Trauma - Mallory Weiss/Boerhaave's Angiodysplasia Generalised bleeding diatheses Epistaxis ```
29
Rectal bleeding differentials?
DRIPING Arse ``` Diverticule Rectal - haemorrhoids Infection - Campy, shigella, E coli, C dif Polyps Inflammation - IBD Neoplasia Gastric bleeding Angio - Ischaemic colitis, HHT ```
30
What is the Rockall score?
Prediction of re-bleed and mortality following upper GI bleed
31
What are the causes of portal hypertension?
Pre hepatic - Portal vein thrombosis Hepatic - Cirrhosis Post hepatic - Budd Chiari, RHF, pericarditis
32
What is the management approach for an upper GI bleed?
Resuscitate - Head down, O2, IV access + fluids, bloods Blood products if still shocked Variceal management: Terlipressin IV + Ciprofloxacin Maintenance: Fluids, CVP, correct coagulopathy, thiamine if EtOH Endoscopy if severe bleed
33
What are the pre-hepatic causes of jaundice?
Haemolytic anaemia | Ineffective erythropoiesis - e.g. thalassaemia
34
What are the hepatic causes of jaundice?
Unconjugated: Contrast agents, CCF, Hypothyroid, Gilberts, C-N synd Conjugated: Hepatocellular dysfunction - Congenital - Wilsons, a1atd
35
What are the post hepatic causes of jaundice?
``` Stones Pancreatic cancer Drugs PBC/PSC Biliary atresia Choledochal cyst Cholangiocarcinoma ```
36
What are the iatrogenic causes of jaundice?
Haemolysis - Antimalarials Hepatitis - Paracetamol, valproate, statins Cholestasis - Fluclox, coamox, COCP
37
What are the causes of liver failure?
``` Cirrhosis Infection - Hep/CMV/EBV Toxins - EtOH, Paracetamol, Isoniazid Vascular - Budd Chiari Obstetric - Eclampsia, acute fatty liver Others - Wilsons, AIH ```
38
What are the signs of liver failure?
``` Jaundice Oedema/ascites Bruising Encephalopathy (asterixis) Fetor hepaticus Spider naevi JVP Caput medusae ```
39
What blood results would you find in liver failure?
``` FBC - Infection, microcytosis if EtOH UnE - Low urea (hepatic synthesis) with raised Cr (hepatorenal syndrome) LFTs: AST:ALT >2 = EtOH AST:ALT <1 = Viral Hypoalbuminaemia (chronic) Raised PT (acute) Clotting - INR raised ABG - metabolic acidosis ```
40
What is the pathophysiology of hepatorenal syndrome and when is it seen?
Seen in advanced chronic liver failure, where cirrhosis causes splanchic vessel dilatation ->RAS activation -> Renal artery vasoconstriction. Persistent underfilling of the renal circulation leads to renal failure
41
What are the complications and preventative measures for each - of liver failure?
Bleeding - Vit K, platelets, FFP, blood Sepsis - Tazocin Ascites - Fluid + salt restrict, spiro, furosemide, ascitic tap, daily weights Hypoglycaemia - regular BMs Encephalopathy - Monitor, avoid sedatives, lactulose, rifamixin Seizures - Lorazepam Cerebral oedema - Mannitol
42
How does rifamixin work for hepatic encephalopathy?
Reduces ammonia production by gut flora
43
What are the examination findings in cirrhosis?
Hands - Dupuytrens contractures, clubbing, Terrys nails (white), palmar erythema, leukonychia (white flecks) Face - Palor, Xanthelesma, parotid enlargement (EtOH) Trunk - Spider naevi, gynaecomastia Abdo - Striae, caput medisae, hepSplenomegaly, testicular atrophy
44
What are some possible complications of cirrhosis?
Decompensation - jaundice, encephalopathy, hypoalbuminaemia, coagulopathy, hypoglycaemia Spontaneous bacterial peritonitis (ascitic fluid infection) ``` Portal hypertension - SAVE Splenomegaly Ascites Varices Encephalopathy ``` HCC
45
What investigations might you do to find the SPECIFIC cause of cirrhosis?
``` EtOH - FBC, LFT NASH - hyperlipidaemia, hyperglycaemia Infection - serology Genetic - ferritin, a1at, caeruloplasmin (low in Wilson's) AIH - SMA, ANA PBC - AMA PSC - ANCA, ANA Cancer - alpha-fetoprotein ```
46
What specific management options are available for cirrhosis caused by: HCV PBC Wilson's
Interferon-alpha Ursodeoxycholic acid Penicillamine
47
What are the components of the Child Pugh score and what is it used for?
Used to assess prognosis in cirrhosis ``` Bilirubin Albumin INR Ascites Encephalopathy ```
48
What are the features of hepatic encephalopathy?
ACDCS ``` Asterixis, Ataxia Confusion Dysarthria Constructional apraxia Seizures ```
49
How would you differentiate ascites due to portal HTN from other causes?
Serum Ascites Albumin Gradient ``` > 1.1 = Portal HTN < 1.1 = Other causes Neoplasia Inflammation - pancreatitis Nephrotic syndrome Infection - TB peritonitis ```
50
What are some complications of chronic alcohol use?
Cirrhosis GI - gastritis, PUD, varices, pancreatitis, carcinoma Neuro - Wernickes, Korsakoffs, peripheral neuropathy Cardio - arrhythmias, DCM, HTN Blood - Microcytosis, folate def
51
What is the role of each medical management of alcoholism?
Baclofen - reduces cravings Disulfaram - Hangover inducer Acamprosate - reduces cravings
52
What are the features of the three phases of viral hepatitis?
Prodrome, Icteric, Chronic Prodrome: Flu, malaise, arthralgia Icteric - Acute jaundice, abdo pain, hepmegaly, cholestatic picture, rash Chronic - Cirrhosis w. HCC risk
53
Which viral hepatitis has the poorest long term prognosis in terms of complications?
Hep C - 80% develop chronic disease and 20% get cirrhosis
54
What is the relationship between NASH and NAFLD?
NASH is the severe form of NASH
55
How might NAFLD present?
Commonly silent Hepmegaly + RUQ pain Metabolic syndrome (as it is a risk factor)
56
What are the causes of Budd Chiari syndrome?
Hypercoagulable states - myeloproliferative disorders, paroxysmal nocturnal haemoglobinuria, anti-phospholipid, OCP Local tumour - commonly HCC Congenital
57
What is the presentation of BC syndrome?
RUQ pain Hepmegaly Ascites (SAAG >1.1) Jaundice
58
What is the pathophysiology of hereditary haemochromatosis?
Increased iron absorption leads to deposition in multiple organs
59
What are the features of hereditary haemochromatosis?
MEALS ``` Myocardial - DCM, arrhythmia Endocrine - DM, hypogonadism, hypocalcaemia Arthritis - big and small Liver - CLD/cirrhosis/HCC, hepmegaly Skin - slate grey ```
60
What are the blood findings in hereditary haemochromatosis (HH)?
``` Deranged LFTs Raised ferritin Raised Iron Reduced TIBC Hyperglycaemia ```
61
What is the management of HH
1st line:Venesection (aim Hct < 0.5) 2nd: Desferroxamine General - Monitor DM, low Fe diet, screening
62
What are the two main features of A1At deficiency?
Cirrhosis | Emphysema
63
What are the features of Wilson's disease?
CLANK ``` Cornea - Kayser Fleischer Liver - Cirrhosis/fluminant necrosis Arthritis Neuro - Parkinsonism, psych, cerebellar syndrome Kidney - Fanconi syndrome ```
64
What investigations would you do for Wilson's disease and what are the results?
Blood - low Cu, low caeruloplasmin (acute phase reactant) Raised 24hr urinary Cu Raised hepatic Cu on biopsy
65
What (and when) is the presentation of autoimmune hepatitis?
``` Mostly teens and early twenties - Constitutional - fever, malaise, fatigue Cushingoid - hirsute, acne, striae Hepatitis HSM Polyarthritis ``` May also resent post-menopausally but more insidiously
66
What is the management and prognosis of AIH?
Pred + Azathioprine | Remission in 80% of patients
67
What is the difference between the pathophysiology of PSC and PBC?
PBC is intrahepatic bile duct destruction only, while PSC also affects extrahepatic ducts
68
True or false, PBC is more common in men and PSC more-so in women
False - PBC is 9x more common in women, while PSC is more commonly seen in men
69
What are the presenting features of PBC?
PPBBCCS ``` Pruritis Pigmentation (facial) Bones - osteomalacia+porosis Big organs - HSM Cirrhosis + coagulopathy Cholesterol - Xanthelasma +xanthomata Steatorrhoea ```
70
What are the features of PSC?
Obstructive jaundice, pruritis, abdo pain, HSM, Cholangiocarcinoma (^Risk)
71
Which is UC associated with? PSC or PBC
PSC - 3% of UC have PSC but 80% of PSC have UC
72
Which disorders are associated with PBC?
Thyroid disease CTDs Coeliac
73
Which antibodies are seen in PBC and PSC?
PBC - AMA (98%) | PSC - pANCA (80%)
74
What is the management of PBC and PSC?
Symptomatic: Pruritis - colestyramine, naltrexone Diarrhoea - Codeine Osteoporosis (PBC) - Bisphosphonates Specific: ADEK vitamins Ursodeoxycholic acid Abx for PSC cholangitis Liver transplant Screening PSC - Cholangiocarcinoma (USS and Ca19-9) and Colorectal
75
What is the prognosis of PBC?
Once jaundice develops, survival is 2 years
76
What are the ERCP findings in PSC?
Beading
77
What are the differences between PSC and PBC on liver biopsy?
PBC- non-caseating granulomatous inflammation PSC- Fibrous, obliterative cholangitis
78
What are the main LFT changes in PBC?
massive ALP, Massive GGT, also raised AST/ALT
79
True or false; HCC is the commonest liver tumour.
False - Metastases are the commonest liver tumours. HCC is the commonest primary liver cancer
80
What are the features of a liver cancer?
``` Commonly silent Irregular hepatomegaly Signs of CLD Jaundice is a late sign RUQ pain ```
81
WHat are the causes of HCC?
Cirrhosis - EtOH, HH, PBC Viral Hep Aflatoxins
82
Cholangiocarcinoma is a tumour of what structure?
Biliary tree
83
What are some possible complications following liver transplant?
``` Acute rejection (50%) Sepsis Hepatic artery thrombosis CMV infection Chronic rejection Recurrence ```
84
Compare the epidemiology of UC and Crohn's
UC more common Crohns presents earlier Smoking is protective for UC but a risk factor for Crohns
85
Compare the pathology of Crohn's and UC
Location - Crohns affects mouth to anus, esp the terminal ileum, while UC affects up to the caecum Distribution - Crohns has skip lesions, UC is contiguous Thickness - Crohns is transmural, UC is mucosal Strictures - Crohn's causes strictures, UC does not
86
Which more commonly causes weight loss, Crohns or UC?
Crohns
87
Which is more strongly associated with PR bleeding, Crohns or UC?
UC
88
What are the GI features of Crohns?
``` Aphthous ulcers Glossitis Abdo tenderness RIF mass Perianal abscesses, fistulae, tags Anal/rectal strictures ```
89
What are the extra-GI features IBD?
Skin: Clubbing Erythema nodosum Pyoderma gangrenosum (UC) Eyes: Ant uveitis Episcleritis Conjunctivitis Joints: Asymmetrical arthritis Sacroilliitis Ankylosing spondylitis Hepatobiliary: PSC + Cholangiocarcinoma (UC only) Gallstones (esp Crohns) Fatty liver Other: Amyloidosis Oxalate renal calculi (Crohns)
90
What complications are associated with UC?
``` Toxic megacolon (>6cm) Bleeding Malignancy - colorectal and cholangiocarcinoma Strictures -> obstruction Venous thrombosis ```
91
Which complications are associated with Crohn's disease/
``` Fistulae Strictures -> obstruction Abscesses Malabsorption: fat ->steatorrhoea, gallstones B12 -> anaemia VitD -> Osteomalacia protein -> oedema ```
92
How would you investigate IBD and what would you find?
Bloods - FBC ( low hb high wcc), LFT (low alb), B12, CRP/ESR, cultures Stool - MCnS (exclusion), C. dif toxin Imaging - C+Axr (perforation + megacolon/wall thickening), CT, gastrograffin
93
Which radiological features would you see in UC?
Lead piping Thumbprinting Pseudopolyps
94
Which radialogical featuers would you see in Crohn'?
Skip lesions Rose thorn ulcers Cobblestoning String sign of Kantor - narrowed terminal ileum
95
What are the Truelove and Witts criteria/
Used to determine UC severity based on: ``` Bowel motions/day PR bleed Temp HR Hb ESR ```
96
What is the management approach for an acute severe flare of UC?
Resus - NBM, IV fluids Hydrocortisone IV LMWH Monitor - bloods, stools, AXR
97
What are the guidelines for remission induction in UC?
1st: 5ASAs e.g. Sulfa/Mesalazine 2nd: Prednisolone
98
What are the guidelines for remission maintenance in UC?
1st: Sulfa/Mesalazine 2nd: Azathioprine or 6-Mercaptopurine 3rd: Infliximab/Adalimumab
99
What are the complications following surgery for UC?
Abdo - SBO, stricture, abscess, bleeding Stoma - retraction, stenosis, prolapse, dermatitis Pouch - pouchitis, leakage
100
Metronidazole is recommended for flare up of which form of IBD?
Crohn's
101
What is the management for induction of remission in Crohns?
Supportive - high fibre diet, vitamin supplements 1st: Budesonide, Sulfasalazine 2nd: tapering Pred 3rd: Methotrexate 4th: inflix/Adalimumab
102
What is the management for maintenance of remission in Crohns?
1st: Azathioprine, 6-Mercaptopurine 2nd: Methotrexate 3rd: Infliximab/Adalimumab
103
What are the complications of bowel resection for Crohn's?
``` As for UC + Short gut - Steatorrhoea ADEK + B12 malabsorption Bile acide dep -> gallstones Hyperoxaluria -> renal stones ```
104
What are the features of Coeliac disease?
GLIAD GI Malabsorption - carbs, fats, proteins, folate, iron, vitamins Lyphoma and carcinoma - EATL, SB adenocarcinoma Immune assocs - IgA def, T1DM, PBC Anaemia - +hyposplenism Det, - Dermatitis herpetiformis (symmetrical vesicles on extensor surfaces, v itchy), aphthous ulcers
105
Which is the most specific antibody to test in Coeliac disease?
Anti-endomysial IgA
106
What are the common causes of malabsorption in the UK?
Coeliac Crohns Chronic pancreatitis
107
What are the risk factors for pancreatic cancer?
DINES ``` DM Inflamm - chronic pancreatitis Nutrition - high fat diet EtOH Smoking ```
108
What is the most common type of cancer affecting the pancreas, and where is it usually found?
Adenocarcinoma, 60% in the head
109
How might a cancer of the pancreatic body/tail present differently to one of the head/
Head cancers are the classic painless obstructive jaundice, while body/tail cancers cause epigastric pain which radiates to the back and is alleviated on sitting forward. Both typically present in males over 60 with anorexia and weight loss
110
How would you investigate a >Panc CA and what might you find?
Bloods - LFTs (cholestatic), Ca19, hypercalcaemia USS - Pancreatic mass, dilated ducts +- hepatic mets ERCP
111
What is the management of pancreatic cancer?
If fit, with no mets and a small tumour - can perform Whipples pancreaticoduodenectomy Otherwise palliate
112
What is the commonest cause of chronic pancreatitis/
Alcohol
113
How woudl you investigate and what would you find in chronic pancreatitis?
Bloods - hyperglycaemia Reduced faecal elastase USS - pseudocyst AXR/CT - speckles pancreatic calcifications
114
What are the complications of chronic pancreatitis?
DM Pancreatic Ca Biliary obstruction Splenic vein thrombosis leading to splenomegaly
115
What is the cell origin of carcinoid tumours, and what might they secrete/
Enterochromaffin cells ``` 5-HT VIP Gastrin Glucagon Insulin ACTH ```
116
Which syndrome are carcinoid tumours assocaited with?
MEN1
117
Where are carcinoid tumours commonly found?
Appendix Ileum Colorectum
118
What are the clinical featuers of Carcinoid syndrome?
FIVE HT ``` Flushing - paroxysmal Intestinal - diarrhoea Valve fibrosis - TrRe, PuSt E - Wheeze Hepatic involvement Tryptophan deficiency (B3 pellagra) - Diarrhoea, dermatitis, dementia ```
119
How would you investigate a ?carcinoid tumour?
Urinary 5-HIAA Plasma Chromogranin A CT to find primary
120
How would you manage Carcinoid syndrome?
Symptoms - octreotide, loperamide Curative - resection
121
What are the features of Vitamin A deficiency?
Dry conjunctivae Corneal ulcerations Night blindness
122
What are the features of Vitamin B1 deficiency?
Wet: HF + oedema Dry: Polyneuropathy Wernickes/Korsakoffs
123
What are the features of Vitamin B3 deficiency?
Pellagra -3Ds Dementia Dermatitis Diarrhoea
124
What are the features of Vitamin B6 deficiency?
Peripheral sensory neuropathy
125
What are the features of Vitamin B12 deficiency?
Megaloblastic anaemia Subacute combined degeneration of the cord (motor and sensory) Peripheral sensory neuropathy Glossitis
126
What are the features of Vitamin C deficiency?
Scurvy Gingivitis Bleeding everywhere Myalgia Oedema
127
Which factors are depleted in vitamin K deficiency?
2,7,9,10,C and S
128
What are some possible examination finding indicating immunosuppression?
Cushingoid Skin tumours (AKs, SCCs in particular) Gingival hypertrophy 2 to ciclosporin
129
What are the possible differentials for a Mercedes Benz scar/
Liver transplant Segmental resection Whipples pancreaticoduodenectomy
130
Which immunosuppressants are commonly given following liver transplant?
Tacrolimus Ciclosporin Azathioprine Prednisolone (withdraw after 3 months)
131
What are the common and rare causes of hepatomegaly?
Common: Hepatitis, CLD, HF ``` Rarer: Malignancy Anatomical variations Budd Chiari Myeloproliferative disorders Sarcoid/Amyloidosis ```
132
How might you investigate an individual with hepatomegaly?
Bloods - FBC (anaemia, lymphocytosis), UnE (CCF -> renal impairment), LFTs, clotting, liver screen Urine dip - Urobilinogen, proteinuria Imaging - USS for anatomy, CT for cancer Biopsy
133
What are the causes of splenomegaly?
``` Myelo/lymphoproliferative disease CLD Infective endocarditis Feltys syndrome Malaria Sarcoid Amyloid RA/SLE/Sjogrens ```
134
What is Felty's syndrome?
A triad of : Rheumatoid arthritis Splenomegaly Neutropaenia Characterised by repeated infections
135
What symptoms might a patient with splenomegaly report?
Haem - fatigue, bruising, infections, bone pain CLD - Viral exposure, FHx Inflammatory arthritis
136
What blood results might point you to an underlying diagnosis in splenomegaly?
CML - Massive WCC (PMNs) Myelofibrosis - pancytopaenia CLL - Lymphocytosis Haemolysis - Microcytic anaemia
137
What blood film results might point you to an underlying diagnosis in splenomegaly?
Myelofibrosis - Leukoerythroblastic teardrop poikiloctytes CLL - Smear cells Haemolysis - Smear cells, reticulocytosis Malignancy - Uraemia Malaria - thick and thin films
138
What genetic mutations are seen in specific causes of splenomegaly?
CML - Philidelphia chromosome t(9;22) leading to BCR-ABL formation Myelofibrosis - 50% are JAK2 pos
139
What are the causes of massive splenomegaly
``` CML Malaria Myelofibrosis Infectious Mononucleosis Gaucher disease (lipid storage disorder) ```
140
What are the features of CML?
Constitutional - Fever, lethargy, weight loss, night sweats Massive HSM Platelet dysfunction Gout
141
What is the pathophysiology of primary myelofibrosis?
Clonal proliferation of megakaryocytes results in extramedullary haematopoiesis in the liver and spleen due to resultant myelofibrosis
142
What are the featuers of myelofibrosis?
Pancytopaenia Constitutional Massive HSM
143
What are the common causes of hyposplenism?
Splenectomy Coeliac IBD Sickle Cell disease
144
What must be done to manage a splenectomy patient?
Immunisations - pneumovax, HiB, MenC, Flu Daily Abs - Pen V Alert card/bracelet
145
What are the possible indications for splenectomy?
Trauma Rupture (2 to EBV for exampls) AIHA ITP
146
What are some complications of splenectomy?
``` Redistributive thrombocytosis Gastric dilatation - transient ileus Left lower lobe atelectesis Pancreatic ischaemia bleeding Infections (esp encapsulates) ```
147
What are the important features of examining a patient with enlarged kidneys?
Inspection - Nephrectomy scar, Rutherford Morrison scar, Tenchkhoff catheter/scar ``` Palpation - Kidneys Liver Spleen Renal transplant (groin ``` Auscultation - Renal bruits Completion - External genitalia Urine dip CV exam (MV prolapse)
148
What might cause bilateral renal enlargement/
ADPKD Bilateral RCC Bilateral cysts - E.g. VHL Amyloidosis
149
What might cause unilateral renal enlargement?
Simple renal cysts RCC Compensatory hpertrophy + contralateral nephrectomy - ADPKD
150
What are the features of ADPKD?
``` 30-50yos HTN Recurrent UTIs Loin pain Haematuria Hepatomegaly (hepatic cysts) Berry aneurysms MV prolapse (MS click w late systolic murmur) ```
151
What investigations might point to the cause of renal enlargement?
Urine - Dip, cytology Bloods - Anaemia 2ary to ESRF UnE Renal osteodystrophy Imaging; Abdo USS, CTMRI may show berry aneurysms
152
What is the management of ADPKD?
General - lots of water, salt and caffeine restrict Monitor BP and UnE Genetic counselling MRI screening Medical - Aggressive HTN management (ACEi best), treat infections Surgical - Nephrectomy
153
What are the features of ARPKD?
Much rarer than AD form Presents perinataly - oligohydramnios, HTN, CRF Congenital hepatic fibrosis -> Portal HTN
154
What are the features of a simple renal cyst?
Common - 1/3 of over 60s have one May present as renal mass and haematuria Solid components only Main differential is RCC
155
What are the renal manifestations of Tuberous Sclerosis?
Cysts, angiomyolipomas
156
What are the risk factors for RCC?
``` Obesity smoking HTN dialysis Heritable - VHL ```
157
What is the classic presenting triad of RCC?
Loin pain Haematuria Loin mass
158
What paraneoplastic features may present as a result of RCC?
``` EPO - polycythaemia PTHrP - hypercalcaemia Renin - HTN ACTH - Cushings syndrome Amyloidosis ```
159
What are the featuers of Von Hippel Lindau syndrome?
``` Bilateral renal cell carcinoma Renal and pancreatic cysts Cerebellar haemangioblastomas Phaeochromocytoma Islet cell tumours ```
160
Where might you find a Rutherford Morrison scar and what does it indicate/
RIF | Renal transplant
161
What are the commonest indications for renal transplant?
Diabetic nephropathy Glomerulonephritis Polycystic kidney disease Hypertensive nephropathy
162
What is the pathophysiology and presentation of hyperacute renal transplant rejection?
Path - ABO incompatability | Pres - Thrombosis and SIRS
163
What is the pathophysiology and presentation of acute renal transplant rejection?
Path - Cell mediated Pres - Fever, pain, low urine output, raised creatinine Responsive to immunosuppression
164
What is the pathophysiology and presentation of chronic renal transplant rejection?
Path - Interstitial fibrosis with tubular atrophy Pres - Gradual rise in Cr and proteinuria Not responsive to immunosuppression
165
What are the common side effects of commonly used adjunctive immunosuppresants?
Ciclosporin - Nephrotoxic, gingival hypertrophy, hypertrichosis, hepatic dysfunction Tacrolimus - Nephrotoxic, diabetogenic, cardiomyopathy, neurotoxic Steroids - Cushings
166
When would you consider commencing renal replacement therapy?
When GFR falls below 15 and the patient is symptomatic
167
What are the complications of dialysis?
``` 20% annual mortality Cardiovascular disease Malnutrition Infections (2ary to uraemia) Anmloidosis Renal cysts -> RCC ```
168
Compare the mechanism of each of the different types of renal replacement therapy
Haemodialysis - blood and dialysate flow in opposite directions separated by semipermeable membrane. Solution transfer by diffusion Haemofiltration - Blood filtered under hydrostatic pressure - less haemodynamic instability Peritoneal dialysis - Dialysate introduced into peritoneal cavity by Tenchkoff catheter with diffusion occuring across the peritoneum
169
What are the complications of haemodialysis?
Disequibrilation syndrome - usually only on first go, rapid osmolarity change causes cerebral oedema Fluid imbalance Electrolyte imbalance Aluminium toxicity -> dementia
170
What are the complications of peritoneal dialysis/
``` Peritonitis Infection Catheter malfunction Obesity (glucose in dialysate) Hernias and back pain ```
171
How would you examine an AV fistula/
Inspection Swelling with scar over distal forearm/elbow Needle marks Evidence of infection Palpation Assess pain, tempearture, thrill Auscultate for bruits
172
What are the advantages and disadvantages of an AV fistula?
Ad: high flow rates, low recirculation, low infection rate, low stenosis rates Dis: 6 weeks to arterialise, body image, must take care
173
What are the possible complications of an AV fistula?
``` Thrombosis Stenosis Infection Bleeding Aneurysm Steal syndrome - Distal tissue ischaemia which may necrose - Rx with banding ```
174
Where does a tunnelled cuffed catheter typically sit?
Internal jugular vein
175
What are the complications of a tunnelled cuffed catheter?
Insertion - e.g. pneumothorax Infection Blockage Retraction
176
What are the two commonest causes of CKD?
DM | HTN
177
What are some other causes of CKD?
``` Renal artery stenosis Glomerulonephritis CKD PKD Drugs Pyelonephritis Myeloma ```
178
What protein:creatinine may indicate CKD?
>300
179
What investigations might you do for CKD/
Urine Dip - protein, haemat, glucosuria PCR - >300 indictes nephrotic syndrome Bence jones proteins - MM ``` Bloods Anaemia Low eGFR Bone profile DM bloods ESR Antibodies Viral serology ``` ``` Imaging CXR - pulmonary oedema Renal USS Bone Xray - renal osteodystrophy CT KUB - cortical scarring from pyelonephritis ```
180
What are the complications of CKD?
CRF HEALS ``` Cardiovascular disease Renal osteodystrophy Fluid (oedema) HTN Electrolyte disturbances Anaemia Leg restlessness Sensory neuropathy ```
181
What are the features of renal osteodystrophy?
``` Osteoporosis Osteomalacia 2/3ry hyperparathyroidism Osteosclerosis Band keratopathy (corneal calcifications) ```
182
What is the mechanism of development of renal osteodystrophy
Renal impairment causes reduction in 1alpha hydroxylase -> less vit D activation -> low Ca -> high PTH -> Phosphate retention further increases PTH -> osteoclast and osteoblast activation and acidosis which also contributes to bone resorption
183
What is the management approach to CKD?
``` General Treat reversible causes Stop nephrotoxic Electrolyte and fluid restriction Optimise CV risk ``` Specifics HTN - If DM give ACEi/ARB Oedema - furosemide Bone disease - Phosphate binders, Vit D analogues, Ca Anaemia - Exclude other causes and give Epo Restless legs - Clonazepam
184
How does diabetes lead to CKD?
Hyperglycaemia leads to renal hypertrophy and ROS production -> glomerulosclerosis and nephron loss Nephron loss results in RAS activation and thus hypertension
185
Which screening programme aims to prevent T2DMs from developing CKD?
Microalbuminuria
186
What are the causes of renal artery stenosis?
Atherosclerosis (80%) Fibromuscular dysplasia Thromboembolism External compression
187
How might renal artery stenosis present?
``` Refractory hypertension Renal artery bruits Woresning renal function in response to ACEi/ARBs Flasu pulmonary oedema Other PVD signs ```
188
Which medications must be avoided in renal artery stenosis?
ACEi/ARBs

Scott's Notes (21 decks)

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