GI Flashcards
GI causes of clubbing
Chronic liver disease IBD Coeliac GI lymphoma Tropical sprue Whipple's disease
Leuconychia
Associated with hypoalbuminaemia, heart failure, renal disease, Hodkin’s lymphoma and DM
Causes of palmar erythema
Vasodilated state - chronic liver disease, hypercapnoea, RA, thyrotoxicosis, pregnancy, fever, exercise
Gynaecomastia in chronic liver disease
Related to altered sex hormone metabolism oestradiol:freetestosterone ratio. Palpabe behind nipple
Hepatic bruit
?TIPPS
Hep C on examination
Tattoos, porphyria cutanea tarda + livedo reticularis from type iii cryoglobulinaemia
PBC signs
Hyperpigmentation, xanthelasma, tendon xanthomata, excoriation marks
Haemochromatois
Bronze pigmentation, arthropathy, finger pinprick (diabetes testing)
Drugs and cirrshosis
Methotrexate, isoniazid, amiodarone, phenytoin
Grading Encephalopathy
West Haven Criteria 1-4 1 - insomnia / reversal of day-night sleep pattern 2 - lethargy / disorientation 3 - confusion / somnolence 4 - coma
Caput Medusae vs IVC obstruction
Occlude vessel and observe refilling. If towards legs = caput medusae, if cephalic = IVC obstruction
Causes of ascites
Cirrhosis Malignancy Heart Failure TB Pancreatitis
Tender Hepatomegaly
Infectious (e.g. viral) Alcoholi hepatitis Malignancy Hepatic congestion Vascular liver disease
Which tumours metastasise to the liver
Which liver tumours are benign
CRC, oesophageal, lung, gastric, breast, lymph, renal, endometrial, neuroendocrine, sarcomatous, bone
Benign - cavernous haemangioma, hepatic adenoma, FNH, NRH
Causes and clinical manifestations of Budd-Chiari syndrome
Obstruction to hepatic venous outflow, thrombosis may occur at hepatic venules, hepatic vein or IVC
Myeloproliferative disease, protein C and S deficiency, fVL, APS, PNH
Acute presentation with jaundice and encephalopathy / subacute with abdominal pain and hepatomegaly
Doppler USS.
Anticoagulation but in severe cases thrombolysis, anigoplasty or liver Tx may be indicated.
What are the hepatic manifestations of SSD
Gall stone disease - chronic haemolysis causing pigment stones
Crisis - sickle thrombosis causeing sinusoidal obstruction
Intrahepatic cholestasis
Iron overload if recurrent transfusions
Splenomegaly (with or without anaemia)
Haematological malignancy
Portal HTN
Haemolytic anaemia
Felty’s syndrome
Jaundice + Splenomegaly
Haemolysis
?Haematological malignancy with cold AIHA with CLL
Splenomegaly with RA hands
Felty’s - neutropenia to confirm
Splenomegaly without lymphadenopathy
Splenomegaly without lymphadenopathy
Myeloproliferative like CML
Lymphoproliferative
Characeristics of spleen on palpation
Enlarges towards RIF Medial notch Dull to percussion Cannot palpate above it Not ballotable
Causes of splenomegaly
Portal HTN Haematological malignancy Infection Congestion Primary splenic disease (e.g. splenic vein thrombosis)
Massive - CML, myelofibrosis, Kala-azar (visceral leishmaniasis), Malaria
Moderate - Portal HTN, lymphoma, leukaemia, thalassaemia
Mild - haemolysis, EBV, IE, AI (SLE, RA), infiltrative (amyloid/sarcoid)
What is the significance of B-symptoms in NHL
Fever >38
Weight loss >10% BW / 6 months
Drenching night sweats
If one is present, then patients clinical staging is altered accordingly
Cytogenetics of CML
Philadelphia chromosome 90-95%
Translocation 9:22, increased oncogene activity through thyrosine kinase
Detection used for diagnosis and monoclonal Ab treatements
Blast Crisis
Phase of disease similar to acute leukamia with survival 3-6 months, blast cells in BM and peripheral blood. Skin and soft tissue infiltration
Managing hyposplenism
Vaccinations - pneumococcal, HiB, Men C with repeat vaccinations
Prophylactic Abx - oral penoxymethylpenicillin / erythromycin
Advice re: presentations to hospital
Malaria prophylaxis and travel advice
Information card / medi-alert bracelet
Felty’s syndrome
Seropositive RA + splenomegaly + neutropenia
(however splenomegaly no longer absolute diagnostic requirement
Presentation of haemochromatosis
Bronze diabetes (cirrhosis / DM and slate-grey pigmentation (classical, rare)
Cutaneous pigmentation >90% (sun-exposed areas most evident) bronze/grey
Koilonychia, chronic liver disease signs are late
Gynaecomastia and loss of bofy hair due to iron deposition in pituitary gland
Hepatomegaly
Restrictive / dilated cardiomyopathy
Diagnosing and managing haemochromatosis
Iron overload - serum studies, transferrin saturation, liver biopsy
Genetics - HFE gene testing (C282Y and H63D) >90%
Phlebotomy to target ferritin and transferring saturation <50% initially 1-2 weekly then maintenence 3 months. HCC monitoring
Can cause restrictive or dilated cardiomyopathy
Desferrioxamine (iron chelating agents)
DDx Splenomegaly
Infiltrative - lymphoma, leukaemia, amyloidosis
Infective - visceral leishmaniasis, malaria, subacute bacterial endocarditis, EBV, brucellosis
Gain of function - thalassaemia, spherocytosis, early sickle cell, Gaucher’s type 1 (Ashkenazi jews)
Disordered AI regulation - RA (felty’s), SLE,
Disordered flow - hepatic / portal vein thrombosis
DDx Splenomegaly
Infiltrative - lymphoma, leukaemia, amyloidosis
Infective - visceral leishmaniasis, malaria, subacute bacterial endocarditis, EBV, brucellosis
Gain of function - thalassaemia, spherocytosis, early sickle cell, Gaucher’s type 1 (Ashkenazi jews)
Disordered AI regulation - RA (felty’s), SLE,
Disordered flow - hepatic / portal vein thrombosis
DDx massive splenomegaly
CML
Kala-Azar (visceral leishmaniasis)
Myelofibrosis
Gaucher’s lipid storage disease
Hereditary spherocytosis
Autosomal dominant
Osmotic fragility test / flow cytometry
Increased reticulocytes with blood film of small dark cels with loss of central pallor
Splenomegaly for mod/severe disease
DDx Hepatomegaly
Cirrhosis Carcinoma CCF Infectious (HBV, HCV) Immune (PBC, PSC, AIH) Infiltrative (amyloid, myeloproliferative
AI in liver disease
AIH - ANA, ASMA, Anti LKM ab
PBC - AMA (M2 in 98%)
PSC - ANA, ASMA may be +ve
DDx gynaecomastia
Physiological Klinfelter's Cirrhosis Drugs - sprironolactone, digoxin Testicular tumour / orchidectomy Endocrinopathy - thyroid / addison's
Genetics of HH
AR chr 6
HFE gene - regulator of gut iron absorption
Homozygous 1:300, carrier 1:10
Females have menstual blood losses so present later
DDx splenomegaly by size
Massive - >8cm Kala-azar, malaria CML, myelofibrosis
Moderate - myelo/lymph proliferative disease, infiltration amyloidosis
Tip - myelo/lympho proliferative, portal HTN, IE, viral hep, EBV, haemolytic anaemia
Indication for splenectomy
Rupture (trauma)
Haematological - ITP, hereditary spherocytosis
Splenectomy workup
Vaccinations at least 2/52 prior - encapsulated bacteria
Meningitis, pneumococcus, haemophilus
Lifelong prophylactic penicillin
Medic calert bracelet
APCKD
Progressive replacement of renal tissue by cysts leading to renal enlargement and failure (5% ESRF in UK)
1:1000
85% APKD1 on chr 16
15% APKD2 chr 4
HTN, recurrent UTIs, abdo pain (cyst bleeding, cyst infection), haematuria
ESRFc by40-60s earlier in pdk1
Heptatic cysts, berri aneurysms and MV prolapse
Genetic coucelling, 10% de novo mutations
Nephrectomy / RRF
