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GI, renal and hepatic medicine Flashcards

1
Q

What is the distribution of UC?

A

Continuous
Mucosal only
Rectum to ileocaecal valve

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2
Q

What is the distribution of Crohn’s?

A

Patchy
Full thickness
Mouth to anus

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3
Q

What are the macroscopic changes seen in UC?

A

Continuous inflammation

Pseudopolyps

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4
Q

What are the macroscopic changes seen in Crohn’s?

A

Cobblestoning
Apthous ulcers
Serpiginous ulcers
Rose thorn ulcers

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5
Q

What are the microscopic changes seen in UC?

A

Crypt abcesses
Decreased goblet cells
Inflammatory infiltrate of the lamina propria

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6
Q

What are the microscopic changes seen in Crohn’s?

A

Granulomas with Langerhan’s giant

Increased goblet cells

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7
Q

What are the radiological changes seen in UC?

A

Lead pipe colon
Fat halo
Thumb printing

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8
Q

What are the radiological changes seen in Crohn’s?

A

Kantor’s string sign on barium xray

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9
Q

What surgical procedure is appropriate for an emergency presentation of UC?

A

Sub total colectomy, end ileostomy and a mucous fistula

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10
Q

Which surgical procedure is appropriate for an elective presentation of UC?

A

Pan proctocolectomy, an ileoanal pouch may be a selected option for some.
Although increased risk of colon cancer.

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11
Q

Which marker is often high in Crohns?

A

ASCA

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12
Q

What are the complications seen in UC?

A

Toxic megacolon

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13
Q

What are the complciations seen in Crohn’s?

A

Stricture - Obstruction
Fistula
Abcess

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14
Q

What are the extra-intestinal symptoms of IBD in general?

A

Skin - pyoderma gangrenosum, erythema nodosum
Eyes - Iritis, uveitis, episcleritis
Joints - Ank spond, sacroilitis, osteoporosis

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15
Q

What are the extra-intestinal symptoms specific to UC?

A

Primary sclerosing cholangitis

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16
Q

What are the extra-intestinal symptoms specific to Crohn’s?

A

Gallstones
Pancreatitis
Hepatic abcess

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17
Q

What are the extra-intestinal symptoms specific to Crohn’s?

A

Gallstones
Pancreatitis
Hepatic abcess
Oxalate renal stones

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18
Q

Does Crohn’s or UC have a higher risk of Ca?

A

UC

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19
Q

What are the symptoms of Crohn’s?

A

Diarrhoea usually non-bloody
Weight loss more prominent
Upper gastrointestinal symptoms, mouth ulcers, perianal disease
Abdominal mass palpable in the right iliac fossa

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20
Q

What are the symptoms of UC?

A

Bloody diarrhoea more common
Abdominal pain in the left lower quadrant
Tenesmus

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21
Q

What is the effect of smoking on Crohn’s and UC?

A

Eases UC

Causes Crohn’s flares

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22
Q

What is the workup for suspected IBD?

A 
Fbc - anaemia, prothrombotic state
U+E - hypokalaemia
CRP - tracking
LFTs- primary sclerosing cholangitis
B12 and folate - terminal ileum involvement

Stool cultures
Faecal calprotectin - inflammatory bowel marker
Abdo xray - obstruction, toxic megacolon
CXR - perforation
Endoscopy and biopsy
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23
Q

How would you manage an acute flare of IBD?

A 
Fluids
Electrolytes
Analgesia - avoid NSAIDs
Rectal mesalazine
then oral prednisolone if no effect
Avoid antibiotics unless severe or septic
Avoid loperamide - risk toxic megacolon
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24
Q

How would you manage IBD pharmacologically?

A
  1. Sulfasalazine
  2. Azathioprine or mesalazine
  3. Infliximab

Plus smoking cessation, b12/iron where possible, refer to surgeons in UC.

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25
What are the indications for infliximab in IBD?
Failed with DMARDS Severe active disease Review every 12 months
26
What are the causes of portal hypertension?
Cirrhosis Right heart failure Budd-Chiari (hepatic vein thrombosis) Schistosomiasis
27
What is the pathophysiology of portal hypertension?
Increased pressure in the portal vein increases back pressure on the gastric vein. This opens up embryonic channels eg between the gastric and azygous vein. They form varices as the pressure increases.
28
What are the complications of portal hypertension?
Ascites - spontaneous peritonitis | Varices
29
Where are the most common sites of varices?
Oesophageal Rectal Caput medusa
30
Describe the histopathology of cirrhosis?
Nodules of hepatocytes surrounded by bands of collagen
31
What are the complications of cirrhosis?
Hepatocellular carcinoma Decompensation Portal hyptension (and therefore ascites and varices)
32
Describe the metabolism of alcohol.
Alcohol dehydrogenase Acetaldehyde (and Mallory's hyaline) Acetaldehyde dehydrogenase Acetate
33
How does alcohol cause cirrhosis?
``` Increased acetaldehyde Inflammation Increased cytokines Increased fibroblasts Fibrosis ```
34
What are the main metabolic causes of cirrhosis?
Alcohol Fat (NASH) Copper (Wilson's) Iron (Haemochromatosis)
35
What are the main inflammatory causes of cirrhosis?
``` Hep B and C Autoimmune Primary biliary cirrhosis Primary sclerosing cholangitis Alpha 1 antitrypsin ```
36
What are the signs of cirrhosis?
``` Jaundice Ascites Visible epigastric vessels Spider naevi Duypuytren's Parotidomegaly Metabolic flap Increased oestrogen - gynaecomastia, palmar erythema, decreased body hair ```
37
What are the signs of a decompensated cirrhosis?
Metabolic flap Increased bilirubin, increased INR, decreased albumin Encephalopathy: - decreased attention - insomnia - confusion - dyspraxia
38
Why does liver disease often cause renal disease?
Hepatorenal syndrome | Bilirubin is toxic to kidneys
39
What is the management for cirrhosis?
Beta blockers to prevent variceal bleeding Spironolactone for ascites - consider paracentesis Monitor alpha fetoprotein - HCC
40
What blood results indicate recent alcohol misuse?
Gamma GT | Increased MCV without anaemia
41
What blood results indicate haemochromatosis?
Very increased ferritin | Decreased total iron binding capacity
42
What are the 3 sequelae of haemochromatosis?
Iron deposits in the liver, pancreas and pituitary Cirrhosis Diabetes Melananin
43
What is the sign of Wilson's disease?
Kayser - Fleischer rings in the eyes
44
How does primary biliary cirrhosis present?
Middle aged woman Fatigue Sjogrens Cholestasis - leads to pruritis, jaundice, steatorrhea and cirrhosis Positive ANA, anti-mitochondrial
45
How does primary sclerosing cholangitis present?
Young with IBD Cholestasis: jaundice and pruritus Right upper quadrant pain Fatigue Abnormal LFTs and positive ANCA
46
Describe the 2 implications of a raised gamma GT.
Alcohol Or Distinguishes obstructive hepatic pathology, not bone related when raised with alk phos
47
What does a raised alk phos indicate?
Cholestasis (especially if also raised gamma GT) Bone remodelling Preganancy
48
What is the differential for raised unconjugated bilirubn?
Gilberts Cirrhosis Heart failure Haemolysis Hypothyroid
49
What is the differential for raised conjugated bilirubin?
Obstruction - cholestasis, PBC, PSC, HCC | Infiltration - amyloid, sarcoid, TB, haemochromatosis
50
What are the markers for synthetic liver function?
INR | Albumin
51
What is the differential for low albumin?
If also proteinuria: AKI and Sepsis Otherwise: Cirrhosis Malignancy
52
Which blood tests are included in the liver screen?
``` Antibodies: Hep A, B, C (hepatitis) ANA, anti-mitochondrial (pbc) ANCA (psc) dsDNA, SM (autoimmune hep) ``` Ferritin and TIBC (haemachromatosis) Alpha 1 antitrypsin Thyroid (hypo) Glucose (diabetes)
53
How does haemachromatosis present?
Fatigue Arthralgia - hands and wrists Anti-dsDNA positive Very high ferritin Low TIBC
54
What are the most useful prognostic markers in paracetamol overdose?
arterial ph creatinine encephalopathy
55
Which blood test indicates a significant upper GI bleed?
Urea | acts as a protein meal and temporarily increases
56
Which blood test indicates coeliac?
positive anti-endomysial antibodies
57
How does coeliac present?
Intermittent oily diarrhoea Failure to thrive Other unexplained GI symptoms Unexplained anaemia
58
What complications are associated with repeated exposure to gluten in coeliac?
Villous atrophy which in turn causes malabsorption | T-cell lymphoma
59
What are the most common causes of CKD?
Diabetes Hypertension Polycystic kidney disease
60
What are the indications for dialysis in?
eGFR<8-10 Uraemic symptoms Refractory acidosis, fluid overload, hyperkalaemia Nephrotoxins that can be removed - eg aspirin OD
61
What are uraemic symptoms?
Pruritis Jaundice Uraemic pericarditis Uraemic flapping tremor ``` Lethargy Cramps Thirst N+V Hiccups Mental status changes - encephalopathy ```
62
What is a nephritic presentation?
Haematuria, hypertension
63
What is a nephrotic presentation?
Proteinuria, oedema, hyperlipidaemia
64
Which glomerulonephritis present as nephritic?
Goodpasture's, ANCA positive vasculitis - eg Wegeners IgA nephropathy Polycystic kidney disease
65
Which glomerulnephritis present as nephrotic?
Diabetic nephropathy Minimal change Focal segmental Membranous
66
What is the pathophysiology of membranous glomerulonephritis?
Thick BM due to IgG deposits | Therefore damage, allows protein out
67
What is the pathophysiology of minimal change glomerulonephritis?
``` Podocyte damage (Allows protein out) ```
68
What is the pathophysiology of focal segmental glomerulonephritis?
``` Podocyte sclerosis (Allows protein out) ```
69
What is the pathophysiology of IgA nephropathy?
IgA deposits in the actual glomerulus (blood vessels) (Inflammation and haematuria) Particularly at the time of simple infection eg sore throat (when iga increases)
70
What is the pathophysiology of Goodpastures vasculitis?
Anti BM antibodies attack BM (type 4 collagen) | Haematuria, also lung haemorrhage
71
What is the pathophysiology of Wegeners granulomatosis? (granulomatosis with polyangitis)
ANCA attacks small and medium vessels | Visible haematuria, lung and URT
72
What is tubulointerstitial nephritis?
Nephritic presentation usually triggered by a drug reaction or chronic pyelonephritis
73
Which drugs are associated with tubulointerstitial nephritis?
``` NSAIDs Lithium Penecillin PPI Lead ``` (Not ACE, they do reversible AKI)
74
What are the symptoms of CKD?
``` Fluid overload Hypertension Bleeding Uraemia Tertiary hyperparathyroid Anaemia Hyperkalaemia Acidosis ```
75
What are patients with CKD at high risk of?
IHD and stroke
76
Why do patients with CKD get anaemia?
Anaemia of chronic disease | Reduced EPO production
77
Why do patients with CKD get fluid overload?
Kidneys no longer managing the homeostasis of Na
78
Why do patients with CKD get hyperparathyroid?
Tertiary Because the kidney can't get rid of phosphate, this increases Therefore Ca is mopped up too much Low Ca, precipitates high PTH Also secondary Where the kidney stops activating vit D Therefore less Ca absorption
79
Which drugs can make symptoms of CKD worse?
Steroids (uraemia) | K sparing diuretics (increase hyperkalaemia)
80
Which drugs can worsen egfr in CKD and AKI?
ACE NSAIDs CT contrast Ciclosporin
81
Which drugs require a higher dose in CKD?
Furosemide
82
Which drugs require a lower dose in CKD/are toxic to the kidney?
``` Digoxin Lithium Morphine Penicillin Gentamicin Vancomycin Erythromicin ```
83
How does the kidney normally compensate for hypoperfusion?
RAAS activation Angiotensin constricts the efferent Juxtaglomerular apparatus detect low sodium in the distal tubule Prostaglandins relax the afferent
84
What are the causes of prerenal AKI?
``` Hypovolaemia Sepsis Decreased oncotic pressure - cirrhosis HF Renal artery stenosis NSAIDs ACE ```
85
What is the name given to the condition when pre renal AKI becomes refractive to fluids?
Acute tubular necrosis
86
What are the causes of acute tubular necrosis?
Pre renal AKI (refractive to fluid) Nephrotoxins Endotoxins - E coli
87
What are the main nephrotoxins?
``` Myoglobin (rhabdomyelisis) Bilirubin (heptaorenal syndrome) Urate (gout) ACE NSAIDs Gentamicin ```
88
What are the causes of post renal AKI?
Within the lumen: 2 stones 2 clots 2 tumours In wall: TB strictures ``` Outside: BPH Prostate Ca Blocked catheter AAA Other tumour - cervical, uterine, renal ```
89
How would you differentiate between pre renal, post renal and intrinsic AKI?
Pre - low bp, sepsis, responds to fluid, fbc for infection Intrinsic - nephrotoxic drugs? blood and protein in dip, red cell casts on microscopy Post - ultrasound for hydronephrosis, palpable bladder, complete anuria
90
Describe the workup for AKI
Careful fluids Monitor input and output U and E - extent Fbc - sepsis? LFT - Hepatorenal? Urine dip - sepsis and intrinsic? Urine microscopy - sepsis and intrinsic? Ultrasound - obstruction? Biopsy if considering intrinsic
91
How do you manage hyperkalaemia?
Ca gluconate and ECG for the heart | Insulin and dextrose plus salbutamol neb to put insulin back into cells
92
Describe the stages of CKD?
eGFR 1 . >90 ml/min, with some sign of kidney damage on dipstick or USS 2 60-90 ml/min, with some sign of kidney damage on dipstick or USS 3a 45-59 ml/min, 3b 30-44 ml/min, 4 15-29 ml/min, 5 Less than 15 ml/min - dialysis or a kidney transplant may be needed
93
Spironolactone
cv fgn
94
Furosemide
dgnegdne
95
What is Henoch-Schonlein purpura? How does it present?
IgA mediated small vessel vasculitis Palpable, erythematous rash on the extensor surfaces of the arms and legs associated with abdominal pain. Haematuria and mild renal failure
96
How does polycystic kidney disease present?
Hypertension and subarachnoid haemorrhage Recurrent UTIs and episodic haematuria Nephritic
97
Describe the genetic profile of polycytic kidney diease.
Autosomal dominant
98
What feature of nephrotic syndrome makes it prone to VTE?
Loss of antithrombin-III, proteins C and S
99
What are the main causes of intrinsic AKI?
``` Acute tubular necrosis Acute on chronic glomerulonephritis Nephrotoxins Tumour lysis syndrome Rhabdomyolysis ```
100
What are the stages of AKI?
Stage 1, 2 and 3 1.5-2 x baseline creatinine 2-3 3+
101
Why are egfr and creatinine poor markers of kidney function? What is a better measure?
If they are not in a steady state the markers will be 1 step behind the actual function as they take time to build up. Albumin: Creatinine is better
102
What is the most common cause of nephrotic syndrome in young people?
Minimal change
103
How do you minimise the risk of CT contrast in a patient with CKD?
Give saline pre and post procedure
104
How can you differentiate between acute tubular necrosis and prerenal AKI?
Prerenal can lead to ATN but.. 1. It responds to fluid challenge 2. It has low URINE Na because the kidneys are still trying to hold on to it to maintain volume In ATN they can't do this so high urine Na (both have low serum Na)
105
What are the symptoms of hypernatraemia?
``` Irritability restlessness muscle twitching spasticity hyperreflexia ```
106
What is the main risk in hypernatraemia?
Seizures
107
What is the main risk in hyponatraemia?
Seizures
108
How do you treat hyponatraemia?
Hypovolaemic - Slowly give saline Euvolaemic - Treat underlying cause Hypervolaemic - loop diuresis and fluid restriction
109
Why do you have to treat hyponatraemia slowly?
Risk of pontine demyelination if you increase sodium too quickly
110
What are the causes of hypovolaemic hyponatraemia?
Na loss Diarrhoea Vomiting Diuretics ACE Nephropathies
111
What are the causes of hypervolaemic hyponatraemia?
Dilution Heart failure Cirrhosis Nephrotic syndrome CKD
112
In hypovolaemic hyponatraemia, how do you know whether there is an intrinsic renal loss of Na or an extra renal loss?
Urinary Na ``` If high (>20) Intrinsic If low (<20) extrarenal ```
113
What are the causes of euvolaemic hyponatraemia?
SIADH Hypothyroid Addissons SSRIs
114
What are the causes of hypernatraemia?
Cushings Conn's HONC/DKA Diabetes insipidus

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