March Flashcards
Rheumatic fever develops due to infection of…
Streptococcus pyogenes (recent 2-6 weeks)
Immune response in rheumatic fever
B and T cells produce IgG and IgM antibodies and CD4+ T cells are activated
there is then a cross-reactive immune response (a form of type II hypersensitivity) thought to be mediated by molecular mimicry
What is M protein?
Virulence factor in cell wall of streptococcus pyogenes
Antibodies against M protein cross react with ryosin and smooth muscles of arteries
What gives rise to the clinical features in rheumatic fever?
Antibodies against M protein cross react with myosin and smooth musce of arteries
Name of the granulomatous bodies found in Rheumatic fever
Aschoff bodies
Diagnosis of Rheumatic fever
Recent streptococcus infection
2 major criteria or 1 major with 2 minor criteria
Major criteria for diagnossi of rheumatic fever
erythema marginatum
Sydenham’s chorea: this is often a late feature
polyarthritis
carditis and valvulitis (eg, pancarditis)
The latest iteration of the Jones criteria (published in 2015) state that rheumatic carditis cannot be based on pericarditis or myocarditis alone and that there must be evidence of endocarditis (the clinical correlate of which is valvulitis which manifests as a regurgitant murmur)
subcutaneous nodules
Minore criteria for diagnosis of Rheumatic fever
raised ESR or CRP
pyrexia
arthralgia (not if arthritis a major criteria)
prolonged PR interval
Evidence of recent streptococcus infection
Antibodies raised
Positive throat swab
Positive rapid group A streptococcal antigen test
Management of rheumatic fever
antibiotics: oral penicillin V
anti-inflammatories: NSAIDs are first-line
treatment of any complications that develop e.g. heart failure
Patau syndrome is caused by which genetic abnormality
Trisomy 13
Which cardiac abnormality is most associated with Trisomy 13?
Ventricular septal defect
Which murmur may be heard with a ventricular septal defect?
Pansystolic murmur
AVSD is mostly associated with which syndrome?
Down’s Trisomy 21
Which condition is associated with coarctation of the aorta?
Marfans
What is Ebstein’s anomaly?
occurs when the tricuspid valve is displaced towards the apex of the right ventricle. It is a rare congenital heart disease and associated with added heart sounds on auscultation
Risk factor for Ebstein’s anomaly?
Maternal lithium used during pregnancy
Post natal presentations of VSD?
failure to thrive features of heart failure hepatomegaly tachypnoea tachycardia pallor
Management of moderate to severe VSD
nutritional support
medication for heart failure e.g. diuretics
surgical closure of the defect
Sign of aortic dissection on chest x-ray
Widened mediastinum
Type A aortic dissection occurs where?
Ascending aorta
Type B aortic dissection occurs where?
Descending aorta
Possible investigations of aortic dissection
Chest X -ray
CT Angiography of chest, abdomen, pelvis
Transoeosophageal echocardiography
Management of type A aortic dissection
Surgery - target systolic BP to 100-120
Management of Type B aortic dissection
Conservative
Bed rest
Reduce pressure with IV labetalol
Complications of aortic dissection
Complications of backward tear
aortic incompetence/regurgitation
MI: inferior pattern is often seen due to right coronary involvement
Complications of a forward tear
unequal arm pulses and BP
stroke
renal failure
What is electrical cardioversion synchronised to?
R wave
Name the subunits of troponin and what they bind to
troponin C: binds to calcium ions
troponin T: binds to tropomyosin, forming a troponin-tropomyosin complex
troponin I: binds to actin to hold the troponin-tropomyosin complex in place
Key suggestive finding of aortic dissection on CT
False lumen
Blurring of the posterior wall of the descending aorta on CT is a sign of ???
retroperitoneal, contained rupture of an aortic aneurysm. This may present with hypovolaemic shock (hypotension, tachycardia, tachypnoea) and collapse.
Classic presentation of rupture aortic aneurysm
Shock
Abdominal pain radiating to the back
Pulsatile mass
How is recurrent DVT in cancer patients who are adequately anticoagulated managed?
‘Consider inferior vena caval filters for patients with recurrent proximal DVT or PE despite adequate anticoagulation treatment only after considering alternative treatments such as:
increasing target INR to 3–4 for long term high-intensity oral anticoagulant therapy or
switching treatment to LMWH.’
Most common cause of sudden cardiac death in the young?
HOCM - Hypertrophic Obstructive Cardiomyopathy
What is Hypertrophic Obstructive Cardiomyopathy?
autosomal dominant disorder of muscle tissue caused by defects in the genes encoding contractile proteins
Pattern of inheritance of HOCM
Autosomal dominant
Genetic defect in HOCM
mutation in the gene encoding β-myosin heavy chain protein or myosin-binding protein C
Describe the cardiac dysfunction seen in HOCM and effect on cardiac output
results in predominantly diastolic dysfunction
left ventricle hypertrophy → decreased compliance → decreased cardiac output
Features of HOCM
often asymptomatic
exertional dyspnoea
angina
syncope
typically following exercise
due to subaortic hypertrophy of the ventricular septum, resulting in functional aortic stenosis
sudden death (most commonly due to ventricular arrhythmias), arrhythmias, heart failure
jerky pulse, large ‘a’ waves, double apex beat
ejection systolic murmur
increases with Valsalva manoeuvre and decreases on squatting
hypertrophic cardiomyopathy may impair mitral valve closure, thus causing regurgitation
When is syncope likely to occur in someone with HOCM?
Following exercise
What type of murumur is present in HOCM?
Ejection systolic murmur
Decreases on squatting
Increases with valsalva manouevre
Name two associations with HOCM
Friedreich’s ataxia
Wolff-Parkinson White
ECHO findings in HOCM
MR SAM ASH
Mitral reurg
Systolic anterior motion of anterior mitral valve leaflet
Assymetric hypertrophy
ECG findings in HOCM
left ventricular hypertrophy
non-specific ST segment and T-wave abnormalities, progressive T wave inversion may be seen
deep Q waves
atrial fibrillation may occasionally be seen
What is murphy’s sign?
Murphy’s sign is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive
LFT results in cholecystitis
raised ALP and liver transaminases. The ALP level result in cholestatic diseases however, is usually raised to a much greater extent than liver transaminases.
Causes of gynaecomastia
Obesity Testicular cancer Cannabis Alcohol Klinefelter syndrome
Why does gynaecomastia occur in testicular cancer?
Increased oestrogen:androgen ratio
AFP is a tumour marker for which cancers?
Testiuclar
Hepatocellular carcinoma
Mechanism of dipyridamole
non-specific phosphodiesterase inhibitor and decreases cellular uptake of adenosine
elevating platelet cAMP levels which in turn inhibits platelet aggregation and thrombus formation
Inhibits thromboxane synthase
Indication of dipyridamole
an antiplatelet mainly used after an ischaemic stroke, transient ischaemic attack or prosthetic valve replacement
action of a direct oral anticoagulant (DOAC), an example being dabigatran.
Factor Xa antagonist
mechanism of antiplatelet agents such as clopidogrel and ticagrelor.
P2Y12 receptor antagonists
Hyperacute transplant rejection is caused by
pre-existing antibodies against ABO or HLA antigens
Branches of the external carotid
eight branches
3 from its anterior surface ; thyroid, lingual and facial. The pharyngeal artery is a medial branch.
The posterior auricular and occipital are posterior branches.
Why does nephrotic syndrome have increased risk of arterial and venous thrombosis?
loss of antithrombin III via the kidneys
Complications of nephrotic syndrome
increased risk of thromboembolism related to loss of antithrombin III and plasminogen in the urine
deep vein thrombosis, pulmonary embolism
renal vein thrombosis, resulting in a sudden deterioration in renal function
hyperlipidaemia
increasing risk of acute coronary syndrome, stroke etc
chronic kidney disease
increased risk of infection due to urinary immunoglobulin loss
hypocalcaemia (vitamin D and binding protein lost in urine)
Presenting features of Wernicke encephalopathy
ataxia, ophthalmoplegia and/or encephalopathy
Features of Korsakoff’s syndrome
chronic neurological deterioration that is characterised by deficits in anterograde and retrograde memory which leads to confabulation
Wernicke-korsakoff syndrome occurs due to which deficiency seen in which groups of patients
Thiamine deficiency
Alcoholic
Symptoms of alcohol withdrawal
disorientation, confusion, sweating, tremor, agitation, and anxiety.
Wernicke’s encephalopathy untreated leads to which condition?
Korsakoff’s syndrome
What is reaction formation?
transforming an unacceptable feeling or impulse into its extreme opposite. Instigating a physical fight with his boyfriend’s other partner would be an example of reaction formation.
What is sublimation?
Replacing an unacceptable wish with a course of action that is similar to the wish but does not conflict with one’s value system
a mature ego defence mechanism whereby one channels unacceptable thoughts, feelings or impulses into socially acceptable alternatives.
how does gentamicin cause AKI?
Renal cell apoptosis
Which drug used in triple therapy for infective endocarditis can cause AKI?
Gentamicin
Triple therapy - gentamicin, vancomycin, amoxicillin
How does penicillin cause AKI?
Acute interstitial nephritis
Genetic mutations in nephrogenic diabetes
the more common form affects the vasopression (ADH) receptor
the less common form results from a mutation in the gene that encodes the aquaporin 2 channel
The vasopressin receptor mutation in nephrogenic diabetes is which type of mutation
X linked
Mutation in the genes endoign the aquaporin 2 channel seen in nephrogenic diabetes is inherited how?
Autosomal recessive
2 aims of treatment in management of hyperkalaemia
Stabilise cardiac membrane - calcium gluconate
Short-term shift in potassium from extracellular to intracellular fluid compartment - insulin/dextrose infusion, nebulised salbutamol, loop diuretics, calcium resonium, dialysis
What type of drug is nicorandil and mechanism of action?
vasodilatory drug used to treat angina. It is a potassium-channel activator with vasodilation is through activation of guanylyl cyclase which results in increase cGMP.
Adverse effects of nicorandil
Headache
Flushing
skin, mucosal and eye ulceration
gastrointestinal ulcers including anal ulceration
Contraindications of nicorandil
Left ventricular failure
Drugs that must be stopped in AKI
non-steroidal anti-inflammatory drugs
aminoglycoside antibiotics (e.g. gentamicin)
angiotensin-converting enzyme inhibitors (e.g. ramipril), angiotensin II receptor antagonists (e.g. losartan
diuretics.
Terlipressin is used to treat
vasopressin-analogue used in the treatment of haemorrhage from oesophageal varices
Desmopressin is used in treatment of which condition
Central diabetes insipidus
Goserelin is used to treat which condition
Prostate cancer
Indapamide is used to treat which conditions
Thiazide like diuretic - heart failure and hypertension
Carbimazole is used to treat which condition
Hyperthyroidsim
2 forms of diabetes insipidus
decreased secretion of antidiuretic hormone (ADH) from the pituitary (cranial DI)
or an insensitivity to antidiuretic hormone (nephrogenic DI).
Causes of cranial diabetes insipidus
idiopathic post head injury pituitary surgery craniopharyngiomas histiocytosis X DIDMOAD is the association of cranial Diabetes Insipidus, Diabetes Mellitus, Optic Atrophy and Deafness (also known as Wolfram's syndrome) haemochromatosis
Causes of nephrogenic Diabetes Insipidus
genetic: the more common form affects the vasopression (ADH) receptor, the less common form results from a mutation in the gene that encodes the aquaporin 2 channel
electrolytes: hypercalcaemia, hypokalaemia
lithium
lithium desensitizes the kidney’s ability to respond to ADH in the collecting ducts
demeclocycline
tubulo-interstitial disease: obstruction, sickle-cell, pyelonephritis
Features of diabetes insipidus
Polyuria
Polydipsia
Investigation of diabetes insipidus
high plasma osmolality, low urine osmolality
a urine osmolality of >700 mOsm/kg excludes diabetes insipidus
water deprivation test
What type of condition is familial hypercholesterolaemia?
Autosomal dominant
Effect of alcohol on ACE-i
Alcohol compounds the antihypertensive effects of ACE inhibitors
Trend in bloods in refeeding syndrome
A large release of insulin in refeeding syndrome causes a rapid shift of K+, Mg2+ and PO4- into cells, causing hypokalaemia, hypophosphataemia and hypomagnesemia
Mode of inheritance of Alport’s Syndrome
X-linked dominant
What is the genetic defect in Alport’s syndrome?
type IV collagen resulting in an abnormal glomerular-basement membrane (GBM).
When does Alport’s syndrome usually present?
In childhood
Features of Alport’s syndrome
microscopic haematuria
progressive renal failure
bilateral sensorineural deafness
lenticonus: protrusion of the lens surface into the anterior chamber
retinitis pigmentosa
renal biopsy: splitting of lamina densa seen on electron microscopy
How is Alport’s syndrome diagnosed?
Renal biopsy#
Molecular genetic testing
Where in the nephron does the maority of glucose reabsoprtion occur?
Proximal convoluted tubule
What is the mechanism of empagliflozin?
inhibitor of the SGLT-2 receptor and prevents glucose reabsorption in the nephron.
Complications of diabetic nephropathy are due to…
Non-enzymatic glycosylation (NEG) of the vascular membrane occurs in both large and medium vessels leading to atherosclerosis. NEG of small vessels results in hyaline arteriosclerosis, which in the renal efferent arteriole results in sclerosis of the glomerulus leading to nephropathy.
What occurs in the kidneys in rhabdomyolysis following a fall?
damaged muscles release myoglobin which is nephrotoxic and causes renal ischaemia, the pathology of acute tubular necrosis
Treatment for rhabdomyolysis
IV fluids
Histological findings for membranous glomerulonephritis
basement membrane thickening on light microscopy
subepithelial spikes on sliver stain
positive immunohistochemistry for PLA2
Features of hypocalcaemia
perioral paraesthesia, cramps, tetany and convulsions
Vitamin B1 is also known as
Thiamine
How do nitrates induce smooth muscle relaxation?
Nitric oxide activates smooth muscle soluble guanylyl cyclase (GC) to form cGMP. Increased intracellular cGMP inhibits calcium entry into the cell, thereby decreasing intracellular calcium concentrations and causing smooth muscle relaxation (click here for details).
Second line therapy when patient unable to tolerate statin (leg cramps)
The second line therapy for patients who are unable to tolerate the side effects of statins is ezetimibe
Which hormone is insufficient in cranial DI?
Antidiuretic hormone
Kidneys cannot concentrate urine even when hypovolaemic
Symptoms of cranial DI
Polyuria
Pale urine
Chronic thirst
Causes of cranial DI
Head trauma
Localised infection
Post-radiotherapy
What investigation can be used to diagnose cranial DI
Water deprivation test
Result of water deprivation test after fluid deprivation in cranial DI
Low urine osmolality
Result of water deprivation test after desmopressin in cranial DI
High urine osmolality
Affect of thyroid disease on muscles
Myopathy
Sign of myopathy in muscle biopsy
Cells of all different sizes - necrosis and regenration : Checkerboard pattern
Causes of thyrotoxicosis
Graves’ disease
toxic nodular goitre
acute phase of subacute (de Quervain’s) thyroiditis
acute phase of post-partum thyroiditis
acute phase of Hashimoto’s thyroiditis (later results in hypothyroidism)
amiodarone therapy
Investigation of thyrotoxicosis
TSH down, T4 and T3 up
thyroid autoantibodies
other investigations are not routinely done but includes isotope scanning
Features in Grave’s disease but not in other causes of thyrotoxicosis
eye signs (30% of patients) exophthalmos ophthalmoplegia pretibial myxoedema thyroid acropachy, a triad of: digital clubbing soft tissue swelling of the hands and feet periosteal new bone formation
Which hormone acts on satiety centres in hypothalamus to decrease appetite?
Leptin
Where is leptin produced?
Adipose tissue
Obesity results in what level of leptin?
Higher levels - more adipose
Leptin stimulates the release of which hormones
stimulates the release of melanocyte-stimulating hormone (MSH) and corticotrophin-releasing hormone (CRH). Low levels of leptin stimulates the release of neuropeptide Y (NPY)
Where is the hormone ghrelin produced?
P/D1 cells lining the fundus of the stomach and epsilon cells of the pancreas
What effect does ghrelin have on hunger and how do the levels change with meals?
Increases hunger
High before meal
Low after meal
How does stiptagliptin reduce blood glucose levels?
It works by inhibiting an enzyme responsible for breaking down incretin, and so leads to increased incretin levels. Increased incretin levels then work to decrease blood glucose levels.
Which class of diabetic drugs is stiptagliptin?
DPP4 inhibitor
Dapagliflozin is which type of diabetic drug?
SGLT2 inhibitor
How do SGLT2 inhibitors reduce blood glucose?
Reduce reabsoprtion of glucose in the kidneys
How does metformin reduce blood glucose levels?
Increases peripheral uptake of insulin
Most common cause of hypothyroidism
Iodine deficiency
ASK ABOUT DIET
What is Hashimoto’s thyroiditis?
autoimmune condition resulting in an inflammation, thus goitre formation, and reduction in thyroid function. The thyroid gland is attacked by a variety of cell and antibody-mediated immune processes such as antibodies to thyroglobulin or thyroid peroxidase resulting in low amounts of T4 and T3 are being produced and released
What is the association with Hashimoto’s thyroiditis?
Other autoimmune conditions eg diabetes, pernicious anaemia
How does secondary hypothyroidism occur?
Pituitary failure
Associations with secondary hypothyroidism
Down’s syndrome
Turner’s syndrome
coeliac disease
What tumour marker is monitored for medullary thyroid cancer recurrence?
Calcitonin
What other electrolyte imbalance can make hypocalcaemia resistant to treatment?
Hypomagnesemia
What is metabolic syndrome?
A clustering of cardiovascular risk factors
Diagnostic criteria for metabolic syndrome
- Increased waist circumference (dependent on ethnicity) or a BMI >30
- Dyslipidaemia with raised triglycerides >150 mg/dL or reduced HDL-cholesterol
- Hypertension
- Impaired glucose tolerance
Features of hyperparathyroidism
Features - ‘bones, stones, abdominal groans and psychic moans’
polydipsia, polyuria
peptic ulceration/constipation/pancreatitis
bone pain/fracture
renal stones
depression
hypertension
Causes of primary hyperparathyroidism
80%: solitary adenoma
15%: hyperplasia
4%: multiple adenoma
1%: carcinoma
Associations with primary hyperparathyroidism
Hypertension
MEN I and II
Investigations for primary hyperparathyroidism
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal
technetium-MIBI subtraction scan
pepperpot skull is a characteristic X-ray finding of hyperparathyroidism
Treatment of primary hyperparathyroidism
the definitive management is total parathyroidectomy
conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
calcimimetic agents such as cinacalcet are sometimes used in patients who are unsuitable for surgery
Features of Addison’s disease
lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’
hyperpigmentation (especially palmar creases)*, vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen
crisis: collapse, shock, pyrexia
What is not produced in Addison’s?
Aldosterone, cortisol
What is the function of aldosterone?
Sodium reabsorption
Potassium excretion
How do sulphonylureas lower blood sugar?
mimicking the role of ATP on potassium-ATP channels block these channels causing membrane depolarisation and thus opening of voltage-gated calcium channels.
stimulation of insulin release.
Main side effect of sulfonylureas
Hypoglycaemia
Major complication of sulfonylureas
Neuroglycopenia
Signs of neuroglycopenia and how is it treated?
Confusion, coma
Oral glucose
Intramuscular glucagon
IV glucose
What antibodies are developed in grave’s disease
IgG to TSH receptors on thyroid gland
Why is liver disease associated with gynaecomastia?
Impaired oestrogen metabolism
Which cells secrete growth hormone?
Somatotroph cells in anterior pituitary
Features of excess growth hormone
thickened skin, enlarged hands and feet, a prominent jaw, carpal tunnel syndrome, tiredness, muscle weakness and hypertension.
Excess growth hormone can increase the risk of which condition
Type II diabetes
Why does excess growth hormone increase the risk of type 2 diabetes?
Glucose moves from muscle into blood
Pancreas secretes more insulin in response to lower blood glucose
What can increase growth hormone secretion?
GHRH
Fasting
Sleeping
Exercise
What decreases growth hormone secretion?
Glucose
Somatostatin
What results from insufficient growth hormone levels?
Short stature
Where is ADH secreted?
Posterior pituitary
Function of ADH
Water reabsorption - inserts Aquaporin 2 channels in collecting ducts of kidneys
What condition arises from ADH deficiency?
Diabetes insipidus
What increases ADH secretion?
Decrease in blood pressure
Volume dcrease
ECF osmolality increase
Angiotensin II
What decreases ADH secretion?
Volume increase
Temperature decrease
ECF osmolality decrease
How is cranial DI treated?
Desmopressin -ADH analog
Difference in general symptoms of hypothyroidism and thyrotoxicosis?
Weight gain, cold intolerance, lethargy - hypothyroidism
Weight loss, heat intolerance, manic/restlessness - thyrotoxicosis
Which anti-diabetic drugs are weight-neutral?
Gliptins - DPP4 inhibitors
Thiazolidinediones (e.g. pioglitazone) activate the peroxisome proliferator-activated receptor gamma (PPAR gamma). Which condition are they contraindicated in?
Heart failure
Side effect of SGLT2 inhibitors
Promote renal glucose ecretion - glycosuria leading to increased UTIs
Risk factors of high level of steroid use
Hyperglycemia High blood pressure Obesity (above the waste and not limbs) Wasting of skeletal muscles Poor wound healing Mood swings and depression
What is Bartter’s Syndrome?
An inherited cause of severe hypokalemia due to mutation in NaK2CL cotransporter in loop of henle
Features of Bartter’s Syndrome
Presents in childhood - failure to thrive Polyuria, polydipsia Hypokalemia Normotension Weakness
What diuretic response can Bartter’s syndrome be likened to ?
Taking large doses of furosemide - inhibits same cotransporter NKCC2
Cells of anterior pituitary gland
50% somatotrophs. Roughly 15% of the cells are lactotrophs, 15% corticotrophs, 10% gonadotrophs and 5% thyrotrophs. The remaining 5% are supporting cells.
What is Waterhouse Friederichsen syndrome?
Waterhouse-Friderichsen syndrome is adrenal gland failure due to bleeding into the adrenal gland.
What is the most common bacterial cause of Waterhouse Friederichsen syndrome?
Neisseria meningitidis
Clinical feautres of Klinefelter’s syndrome
poor coordination, muscle weakness, reading difficulties, gynaecomastia, secondary sexual characteristic development delay, taller than average, rounded body, and microorchidism.
Karyotype for Klinefelter’s syndrome
47 XXY
Mnemonic for hypercalcaemia - CHIMPANZEES
C alcium supplementation H yperparathyroidism I atrogentic (Drugs: Thiazides) M ilk Alkali syndrome P aget disease of the bone A cromegaly and Addison's Disease N eoplasia Z olinger-Ellison Syndrome (MEN Type I) E xcessive Vitamin D E xcessive Vitamin A S arcoidosis
Increased secretion of insulin
Glucose Amino acid Vagal cholinergic Secretin/Gastrin/CCK Fatty acids Beta adrenergic drugs
What drugs inhibit insulin release?
Beta blockers
Twitching of the facial muscles on tapping is known as which signs and why does it occur?
Chvostek’s sign is seen in hypocalcaemia due to increased irritability of the peripheral nerves
Why does hyperthyroidism cause weight loss?
Thyroid hormones increase basal metabolic rate - by affecting protein synthesis
In growth - increase sensitivity to catecholamines
Explain thyroid hormone effect on catabolism and subsequent lipolysis
Thyroid hormones act on the membrane stimulating the sodium-potassium pump thereby increasing the uptake and catabolism of glucose and amino acids. This results in a calorigenesis while also acting on the mitochondria for ATP formation for the pump. the catabolic effects on fat mean they are lipolytic and thus increase cholesterol breakdown and LDL receptors.
Other metabolic effects of thyroid hormones
- Increased gut motility and intestinal glucose absorption
- Increase hepatic glycogenolysis
- Potentiation of insulin’s effects on liver and muscle for glucose uptake
- Breaking down of insulin to prevent glucose storage
- Potentiation of the glycogenolysis effects of Adrenaline
Cardiac and respiratory effects of thyroid hormones
increasing oxygen consumption, they also act to increase erythropoiesis for more oxygen transport, increase cardiac contractility and maintain the hypoxic and hypercapnic drive in the respiratory centre.
First-line treatment of acromegaly
Trans-sphenoidal surgery
Indication for medication to treat acromegaly
Surgery unsuccessful or pituitary tumour inoperable
Medications used to treat acromegaly
Somatostatin analogue
Pigvesomant - s/c
Dopamine agonists
Which type of drug is octreotide and what is its mechanism?
Somatostatin analogue
Directly inhibits growth hormone release
Features of cardiac tamponade presentation
Can present in shock
muffled heart sounds, elevated JVP, and dyspnoea
Where is prolactin secreted from>
Anterior pituitary
What inhibits prolactin release?
Dopamine
What increases prolactin secretion?
Pregnancy Thyrotropin releasing hormone Oestrogen Breast feeding Sleep Stress DRugs - metaclopramide, antipsychotics
Side effect of carbimazole
Bone marrow suppression - neutropenia, agranulocytosis
Sore throat
Which symptom if arises suggests stopping treatment with carbimazole?
Sore throat
Which condition is treated using carbimazole?
Grave’s disease
consequences of metabolic syndrome - diabetes and hypertension present in patient with chest pain as case example
- Strokes
- Non-insulin dependant diabetes
- Cardiovascular disease
- Cancers - including breast, colon and endometrial
- Polycystic ovarian syndrome
- Obstructive sleep apnea
- Fatty liver
- Gall stones
- Mental health problems
What is the mode of inheritance of Haemochromatosis
Autosomal recessive
What type of disorder is haemochromatosis?
Iron absorption resulting in accumulation
Investigation for haemochromatosis?
Transferrin saturation
Diagnostic test for haemochromatosis
molecular genetic testing for the C282Y and H63D mutations
liver biopsy: Perl’s stain
Iron study profile for haemochromatosis
transferrin saturation > 55% in men or > 50% in women
raised ferritin (e.g. > 500 ug/l) and iron
low TIBC
Management of haemochromatosis
Venesection
desferrioxamine as second line - long-term iron chelation
Example presentation of haemochromatosis
A 45-year-old man has chronic liver disease. He presents with chronic progressive pain in his metacarpophalangeal and proximal interphalangeal joints. He does not complain of joint stiffness but mentions that he cannot get an erection. His sister developed a similar set of problems when she was 55-years-old.
On examination, he has grey skin, hepatomegaly, and swollen joints in his hands.
Main risk factor for developing hepatocellular carcinoma
Cirrhosis
Cirrhosis can occur secondary to?
hepatitis B & C,
alcohol,
haemochromatosis
and primary biliary cirrhosis.
Risk factor for hepatocellular carcinoma
alpha-1 antitrypsin deficiency hereditary tyrosinosis glycogen storage disease aflatoxin drugs: oral contraceptive pill, anabolic steroids porphyria cutanea tarda male sex diabetes mellitus, metabolic syndrome
Signs of hepatocellular carcinoma
Features of cirrhosis jaundice ascites RUQ pain hepatomegaly pruritus splenomegaly Raised AFP
Screening of hepatocellular carcinoma
Ultrasound
AFP
Management of hepatocellular carcinoma
early disease: surgical resection liver transplantation radiofrequency ablation transarterial chemoembolisation sorafenib: a multikinase inhibitor
Why is metaclopramide contraindicated in bowel obstruction?
It is a pro kinetic antiemetic - can cause bowel perforation
Acute treatment of variceal haemorrhage
ABC
Correct clotting - FFP, vitamin K
Vasoactive agents - terlipressin, octreotide
Prophylactic antibiotics - quinolones
Endoscopic variceal band ligation
Sengstaken Blakemore tube if bleeding persists
Transjugular Intrahepatic Portosystemic Shunt (tips)
Prophylaxis of variceal haemorrhage
Propanolol
Endoscopic variceal band ligation
How is Ulcerative Colitis classed by severity?
Mild - less than 4 stools a day, small amount of blood
Moderate - 4 to 6 stools a day, varying blood, no systemic upset
Severe - more than 6 bloody stools a day, systemic upset (pyrexia, tachycardia, anaemia, raised inflammatory markers)
Omeprazole and other PPIs are associated with which side effect?
Hyponatraemia
Features of Budd Chiari Syndrome
abdominal pain: sudden onset, severe
ascites → abdominal distension
tender hepatomegaly
Causes of budd chiari syndrome
Polycythaemia vera
Thrombophilia
Pregnancy
COCP
Invesitgation for Budd Chiari Syndrome (hepatic vein thrombosis)
Ulstrasound doppler
Management of ascites
Sodium and fluid restriction Aldosterone antagonists - spironolactone - can add loop diuretic Drainage if tesne Prophylactic antibiotics TIPS
Acetazolimide is which type of drug and used for treatment of which condition
Carbonic anhydrase inhibitor
Glaucoma
Triad of mesenteric bowel ischaemia
CVD, high lactate and soft but tender abdomen
Predisposing factors to bowel ischaemia
Age
AF
Endocarditis, malignancy - causes of emboli
Cardiovascular risk factors - smoking, diabetes, hypertension
Cocaine
Common features of bowel ischaemia
abdominal pain - in acute mesenteric ischaemia this is often of sudden onset, severe and out-of-keeping with physical exam findings
rectal bleeding
diarrhoea
fever
bloods typically show an elevated white blood cell count associated with a lactic acidosis
Diagnostic investigation of mesenteric bowel ischaemia
CT
Most common organisms of liver abscess
Children - Staph aureus
Adult - E coli
Managmeent of liver abscess
Drainage and antibiotics
Amoxicilllin, metronidazole and ciprofloxacin
Clindamycin if penicillin allergic
