Medical Abdomen Flashcards
Causes of splenomegaly
Infections Haemolysis Portal hypertension Malignancy Felty's syndrome Infective endocarditis
Signs of decompensated liver disease
Jaundice Encephalopathy: asterixis, confusion Foetor hepaticus: ammonia and ketones Hypoalbuminaemia: oedema and ascites Coagulopathy: bruising
Causes of CLD
Common
EtOH
Viral
NASH
Rare
Genetic: HH
AI: AH
Drugs: methotrexate
Drug for pruritus
Cholestyramine
Mx of Hepatitis C
interferon-α + ribavarin
Mx of encephalopathy
Nurse in well lit, calm environment
Correct any precipitants
Avoid sedatives
Give Lactulose + rifaximin
How to treat hepatorenal syndrome?
IV albumin + terlipressin
Mx ascites?
Conservative: fluid and salt restrict, daily weight
Medical: Spironolactone/ Furosemide
Surgical: Ascitic Tap, TIPS
Complications of chronic liver disease
- Liver failure/decompensation
- SBP
- Portal HTN: SAVE
- HCC
How is Cirrhosis graded?
Child Pugh Score
Graded A-C using severity of 5 factors (ABCDE)
Albumin Bilirubin Clotting Distension: ascites Encephalopathy
Precipitants of Encephalopathy
DIGS
Diuretics
Infection
GI bleed
Sepsis/ stroke
How would you manage decompensated liver disease?
General Mx HDU or ITU Rx any precipitant Good nutrition: e.g. via NGT with high carbs Thiamine supplements Prophylactic PPIs vs. stress ulcers
Monitoring
Fluids: urinary and central venous catheters
Bloods: daily FBC, U+E, LFT, INR
Glucose: 1-4hrly + 10% dextrose IV 1L/12h
Mx Complications
Ascites: daily wt, fluid and Na restrict, diuretics, tap
Coagulopathy: Vit K, FFP, platelets
Encephalopathy: avoid sedatives, lactulose, rifaximin
Sepsis / SBP: tazocin or cefotaxime
Hypoglycaemia: dextrose
Hepatorenal syndrome: IV albumin + terlipressin
Pathophysiology of encephalopathy
↓ hepatic metabolic function
Diversion of toxins from liver directly into systemic
system.
Ammonia accumulates and passes to brain where
astrocytes clear it causing glutamate → glutamine
↑ glutamine → osmotic imbalance → cerebral oedema.
Presentation of encephalopathy
Asterixis, Ataxia Confusion Constructional apraxia Dysarthria Seizures
What is Hepatorenal syndrome?
Cirrhosis → splanchnic arterial vasodilatation → effective circulatory volume → RAS activation → renal arterial vasoconstriction.
Persistent underfilling of renal circulation → failure
What makes up the portal triad?
Hepatic artery
Portal vein
Bile duct
Mx of SBP
Tazocin or cefotaxime until sensitivities known
Causes of ascites
Cirrhosis CCF Carcinomatosis Budd Chiari TB Pancreatitis
SAAG interpretation
Serum Ascites Albumin Gradient
SAAG = Se albumin – Ascites Albumin
SAAG ≥1.1g/dL = Portal HTN (97% accuracy)
Cirrhosis in 80%
SAAG <1.1g/dL Neoplasia: e.g. peritoneal mets or ovarian Ca Inflammation: pancreatitis Nephrotic syndrome Infection: TB peritonitis
Causes of portal HT
Pre-hepatic: Portal vein thrombosis PV, ET PNH Nephrotic syndrome
Hepatic:
Cirrhosis
Post-hepatic
Cardiac: RHF, TR, constrictive pericarditis
Budd-Chiari (hepatic vein thrombosis)
Symptoms of SBP
Fever, abdo pain and ascites
Management of refractory ascites
TIPSS
Transplant
Causes of Jaundice
Pre-hepatic (haemolysis - unconjugated)
- AIHA
- HS
- SCD
Hepatic (conjugated/ unconjugated)
- CLD
- Hepatitis
- Drugs
Post Hepatic (conjugated)
- Gallstones
- Ca Head Panc
- LN enlargement
Mercedes Benz scar ddx
Liver transplant
Segmental resection
Whipples’: pancreaticoduodenectomy
Causes of Hepatomegaly
Malignancy Cirrhosis (ALD, NASH, PBC) Congestion Infections (Viral, Toxo, Abscess) Infiltration (amyloid, sarcoid) Vasc (Budd-chiari, Sickle Cell)
Imaging you would consider for hepatomegaly
Abdo US
PV + Hepatic duplex
CT
MRI (enhanced with gadolinium)
How do you treat HH?
Venesection + desferrioxamine
How do you treat Wilson’s?
Penicillamine
How can you tell you are palpating the spleen?
Can’t get above it Moves inferiorly toward RIF on respiration Notch Dull PN Not ballotable
Function of the spleen
Phagocytosis of old RBCs, WBCs Phagocytosis of opsonised bugs: esp. encapsulates Antibody production Sequestration of formed blood elements Platelets, lymphocytes and monocytes Haematopoiesis
Causes of hyposplenism
Splenectomy
Coeliac disease
IBD
SCD
Indications of a splenectomy
Trauma - uncontrollable splenic bleeding, hilar vascular injuries, devascularised spleen Rupture: e.g. secondary to EBV AIHA ITP HS Hypersplenism
Complications of splenectomy
Redistributive thrombocytosis → early VTE
Temporary post-op aspirin prophylaxis
Gastric dilatation: transient ileus
May disturb gastro-omental vessel ligatures
Prophylactic NGT post-op
Left lower lobe atelectasis
Pancreatitis: tail shares blood supply ̄c spleen
↑ susceptibility to infections
Encapsulates: haemophilus, pneumo, meningo
Causes of enlarged kidneys
Bilateral ADPKD Diabetes HIV Bilateral RCC (5%) Bilateral cysts: e.g. in VHL Amyloidosis
Unilateral Simple renal cyst RCC Compensatory hypertrophy + contralateral nephrectomy: ADPKD
Mx of ADPKD
General
↑ water intake, ↓ Na, ↓ caffeine (may ↓ cyst formation)
Monitor U+E and BP
Genetic counselling
50% chance of transmission
10% are de novo mutations
MRA screen for berry aneurysms
Medical
Rx HTN aggressively: <130/80 (ACEi best)
Rx infections
Surgical: Nephrectomy
Recurrent bleeds or infections
Abdominal discomfort
Risk factors for RCC
Smoking Obesity HTN Dialysis: 15% of pts. develop RCC 4% heritable: e.g. VHL syndrome
Presentation of RCC
Haematuria
Loin pain
Loin mass
Invasion of L renal vein → varicocele
Mx of RCC
Medical
Reserved for pts. ̄c poor prognosis
Temsirolimus (mTOR inhibitor)
Surgical
Radical nephrectomy
Consider partial if small tumour or 1 kidney
Prognosis: 45% 5ys
Differentials for gum hypertrophy
Drugs: ciclosporin, phenytoin, nifedipine Familial AML Scurvy Pregnancy
Commonest indications for a renal transplant
Diabetic nephropathy
GN
Polycystic Kidney Disease
Hypertensive nephropathy
Contraindications for a renal transplant
Active infection
Cancer
Severe co-morbidity
Failed pre-implantation x-match
Symptoms of renal transplant rejection
Hyperacute rejection: minutes
Path: ABO incompatibility
Presentation: thrombosis and SIRS
Acute Rejection: <6mo Path: Cell-mediated response Presentation Fever and graft pain ↓ urine output ↑ Cr Rx: Responsive to immunosuppression
Chronic Rejection: >6mo
Presentation: Gradual ↑ in Cr and proteinuria
Path: Interstitial fibrosis + tubular atrophy
Rx: supportive, not responsive to immunosuppression
Complications of dialysis
Cardiovascular disease Malnutrition Infection Amyloidosis β2-microglobulin accumulation Renal cysts → RCC
Complications of AV access
Bleeding Aneurysm Thrombosis and stenosis Infection Steal syndrome
General complications of dialysis
Malnutrition Infection Cardiovascular disease Amyloidosis Renal cysts → RCC
Complications of haemodialysis
Disequilibration syndrome (leads to cerebral oedema)
Fluid balance: BP↓, pulmonary oedema
Electrolyte imbalance
Aluminium toxicity (in dialysate) → dementia
Psychological factors
Methods of renal replacement therapy
Haemodialysis
Peritoneal dialysis
Renal transplant
Haemofiltration
Catheter used with peritoneal dialysis
Tenchkhoff catheter
Types of AV fistula
Radio-cephalic @ wrist = Cimino-Brescia
Brachio-cephalic @ the elbow
Complications of a tunnelled cuffed catheter
Adverse events @ insertion: e.g. pneumothorax Line or tunnel infection
Blockage
Retraction
The commonest cause of CKD
HT
DM
RAS
GN
Complications of CKD
CRF HEALS
Cardiovascular disease
Renal osteodystrophy
Fluid (oedema)
HTN Electrolyte disturbances: K, H Anaemia Leg restlessness Sensory neuropathy
Signs of IBD
General Often young female pt. Laparotomy scars Malnutrition or wt. loss Cushingoid Pallor
Hands
Clubbing
Leukonychia
Beau’s lines
Eyes
Pale conjunctivae
Iritis, episcleritis
Mouth
Aphthous ulcers
Gingival hypertrophy (cyclosporin)
Legs
Erythema nodosum
Pyoderma gangrenosum
Acute Severe Exacerbation or IBD Criteria
True-Love and Witts Criteria
Symptoms
BMs>6x/d
Large PR bleed
Systemic Signs
↑HR>90
Pyrexia >37.8
Laboratory Values
↓ Hb <10.5g/dL
ESR >30mm/Hr
Drugs for UC induction
Oral
1: 5-ASAs
2: prednisolone
3: ciclosporin / infliximab
Topical: Enemas / foams
- 5-ASA
- Pred
Drugs for CD induction
Oral
1: Ileocaecal: budesonide
1: Colitis: sulfasalazine
2: prednisolone (tapering)
3: methotrexate
4: infliximab / adalimumab
Drugs for UC maintenance
1: 5-ASA
2: azathioprine
3: infliximab / adalimumab
Drugs for Crohn’s maintenance
1: azathioprine/mercaptopurine
2: methotrexate
3: infliximab / adalimumab