Medical Abdomen Flashcards

Question

SBP management

Answer 1

taxocin or cefuroxime until sensitivities known prophylaxis: high recurrence therefore long term cipro given

Answer 2

**Worsening encephalopathy ↑ age ↓ albumin ↑ INR**

Answer 3

* **Peripheral inspection: Cause** * Signs of **CLD** * **CCF**: ↑ JVP, bibasal creps, peripheral oedema * **Nephrotic**: periorbital oedema * **Budd Chiar**i: abdo pain, hepatomegaly, jaundice * **Abdomen** * Shifting dullness * Portal HTN: splenomegaly * **Completion** * CVS and Resp for CCF * Urine dip: proteinuria in nephrotic syndrome * **Significant Negatives** * CLD * Acute liver failure / decompensation * Cause: ↑ JVP, periorbital oedema

Answer 4

**Commonest** 1. Cirrhosis 2. CCF 3. Carcinomatosis **Serum Ascites Albumin Gradient (**SAAG**)** = Se albumin – Ascites Albumin SAAG **_≥1.1g/dL_** = Portal HTN (97% accuracy) (transudate) * Cirrhosis in 80% SAAG **\<1.1g/dL** (exudate) * Neoplasia: e.g. peritoneal mets or ovarian Ca * Inflammation: pancreatitis * Nephrotic syndrome * Infection: TB peritonitis

Answer 5

Portal pressure **_\>10mmHg_** (norm 5-10): 80% _cirrhosis_ in UK **Pre-hepatic** * Portal vein thrombosis * PV, ET (polycythemia vera (PV), essential thrombocythemia (ET)) * PNH * Nephrotic syndrome **Hepatic** * Cirrhosis **Post**-**hepatic** * Cardiac: RHF, TR, constrictive pericarditis * Budd-Chiari (hepatic vein thrombosis)

Answer 6

* SBP: fever, abdo pain * Cause * Liver disease * Cardiac failure, MI

Answer 7

**Bedside** * Urine: dip ± MC+S * Exclude nephrotic syn. * ? UTI **Bloods** * FBC * U+E * LFTs: esp. albumin * INR * Glucose * Liver screen **Ascitic tap** * Chemistry * Cytology: malignancy, PMN (\>250/mm3 = SBP) * Bacteriology: MC+S, Ziehl-Neelson Stain * SAAG **US + PV duplex** * Liver size and texture * Focal lesions * Ascites * Portal vein flow

Answer 8

**General** * EtOH abstinence * Daily wts: aim for ≤0.5kg/d reduction * Fluid restrict: \<1.5L/d * Low Na diet: 40-100mmol/d **Diuretics** * Spironolactone * Add frusemide if response poor **Therapeutic Paracentesis** * Temporary insertion of pig-tail drain or Bonnano catheter * Indications * Respiratory compromise * Pain / discomfort * Renal impairment * Risks * Severe hypovolaemia: replenish albumin * SBP

Answer 9

TIPSS Transplant

Answer 10

* *Rx**: *Tazocin* or *cefotaxime* until sensitivities known * *Prophylaxis**: high recurrence -\> *cipro* long-term

Answer 11

**Cause** * CLD * Pancreatic Ca: cachexia, Virchow’s node * Haemolysis: pallor **Abdomen** * Excoriations and pruritus * Splenomegaly * Hepatomegaly * Palpable gallbladder: Ca head of pancreas **Completion** * Urine dip: look for BR, urobilinogen and Hb **Significant Negatives** * Acute liver failure / decompensation * CLD * Organomegaly

Answer 12

* **CLD**: EtOH, viral, NAFLD * **Splenomegaly** * Haemolysis * CLD ( → portal HTN) * Viral hepatitis: e.g. EBV * **Hepatomegaly** * Hepatitis * CLD * **No CLD or organomegaly** * Biliary obstruction * Haemolysis * Drugs: fluclox, OCP * Gilberts

Answer 13

**Peripheral Inspection** * **General** * Evidence of CLD * Pigmentation: HH * Tattoos and needle marks: Hep B/C * **Immunosuppressant Stigmata** * Cushingoid * Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM * Gingival hypertrophy: ciclosporin **Abdomen** * Mercedes-Benz scar **Significant Negatives** * Evidence of CLD or cause for Tx * Evidence of immunosuppression * Absence of features of liver failure = working Tx **Differential for Mercedes Benz Scar** * _Hepatobiliary_ surgery * Liver _transplant_ * _Segmental resection_ * _Whipples’: pancreaticoduodenectomy_

Answer 14

* **Cause** * EtOH * Sexual Hx, IVDU, transfusions * FH * Other AI disease: e.g. DM, thyroid * DH * **Transplant** * adaveric or live segmental * Any complications * **Current health** * Acute rejection: fever, graft pain * Immunosuppression * Infection: e.g. CMV pneumonitis * Skin Ca * DH

Answer 15

**Bloods** * FBC: infection * U+E: ciclosporin can → renal impairment * LFTs: assess graft function * Clotting * Fasting glucose: tacrolimus and steroids → DM * Drug levels: ciclosporin, tacrolimus **Other** * Liver biopsy: if rejection suspected

Answer 16

* Cirrhosis * Acute liver failure * Hep A, B * Paracetamol overdose * Malignancy

Answer 17

80% 1 year survival 70% 5 year survival

Answer 18

Tacrolimus/ciclosporin azathioprine prednisolone (+/- withrawal @3mo)

Answer 19

* *Peripheral Inspection** * Cause* * CLD * EtOH: palmar erythema, Dupuytren’s * HH: skin discolouration * Ca: cachexia * CCF: ↑ JVP, bibasal creps, ascites, peripheral oedema * Haematological: pallor, bruising, purpura, LNs **Abdomen** * Hepatomegaly * Define fingerbreadths below costal margin at which liver edge palpable. * Moves inferiorly on inspiration * Can’t get above it * Dull PN * Features to note * Edge: smooth, craggy, nodular * Tenderness * Pulsatile * Percuss above and below to confirm enlargement * Auscultate for liver bruit * HCC * Other * Splenomegaly * Inguinal nodes * Ascites **Completion** * CVS and Resp: CCF **Significant Negatives** * Splenomegaly * Acute liver failure / decompensation * Cause: CLD, ↑JVP, pallor, bruising, LNs

Answer 20

**Common Causes** * ***Hepatitis***: EtOH, viral, NAFLD * ***CLD*** * ***Congestion*** 2O to cardiac failure **Other Causes: MACHO** * ***Malignancy***: 2O * ***Anatomical***: Riedel’s lobe, hyperexpanded chest * ***Congestion***: TR, Budd Chiari * ***Haem***: leukaemia, lymphoma, myeloproliferative, SCD * ***Other***: sarcoidosis, amyloidosis, Gaucher’s, ADPKD

Answer 21

* **Hepatitis** / **CLD**: EtOH, viral exposure, FH * **Cardiac**: dyspnoea, PND, previous MI, rheumatic fever * **Haem**: tiredness, bruising, infections, bone pain

Answer 22

**Urine dip** * BR, urobilinogen * Proteinuria: amyloid **Bloods** * FBC * ↓Hb: malignancy, chronic disease * Lymphocytosis: hepatitis viruses, EBV (atypical) * U+E: CCF → renal impairment * LFT * Clotting * Liver screen **Imaging** * Abdo US + PV and hepatic duplex * Liver size and texture * Focal lesions * Ascites * Portal vein flow * Hepatic veins: thrombosis * CT: e.g. for tumour * MRI: good quality images of liver parenchyma **Liver Biopsy** * Check clotting first * Nodular Pattern * ***Micr***onodular: EtOH, HH, Wilson’s * ***Mac***ronodular: viral * Iron: Pearl’s stain * Copper: Rhodamine stain * α1ATD: PAS stain (α1AT globules accumulate in liver) * Amyloid: apple-green birefringence c¯ Congo Red * Granulomata: PBC

Answer 23

* **EtOH**: abstinence + support * **Viral**: supportive or anti-viral therapy * **HH**: venesection ± desferrioxamine * **Wilson’s**: penicillamine * **CCF**: ACEi, β-B and diuretics * **Haematological**: monitoring or chemo

Answer 24

**Peripheral Inspection: Cause** * Haematological: pallor, bruising, purpura, LNs, cachexia * Cervical, axilla, inguinal * Portal HTN: CLD signs * IE: splinter’s, clubbing * Felty’s Syndrome: rheumatoid hands * *Abdomen** * Inspection*:Asymmetry * Palpation* * Splenomegaly * Can’t get above it * Moves inferiorly toward RIF on respiration * Notch * Dull PN * Not ballotable * Size: big or small? * Hepatomegaly? * Inguinal nodes? **Completion** * Cardio and Resp exam: IE and sarcoid * Urine dip: haematuria (IE), proteinuria (amyloid) **Significant Negatives** * Hepatomegaly * Haem: pallor, bruising, LNs * CLD * IE: splinters, clubbing * RA hands: Felty’s Syndrome

Answer 25

* **Myeloproliferative**: CML, MF * **Lymphoproliferative**: CLL, lymphoma * **Infiltrative**: amyloidosis, Gaucher’s * **Developing world**: malaria, visceral leishmaniasis

Answer 26

**Common** * Haem: myelo- / lympho-prolif disorders, haemolysis * Portal HTN: mostly 2O to cirrhosis * Infection: EBV **Other** * Infection: herpes viruses, hepatitis virus, IE, malaria * Inflammation: RA, SLE, Sjogren’s * Rare: sarcoidosis, amyloidosis, Gaucher’s, CVID

Answer 27

same differentials as isolated splenomegaly (except inflammatory)

Answer 28

Causes of Massive Splenomegaly: \>20cm * C**M**L * **M**yelofibrosis * **M**alaria * Leish**M**aniasis * Gaucher’s (AR, glucocerebrosidase deficiency)

Answer 29

* Haem: tiredness, bruising, infections, bone pain * CLD: EtOH, viral exposure, FH * Infections: fever, sore throat, jaundice, foreign travel * Inflammation: arthritis

Answer 30

* **FBC** * CML: ↑↑↑WBC – PMN, basophils, myelocytes * MF: pancytopenia * CLL: lymphocytosis * Haemolysis: ↓ Hb, ↑MCV, ↑RDW * **Film** * MF: leukoerythroblastic c¯ teardrop poikiolcytes * CLL: smear cells * Haemolysis: spherocytes, reticulocytosis * **Other Bloods** * DAT * U+E and urate: ↑ malignancy → uropathy * **Imaging** * Abdo US * CT chest and abdomen * PET scan * **Histology / Cytology** * LN biopsy * BM aspirate or trephine biopsy (MF) * **Genetic Analysis** * CML: Ph Chr, t(9:22) * MF: Jak2+ in 50%

Answer 31

* **Urine Dip** * Haematuria: IE * **Bloods** * FBC: lymphocytosis (may be atypical in EBV) * U+E: renal impairment in IE * Thick and thin films * **Imaging** * Abdo US * Echo: IE

Answer 32

* **Bloods** * FBC * LFT * Clotting * Liver screen * **Imaging** * Abdo US + PV duplex

Answer 33

**CML** *Clonal proliferation of myeloid cells 15% of leukaemia* **Symptoms** * **Hypermetabolism**: wt. loss, fever, night sweats, lethargy * Massive **HSM** → abdo discomfort * Bruising / bleeding (platelet dysfunction) * Gout * Hyperviscosity ***Philadelphia Chromosome*** * *Reciprocal translocation: t(9;22)* * *Formation of BCR-ABL fusion gene* * *Constitutive tyrosine kinase activity* * *Present in \>80% of CML* * *Discovered by Nowell and Hungerford in 1960*

Answer 34

* ↑↑WBC * PMN and basophils * Myelocytes * ± ↓Hb and ↓plat (accelerated or blast phase) * ↑urate * BM cytogenetic analysis: Ph+ve

Answer 35

* **Imatinib**: tyrosine kinase inhibitor * → \>90% haematological response * 80% 5ys * Allogeneic **SCT** * Indicated if blast crisis or TK-refractory

Answer 36

*Clonal proliferation of megakaryocytes → ↑ PDGF →Myelofibrosis Extramedullary haematopoiesis: _liver and spleen_* **Symptoms** * Elderly * Massive **HSM** * Hypermetabolism: wt. loss, fever, night sweats * BM failure: anaemia, infections, bleeding

Answer 37

* Film: leukoerythroblastic c¯ _teardrop_ poikilocytes * Cytopenias * BM: _dry_ tap (need trephine biopsy) * 50% _JAK2_+ve

Answer 38

* Supportive: blood products * Splenectomy * Allogeneic BMT may be curative in younger pts.

Answer 39

5 yr median survival

Answer 40

*Intraperitoneal structure lying in the LUQ Measures 1x3x5 inches Weighs ~7oz Lies anterior to ribs 9-11*

Answer 41

**Function**: part of the mononuclear phagocytic system * Phagocytosis of old RBCs, WBCs * Phagocytosis of opsonised bugs: esp. encapsulates * Antibody production * Sequestration of formed blood elements * Platelets, lymphocytes and monocytes * Haematopoiesis

Answer 42

* Pancytopenia due to pooling and destruction w/i an enlarged spleen. * Anaemia, bruising, infections * Sequestration crisis in SCD → hypovolaemic shock

Answer 43

1. splenectomy 2. coeliac disease 3. IBD 4. SCD

Answer 44

1. ↑ platelets transiently after splenectomy 2. Howell-Jolly bodies 3. Pappenheimer bodies 4. Target cells

Answer 45

1. Immunisations: * Pneumovax * HiB * Men C * Yrly flu 2. Daily Abx: Pen V or erythromycin 3. Warning: Alert Card and/or Bracelet

Answer 46

* Trauma * Rupture: e.g. 2ndary to EBV * AIHA * ITP * HS * Hypersplenism

Answer 47

* 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

Answer 48

**Peripheral Inspection** * Renal Impairment * HTN * Pallor * Renal Replacement Therapy * AV fistula (or scar) * Tunnelled dialysis lines (or scar) * Tenchkhoff catheter (or scar) * Immunosuppressant Stigmata * Cushingoid * Skin tumours: AKs, SCC, BCC and MM * Gingival hypertrophy: ciclosporin **Abdomen** * Inspection * Nephrectomy scar * Rutherford Morrison scar * Tenchkhoff catheter (or scar) * Palpation * Palpable Kidney * Flank mass * Can get above it * Ballotable * Moves inferiorly c¯ respiration * Resonant PN * Hepatomegaly * Renal Transplant * Auscultation * Renal bruit **Completion** * External genitalia: hydrocele 2O to RCC * Urine dip: proteinuria, haematuria * CVS: mitral valve prolapse **Significant Negatives** * Unilateral enlargement * Hepatomegaly * Evidence of RRT or immunosuppression

Answer 49

**Bilateral** * ADPKD * Bilateral RCC (5%) * Bilateral cysts: e.g. in VHL * Amyloidosis **Unilateral** * Simple renal cyst * RCC * Compensatory hypertrophy * + contralateral nephrectomy: ADPKD

Answer 50

* **ADPKD**: FH, loin pain, haematuria, headaches * **RCC**: haematuria, loin pain * **Compensatory hypertrophy**: previous infections, stones

Answer 51

**Urine** * Dip: haematuria, proteinuria * Cytology **Bloods** * FBC: ↓Hb 2ndary to ESRF * U+E: ↓eGFR, electrolyte disturbance * Bone profile: ↓Ca, ↑ PO4, ↑PTH **Imaging** * Abdo US * Confirm renal enlargement * Cysts * Hydronephrosis * Masses * Liver enlargement * CT/MRI * MRA: Berry aneurysms * CT abdo: esp. if RCC suspected **Other** * Genetic studies to look for mutation in * PKD1 gene on Chr 16: 85% * PKD2 gene on Chr 4: 15% * Family screen

Answer 52

**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

Answer 53

*ESRF in **70**% by **70yrs** Mx complications: CRF HEALS _Dialysis_ or _transplant_*

Answer 54

* Prev: 1:1000 * 5% of ESRF in UK * Genetics * PKD1 gene on Chr 16: 85% * PKD2 gene on Chr 4: 15% * Involve cell-cell interactions

Answer 55

* Age: 30-50s * HTN * Recurrent UTIs * Loin pain: cyst haemorrhage or infection * Haematuria

Answer 56

* Hepatic cysts → hepatomegaly * Intracranial Berry aneurysms → SAH * MV Prolapse: mid-systolic click + late systolic murmur

Answer 57

* *Prev**: 1:40000 * *Genetics**: PKHD1 (fibrocystin) gene on Chr6

Answer 58

* Perinatal * Oligohydramnios: may → Potter sequence * Clubbed feet, pulm. hypoplasia, cranial abnormalities * Bilateral abdominal masses * HTN and CRF Extra-renal involvement: comgenital hepatic fibrosis-\> portal HTN

Answer 59

ESRF by **20yrs!** NEED transplant

Answer 60

* Common: 1/3 of pts over 60yrs * May present as renal mass and haematuria * Contain fluid only: no solid elements * Main differential is RCC

Answer 61

* Seen after prolonged dialysis * 2O to obstruction of renal tubules by oxalate crystals * ↑ risk of RCC in cyst: 15% of pts on haemodialysis

Answer 62

AD condition c¯ **_hamartomas_** in skin, brain, eye, kidney * *Skin**: nasolabial adenoma sebaceum, ash-leaf macules, peri-ungual fibromas * *Neuro**: ↓IQ, epilepsy, astrocytoma * *Renal**: cysts, angiomyolipomas

Answer 63

* *90**% of renal cancers * *Age**: 55yrs * *Sex**: M\>F=2:1

Answer 64

* Smoking * Obesity * HTN * Dialysis: 15% of pts. develop RCC * 4% heritable: e.g. VHL syndrome

Answer 65

``` *Adenocarcinoma from proximal renal tubular epithelium Clear Cell (glycogen) subtype: 70-80%* ```

Answer 66

50% incidental finding **Triad**: Haematuria, loin pain, loin mass Invasion of L renal vein → varicocele (1%) Cannonball mets → SOB

Answer 67

**EPO** → polycythaemia **PTHrP** → ↑ Ca **Renin** → HTN **ACTH** → Cushing’s syn. **Amyloidosis**

Answer 68

* Direct: renal vein * Lymph * Haematogenous: bone, liver and lung

Answer 69

* **Blood**: polycythaemia, ESR, U+E, ALP, Ca * **Urine**: dip, cytology * **Imaging** * CXR: cannonball mets * US: mass * IVU: filling defect * CT/MRI

Answer 70

**Medical** * Reserved for pts. c¯ poor prognosis * _Temsirolimus_ (mTOR inhibitor) **Surgical** * Radical nephrectomy * Consider partial if small tumour or 1 kidney **Prognosis**: 45% 5ys

Answer 71

* Autosomal Dominant * Renal and pancreatic cysts * _Bilateral_ renal cell carcinoma * Haemangioblastomas (Often in cerebellum → cerebellar signs) * Phaeochromocytoma * Islet cell tumours

Answer 72

**Peripheral Inspection** * Renal Impairment * HTN * Pallor * Renal Replacement Therapy * AV fistula (or scar) * Tunnelled dialysis scars * Tenchkhoff catheter scars * Immunosuppressant Stigmata * Cushingoid * Skin tumours: AKs, SCC (100x ↑ risk), BCC and MM * Gingival hypertrophy: ciclosporin * **Cause** * DM * Finger pricks from BM monitoring * Insulin marks on abdomen, lipodystrophy * Cystic Kidney Disease * Nephrectomy scars or ballotable kidneys * Connective Tissue Disease * SLE, SS, RA **Abdomen** * Inspect * Rutherford Morrison Scar in RIF * Nephrectomy scars * Tenchkoff catheter scars * Palpate * Smooth oval mass under scar * Dull PN * Can get below it * Doesn’t move with respiration * Auscultate * Renal bruit over transplant **Completion** * Dipstick: haematuria and proteinuria * Drug chart: any potentially nephrotoxic drug (e.g. ACEi) * BP: HTN common post-Tx **Significant Negatives** * Evidence of immunosuppression Signs of a cause: DM and PKD Working Tx Renal replacement therapy not in use No pain over Tx site

Answer 73

* Drugs: *ciclosporin, phenytoin, nifedipine* * Familial * AML * Scurvy * Pregnancy

Answer 74

* **Cause** * DM * GN * **Transplant** * Cadaveric or live * any complications: e.g. urinary leaks, infection * **Current health** * Acute rejection: fever, graft pain * Graft function: Cr levels, BP, urine output * Immunosuppression * Infection: e.g. CMV pneumonitis * Skin Ca * CV risk * DHx

Answer 75

**Urine** * Dip: haematuria, proteinuria * MC+S **Bloods** * FBC: infection * U+E: eGFR – look @ trend * LFTs: ciclosporin can → hepatic dysfunction * Fasting glucose: tacrolimus is diabetogenic * Drug levels: ciclosporin, tacrolimus **Other** * Renal biopsy: if rejection suspected

Answer 76

* Diabetic nephropathy * GN * Polycystic Kidney Disease * Hypertensive nephropathy

Answer 77

* **Virology**: CMV, HIV, VZV, hepatitis * **Co-morbidities**: esp. CVD * **ABO** * **anti-HLA Abs**: may be acquired from blood transfusion * **Haplotype** * Importance: HLA-**DR** \> HLA-**B** \> HLA-**A** * 2 alleles @ each locus → 6 possible mismatches * ↓ mismatches → ↑ graft survival * Pre-implantation **cross-match** * Recipient serum vs. donor lymphocytes

Answer 78

* Active infection * Cancer * Severe co-morbidity * Failed pre-implantation x-match

Answer 79

1. **Cadaveric**: brainstem death c¯ CV support 2. **Non-heart beating donor**: no active circulation 3. **Live-related** * Optimal surgical timing * HLA-matched * Improved graft survival 4. **Live unrelated**

Answer 80

* *Pre-op**: _campath_ / _alemtuzumab_ (anti-_CD52_) * *Post-op:** * Short-term: _prednisolone_ * Long-term: _tacrolimus_ or _ciclosporin_

Answer 81

15yrs vs \>20yrs

Answer 82

**Post-op** * Bleeding * Graft thrombosis * Infection * Urinary leaks * *_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

Answer 83

**Ciclosporin**: calcineurin inhibitor (blocks IL2 production) * Nephrotoxic: may contribute to chronic rejection * Gingival hypertrophy * Hypertrichosis * Hepatic dysfunction **Tacrolimus**: calcineurin inhibitor (blocks IL2 production) * \< nephrotoxicity cf. ciclosporin * Diabetogenic * Cardiomyopathy * Neurotoxicity: e.g. peripheral neuropathy **Steroids** → Cushing’s Syndrome and of course immunosuppression...

Answer 84

↑ risk of **infection**: CMV, PCP, fungi, warts ↑ risk of **malignancy** * Skin: SCC, BCC, MM, Kaposi’s * Post-Tx lymphoproliferative disease (2O EBV)

Answer 85

*Hypertension Atheromatous vascular disease A leading cause of death*

Answer 86

* Suggested to start when GFR**\<15ml/min** + symptoms * Psychological preparation necessary * PD vs. HD depends on med, social and psych factors

Answer 87

* 20% annual mortality * Cardiovascular disease * Malnutrition * Infection * uraemia → granulocyte dysfunction → ↑ sepsisrelated mortality * Amyloidosis * β2-microglobulin accumulation * Carpal tunnel, arthralgia * Renal cysts → RCC

Answer 88

**Counter-current flow** * Blood flows on one side of semipermeable membrane * Dialysate flows in the opposite direction on the other side. * Solute transfer by diffusion **Ultrafiltration:** *Fluid removal by creation of –ve transmembrane pressure by decreasing the hydrostatic pressure of the dialysate.*

Answer 89

* Disequilibration syndrome (usually only 1st dialysis) * Rapid changes in plasma osmolarity → cerebral oedema * n/v, headache and ↓GCS * Fluid balance: BP↓, pulmonary oedema * Electrolyte imbalance * Aluminium toxicity (in dialysate) → dementia * Psychological factors

Answer 90

*Usually only used in ITU Takes longer cf. HD but there is less haemodynamic instability.*

Answer 91

* Use a Vas Cath * Blood filtered across a highly permeable membrane by hydrostatic pressure and water and solutes are removed by convection. * Ultrafiltrate is replaced by isotonic replacement.

Answer 92

* Dialysate introduced into peritoneal cavity by Tenchkhoff catheter. * Uraemic solutes diffuse into fluid across peritoneum * Ultrafiltration: addition of osmotic agent (e.g. glucose) * ~3L 4x /day c¯ ~4h dwell times

Answer 93

Continuous Ambulatory Peritoneal Dialysis *CAPD: fluid exchange during **day** c¯ long dwell @ night* Assisted Peritoneal Dialysis *APD: fluid exchanged during **night** by machine c¯ long dwell throughout day.*

Answer 94

**Advantages** * Simple to perform * Requires less equipment-\> *Easier @ home or on holiday* * Less haemodynamic instability -\> useful if cardio disease **Disadvantages** * Inconvenience * Body image * Anorexia

Answer 95

* Peritonitis * Exit site infection * Catheter malfunction * Obesity (glucose in dialysate) * Mechanical: hernias and back pain

Answer 96

**Inspection** * Swelling c¯ surgical scar over distal forearm or @ elbow * Evidence of use: needle marks * Evidence of infection **Palpation** * Check if painful * Temperature * Palpable thrill **Auscultate** * Audible bruit **Significant Negatives** * Evidence of infection, stenosis, aneurysm

Answer 97

***Surgically created connection between artery and vein*** * **Radio-cephalic** @ wrist = Cimino-Brescia * **Brachio-cephalic** @ the elbow Venous limb (from machine) is **proximal** Side-to-side anastomosis c¯ ligation of the distal vein

Answer 98

**Advantages** * High flow rates, low recirculation (\<10%) * Low infection rates * Less chance of stenosis cf. grafts **Disadvantages** * Take ~6 weeks to arterialise * Affect pts. body image * Must take care: avoid shaving, don’t take BP/blood here

Answer 99

* Thrombosis and stenosis * Infection * Bleeding * Aneurysm

Answer 100

* Distal tissue ischaemia * Pallor, pain, ↓ pulses * May → necrosis * ↓ wrist:brachial pressure index * Rx: banding (plication)

Answer 101

Two lines tunnelled under skin and entering **IJV** aka: Tessio Lines

Answer 102

Disadvantages * May have ↑ recirculation cf. AVF * Lower flow rates * ↑ risk of infection and thrombosis *(advantages ==\>DON't have to...* 1. *wait ~6 weeks for AVF to arterialise* 2. *Suffer same affect on pts. body image* 3. *don't have to take care: e.g. avoid shaving, taking BP/blood from AVF arm)*

Answer 103

* Adverse events @ insertion: e.g. pneumothorax * Line or tunnel infection * Blockage * Retraction

Answer 104

* Kidney damage ≥3mo indicated by ↓ function * Symptoms usually only occur by stage 4 (GFR\<30) * ESRF is stage 5 or need for RRT

Answer 105

**Common**: * DM * HTN **Other** * RAS * GN * CTD: SLE, SS, RA * Polycystic disease * Drugs: e.g. analgesic nephropathy * Pyelonephritis: usually 2O to VUR * Myeloma and amyloidosis

Answer 106

**Urine** * Dip: haematuria, proteinuria, glycosuria * PCR * Normal = \<20mg/mM * Nephrotic = \>300mg/mM * BJP: myeloma **Function** * FBC: ↓Hb * U+E: ↓ eGFR * Bone: ↓Ca, ↑PO4, ↑PTH, ↑ALP **_Renal Screen_** * DM: fasting glucose, HbA1c * ESR * Immune * SLE: ANA, C3, C4 * Goodpasture’s: anti-GBM * Vasculitis: ANCA * Hepatitis: viral serology * Se protein electrophoresis **Imaging** * CXR: pulmonary oedema * Renal US * Usually small (\<9cm) * May be large: polycystic, amyloid * Bone X-rays: renal osteodystrophy (pseudofractures) * CT KUB: e.g. cortical scarring from pyelonephritis **Renal biopsy**: if cause unclear and size normal * Histology subtype * Amyloid: apple-green birefringence c¯ Congo Red

Answer 107

* *C**ardiovascular disease * *R**enal osteodystrophy * *F**luid (oedema) * *H**TN * *E**lectrolyte disturbances: K, H * *A**naemia * *L**eg restlessness * *S**ensory neuropathy

Answer 108

1. **Osteoporosis**: ↓ bone density 2. **Osteomalacia**: ↓ mineralisation of osteoid (matrix) 3. *2O/3O HPT* → ***osteitis fibrosa cystica*** * Subperiosteal bone resorption * Acral osteolysis: short stubby fingers * Pepperpot skull 4. **Osteosclerosis** of the spine → Rugger Jersey spine * Sclerotic vertebral end plate c¯ lucent centre 5. **Extraskeletal calcification**: e.g. band keratopathy

Answer 109

* *↓ 1α-hydroxylase → ↓ vit D activation → ↓Ca → ↑PTH* * *Phosphate retention → ↓Ca and ↑PTH (directly)* * *↑PTH → activation of osteoclasts ± osteoblasts* * *Also acidosis → bone resorption*

Answer 110

**_General Mx_** * Rx reversible causes * Stop nephrotoxic drugs * Na, K, fluid and PO4 restriction **Optimise CV Risk** * Smoking cessation, exercise * Statin + antiplatelet * Rx DM * *_Specific Mx_** * *Hypertension** * Target \<140/90 (\<130/80 if DM) * In DM kidney disease give **ACEi/ARB** (inc. if normal BP) * *Oedema**: frusemide * *Bone Disease** * Phosphate binders: calcichew, sevelamer * Vit D analogues: alfacalcidol (1 OH-Vit D3) * Ca supplements * Cinacalcet: Ca mimetic **Anaemia** * Exclude IDA and ACD * EPO to raise Hb to 11g/dL (higher = thrombosis risk) **Restless Legs**: clonazepam

Answer 111

*Commonest cause of ESRF: **\>20%** Advanced / ESRF occurs in **40%** of T1 and T2 DM* **Pathology** Diabetic nephropathy describes conglomerate of lesions occurring concurrently. * Hyperglycaemia → hypertrophy and ROS production * Hallmark is glomerulosclerosis and nephron loss * Nephron loss → RAS activation → HTN

Answer 112

* Microalbuminuria * 30-300mg/d or albumin:creatinine \>3mg/mM * Strong independent RF for CV disease * Progresses to proteinuria: albuminuria \>300mg/d * Usually coexists c¯ other micro- and macro-vasc disease * **Screening**: T2DMs should be screened for microalbuminuria 6moly

Answer 113

* Good glycaemic control delays **onset** and **progression** * *UKPDS*: UK Prospective Diabetes Study * *DCCT*: Diabetes Control and Complications Trial * Control **HTN**: BP target **130/80** * **ACEi/ARB**: even if normotensive * Stop **smoking** * Combined kidney pancreas **Tx** possible in selected pts

Answer 114

1. NSAIDs → ATN 2. Penicillamine and gold → membranous GN 3. AA amyloidosis occurs in 15%

Answer 115

**Pathogenesis** * Involves glomerulus in 40-60% → ARF/CRF * Immune complex deposition → T3 hypersensitivity * Typically membranous GN * Proteinuria and ↑BP **Rx** * Proteinuria: **ACEi** * Aggressive GN: **immunosuppression**

Answer 116

* Renal crisis: malignant HTN + ARF * Commonest cause of death * Rx: **ACEi** if ↑BP or renal crisis

Answer 117

* *Excess production of monoclonal Ab ± light chains (excreted and detected in 60% as urinary BJP).* * *Light chains block tubules and have direct toxic effects → ATN.* * *Myeloma also assoc. c¯ ↑↑Ca2+*

Answer 118

**Presentation** * ARF / CRF * Amyloidosis **Rx** * Ensure fluid intake of 3L/d to prevent further impairment * Dialysis may be required in ARF

Answer 119

Cause * Atherosclerosis in 80% * Fibromuscular dysplasia * Thromboembolism * External mass compression

Answer 120

**Presentation** * Refractory hypertension * Renal bruits * Worsening renal function after ACEi/ARB * Flash pulmonary oedema (no LV impairment on echo) * Other signs of PVD **Ix** * CT/MR angio * Renal angiography **Rx** * Rx medical CV risk factors * Angioplasty and stenting * **AVOID ACEi/ARB**

Answer 121

**Peripheral Inspection** * **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 (ciclosporin) * **Legs** * Erythema nodosum * Pyoderma gangrenosum **Abdominal** * **Inspection** * Scars * May be multiple and atypical in Crohn’s * Healed stoma sites * Healed drain sites * Stomas or healed stoma sites * Enterocutaneous fistulae * **Palpation** * Tendernes * RIF mass * ± hepatomegaly **Completion** * Inspect perineum for perianal disease * Examine for extra-intestinal features * Large joint monoarthritis * Sacroileitis * Bronchiectasis

Answer 122

* Crohn’s * UC * Malabsorption: coeliac * Mid-line lap: FAP

Answer 123

* Symptoms * Wt. loss, fever, malaise * Abdominal pain * Diarrhoea, blood and/or mucus PR * Peri-anal disease: abscesses, fistulae * Extra-intestinal: EN, arthritis, iritis, gallstones, PSC * Therapy * Admissions * Medical therapy * Operations

Answer 124

**Bloods** * FBC: ↓Hb, ↑WCC * U+E: dehydration, ↓K * LFTs: ↓ albumin, deranged LFTs * Clotting: ↑INR * ↑ ESR, ↑ CRP: used to monitor activity * Haematinics: Fe, B12, folate * ***_Markers of Activity in CD:_*** ↓Hb, ↑ESR, ↑CRP, ↑WCC, ↓albumin **Stool** * Culture + CDT: exclude infective causes * Campy, Yersinia, Shigella, C. diff, TB **Imaging** * AXR * Toxic megacolon in UC * Bowel obstruction 2O to strictures in Crohn’s * Contrast studies * Ba or Gastrograffin enema in UC * Small bowel follow-through in Crohn’s * MRI: perianal disease in Crohn’s **Endoscopy** * Ileocolonoscopy + regional biopsy * Ix of choice * Safe in acute disease * Distinguish UC from Crohn’s * Assess disease severity * Wireless capsule endoscopy

Answer 125

Dx: **True-Love and Witts Criteria** 1. Symptoms * BMs \>6 x /d * Large PR bleed 2. Systemic Signs * ↑ HR \>90 * Pyrexia \>37.8 3. Laboratory Values * ↓ Hb \<10.5g/dL * ESR \>30mm/Hr

Answer 126

**General points** * patients should be strongly advised to stop smoking * some studies suggest an increased risk of relapse secondary to NSAIDs and the combined oral contraceptive pill but the evidence is patchy **Inducing remission** * **_glucocorticoids_** (oral, topical or intravenous) are generally used to induce remission. * _enteral feeding with an elemental diet_ may be used in addition to or instead of other measures to induce remission, particularly if there is concern regarding the side-effects of steroids (for example in young children) * _5-ASA drugs_ (e.g. mesalazine) are used second-line to glucocorticoids but are not as effective * _azathioprine or mercaptopurine\*_ may be used as an add-on medication to induce remission but is not used as monotherapy. Methotrexate is an alternative to azathioprine * _infliximab_ is useful in **refractory** disease and fistulating Crohn's. Patients typically continue on azathioprine or methotrexate * _metronidazole_ is often used for **isolated peri-anal** disease **Maintaining remission** * as above, stopping smoking is a priority (remember: smoking makes Crohn's worse, but may help ulcerative colitis) * **_azathioprine or mercaptopurine_** is used first-line to maintain remission * _methotrexate_ is used second-line * _5-ASA_ drugs (e.g. mesalazine) should be considered if a patient has had previous surgery **Surgery**: around 80% of patients with Crohn's disease will eventually have surgery

Answer 127

**_Inducing remission_** * treatment depends on the extent and severity of disease * rectal (topical) **_aminosalicylates or steroids_**: for *distal colitis* **_rectal mesalazine_** has been shown to be superior to rectal steroids and oral aminosalicylates * oral **_aminosalicylates_** * oral prednisolone is usually used second-line for patients who fail to respond to aminosalicylates. NICE recommend waiting around 4 weeks before deciding if first-line treatment has failed * *severe colitis* should be treated in hospital. **_Intravenous steroids_** are usually given first-line **_Maintaining remission_** * oral **_aminosalicylates e.g. mesalazine_** * **_azathioprine and mercaptopurine_** * methotrexate is not recommended for the management of UC (in contrast to Crohn's disease) * there is some evidence that probiotics may prevent relapse in patients with mild to moderate disease

Answer 128

**Ulcerative colitis** * Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids. * Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. * Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula. * Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory. * Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy. * Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling. **Crohns disease** * Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement. * Indications for surgery include complications such as fistulae, abscess formation and strictures. * Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. * Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis). * Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence. * Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended. * Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections. * Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Answer 129

* Obstruction * Megacolon * Perforation * Severe GI bleeding * Failure to respond to medical therapy

Answer 130

* **Skin** * Clubbing * Erythema nodosum * PG (esp. UC) * **Mouth** Aphthous ulcers * **Eyes** * Anterior uveitis * Episcleritis * **Joints** * Large joint arthritis * Sacroileitis * Hepatic * Fatty liver * Chronic hepatitis → cirrhosis * Gallstones (esp. CD) * PSC + cholangiocarcinoma (esp. UC) * **Other** * AA amyloidosis * Oxalate renal stones