Medical Abdomen Flashcards

Question

Signs of Liver Transplant on Examination

Answer 1

**Inspection** Nystatin for oral thrush Signs of CLD Pigmentation - haemochromatosis Tattoos and needle marks: Hep B/ Hep C **Immunosuppression stigmata** Cushingoid Skin tumours: Actinic keratosis, Squamous cell carcinoma, basal cell carcinoma, melanocytic melanoma Gingival hypertrophy: ciclosporin **Abdomen:** mercedes-benz scar Significant negatives: CLD, immunosuppression,

Answer 2

**Hepatobiliary surgery** Liver transplant Segmental resection Whipples: pancreaticoduodenectomy

Answer 3

**Bloods** FBC: infection U+Es: ciclosporin can cause renal impairment LFTs: assess graft function Clotting Fasting glucose: tacrolimus and steroids --\> DM Drug levels: tacrolimus and ciclosporin **Liver biopsy** if signs of rejection

Answer 4

**Cirrhosis** **Acute liver failure** Hep A, B Paracetamol overdose **Malignancy** Prognosis: 70% 5 yrs

Answer 5

Tacrolimus / Ciclosporin Azathioprine Prednisolone

Answer 6

**Signs of cause:** CLD Alcohol: Dupuytren's, palmar erythema Haemochromatosis: pigmentation Cancer: cachexia CCF: increased JVP, bibasal creps, peripheral oedema, ascites Haematological: pallor, bruising, purpura, LNs **Hepatomegaly** Define size in fingerbreadths below costal margin Moves inferiorly with inspiration Can't get above it Dull percussion note Edge: smooth, craggy, nodular Pulsatile? Tender? Percuss above and below Auscultate for liver bruit --\> HCC **?Associated splenomegaly** Inguinal nodes **Ascites** **Significant negatives:** splenomegaly, acute liver failure

Answer 7

_Common Causes_ **Hepatitis:** Alcholic hepatitis Viral hepatitis NAFLD **Chronic Liver Disease** **Congestion secondary to cardiac failure** Other Causes: **MACHO** **M**alignancy: secondary **A**natomical: Reidel's lobe, hyperexpanded chest **C**ongestion: Tricuspid regurg, Budd Chiari **H**aematological: Leukaemia, Lymphoma, Myeloproliferative, SCD **O**ther: sarcoidosis, Amyloidosis, Gaucher's, ADPKD

Answer 8

Alcoholic liver disease Haemochromatosis Wilson's

Answer 9

Viral hepatitis C B

Answer 10

Wilson's disease Copper

Answer 11

Haemochromatosis Stains iron

Answer 12

Primary biliary cholangitis

Answer 13

**Signs of cause:** Haematological: pallor, bruising, purpura, LNs, cachexia Portal HTN: CLD Infective endocarditis: splinter haemorrhages, clubbing Felty's syndorme: rheumatoid hands **Abdomen** Asymetrical appearance Splenomegaly: can't get above it, moves inferiorly towards RIF with inspiration, has notch, dull percussion note, ?hepatomegaly ?inguinal nodes How big? **Completion:** Cardio and resp --\> infective endocarditis or sarcoidosis

Answer 14

**Myeloproliferative:** chronic myeloid leukaemia, myelofibrosis **Lymphoproliferative:** Chronic lymphocytic leukaemia, lymphoma **Infiltrative:** amyloidosis, Gaucher's **Infectious:** malaria, visceral leishmaniasis

Answer 15

**Haematological:** myeloproliferative, lymphoproliferative, haemolysis **Portal HTN:** secondary to cirrhosis **Infection:** EBV, herpes viruses, hepatitis viruses, infective endocarditis, malaria **Inflammation:** Rheumatoid arthritis, SLE, Sjogren's **Rare:** sarcoidosis, amyloidosis, Gaucher's CVID

Answer 16

Genetic disorder of deficiency of the enzyme glucocerebrosidase Characterized by bruising, fatigue, anemia, low blood platelet count and enlargement of the liver and spleen Glucocerebroside accumulates, particularly in white blood cells and especially in macrophages (mononuclear leukocytes) Glucocerebroside can collect in the spleen, liver, kidneys, lungs, brain, and bone marrow.

Answer 17

**Bloods** FBC, U+Es, LFTs, ... **Blood film** Leukoerythroblastic with teardrop poikiolcytes = myelofibrosis Smear cells = CLL Haemolysis = hereditary spherocytosis, reticulocytosis **DAT** Urate: malignancy --\> uropathy **Imaging:** Abdo USS CT chest and abdopelvis **Histology** BM aspirate **Genetics**

Answer 18

**Clonal proliferation of myeloid cells** 15% of leukaemias **Presentation** * Hypermetabolism: weight loss, fever, night sweats, lethargy * Massive hepatosplenomegaly --\> ando discomfort * Bruising * Bleeding * Gout * Hyperviscosity **Invx** * **Increased White cell count** * Myelocytes * PMN and basophils * Anaemia * Thrombocytopenia * Increase urate * BM cytogenetic analysis: Ph +ve t:(9,22) **Mx** Imatinib: tyrosine kinase inhibitor Allogenic stem cell transplant

Answer 19

**Reciprocal translocation t(9:22)** Formation of BCR-ABL fusion gene ---\> Constitutive tyrosine kinase activity Present in \>80% of CML

Answer 20

Clonal proliferation of megakaryocytes --\> Increased PDGF --\> **myelofibrosis** Extramedullary haematopoiesis: Liver and spleen **Presentation** Elderly **Massive hepatosplenomegaly** Hypermetabolism: weight loss, fever, night sweats Bone marrow failure: anaemia, infections, bleeding **Invx** Blood film: leukoerythroblastic changes with teardrop poikilocytes Cytopenias **Bone marrow: Dry tap** 50% JAK2 +ve **Mx** Supportive: blood products EPO, Allopurinol, Ruxolitinib Hydroxycarbamide: Splenectomy Allogenic BMT may be curative 5yr median survival

Answer 21

**Part of the mononuclear phagocytic system** **Phagocytosis of:** Old RBCs, WBCs Opsonised bugs esp. encapsulated Sequestration of formed blood elements: platelets, lymphocytes, monocytes **Haematopoiesis**

Answer 22

**Splenectomy** Coeliac disease Inflammatory bowel disease Sickle cell disease

Answer 23

**Howell-Jolly bodies** Pappenhemier bodies Target cells Increased platelets transiently after splenectomy

Answer 24

**Daily erythromycin as prophylaxis** Immunisations: pneumovax, HiB, Men C, Yearly Flu Warning bracelet **Susceptible to encapsulated bacteria:** Haemophilus Meningococcus Pneumococcus

Answer 25

**Early** Redistribution thrombocytosis --\> early VTE (give temporary post-operative aspirin) Gastric dilatation: transient ileus (use prophylactic NG tube after surgery) Left lower lobe atelectasis Pancreastitis, tail shares blood supply with spleen **Late** Increased susceptibility to encapsulated bacteria HMS Haemophilus Meningococcus Strep Pneumo

Answer 26

**Renal impairment** Hypertension Pallor **Renal Replacement Therapy** AV fistula (or scar) Tunnelled dialysis lines (or scar) Tenchkhoff catheter (or scar) **Immunosuppressant stigmata** Cushingoid Skin tumours: Actinic keratosis, Squamous cell carcinoma, Basal cell carcinoma, Malignant melanoma Gingival hypertrophy: ciclosporin **Abdomen** Nephrectomy scar Rutherford Morrison scar Tenchkhoff catheter Palpable kidneys Flank mass, able to get above it, ballotable, moves inferiorly with inspiration, resonant percussion note Renal bruit **Completion:** External genitalia (hydrocele secondary to RCC) Urine drip (proteinuria and haematuria), CVS: mitral valve prolpase (increased in ADPKD) Significant negatives: unilateral enlargement, hepatomegaly, evidence of RRT, immunosupression

Answer 27

Tenckhoff Catheter indwelling peritoneal catheter

Answer 28

**Bilateral (AABB)** **A**DPKD **A**myloidosis **B**ilateral renal cell carcinoma (5%) **B**ilateral cysts (in Von Hippel–Lindau disease) **Unilateral** Simple renal cyst Renal cell carcinoma Compensatory hypertrophy + contralteral necphrectomy: ADPKD

Answer 29

PKD1 gene on chromosme 16: 85% PKD2 gene on chromosome 14: 15% **Presentation** Age 30-50 Hypertension Recurrent UTIs Loin pain: cyst haemorrrhage or infection Haematuria **Extra-Renal Involvement** Hepatic syst --\> hepatomegaly Intracranial berry aneurysms --\> SAH Mitral valve prolapse: mid-diastolic click and late systolic murmur **Mx** General Increase water intake, decrease Na, decrease caffeine (may decrease cyst formation) Monitor U+Es, BP Genetic counselling MRA for Berry aneurysm **Medical** Treat hypertension \<130/80 aggressively Treat infections **Surgical** Nephrectomy if recurrent bleeds or infections If painful **Renal Replacement Therapy**

Answer 30

Fibrocystin gene on chromosome 6 (PKHD1) **Presentation** **Perinatal** Oligohydramnios may --\> Potter sequence (clubbed feet, pulmonary hypoplasia, cranial abnormalities) Bilateral abdominal masses Hypertension Chronic renal failure Can lead to congenital hepatic fibrosis --\> portal hypertension ESRF by 20 years

Answer 31

1/3 of patients over 65 - Common Renal mass Haematuria Contain fluid only, no solid elements **Differential: RCC**

Answer 32

Seen after prolonged dialysis use Secondary to obstruction of renal tubules by **oxalate crystals** **Increased risk of RCC - 15% of patients on haemodialysis**

Answer 33

Autosomal dominant condition characterised by hamartomas in the skin, brain, eye and kdiney **Skin:** Nasolabial adenoma sebaceum Ash-leaf macules Peri-ungal fibromas **Neurological:** Astrocytoma Epilepsy Decreased IQ **Renal** Cysts Angiomyolipomas

Answer 34

90% of renal cancer Age: 55 yrs **Adenocarcinoma of proximal renal tubular epithelium** Clear cell subtype makes up 80% **Presentation** _Triad: Haematuria, loin Pain and Loin Mass_ 50% incidental Invasion of left renal vein --\> varicocele Cannonball mets --\> SOB Paraneoplastic features (polycythaemia etc.) Spread: direct to renal vein, lymph, haematogenous (bone, liver and lung) **Invx** Blood: polycythaemia, ESR, U+Es, ALP, calcium Urine: dip and cytology **Imaging:** CXR: cannonball mets USS: Abdominal mass IVU: filling defect CT/MRI **Mx** **Medical** Temsirolimus - pecific inhibitor of mTOR (reserved for patients with poor prognosis) **Surgical** Radical nephrectomy Consider partial if small or only 1 kidney Prognosis 45% 5 year survival

Answer 35

**Risk factors** **Smoking** Obesity Hypertension _Dialysis: 15% develop RCC_ 4% heritableL Von-Hippel Lindau

Answer 36

**Autosomal dominant** genetic disorder **characterised** by **multiple** **visceral cysts** and **benign tumors** (with potential for subsequent malignant transformation) Type of phakomatosis that results from a mutation in the **von Hippel–Lindau tumor suppressor gene on chromosome 3** **Complications** Renal and pancreatic cysts Bilateral renal cell carcinoma Haemangioblastoma: often in cerebellum --\> cerebellar signs Phaeochromocytoma Islet cell tumouts

Answer 37

**Renal impairment:** anaemia, HTN **Renal replacement therpay** * AV fistula * Tunnelled dialysis line * Tenckhoff catheter **Immunosuppressant stigmata** * Cushingoid * Skin tumours: actinic keratosis, squamous cell carcinoma, basal cell caricnoma, malignant melanoma * Gingival hypertrophy: ciclosporin **Signs of cause:** DM - finger pricks from BM monitoring, lipodystrophy Cystic kidney disease: nephrectomy Connect tissue: SLE, Systemic slerosis, Rheumatoud arthritis **Abdomen** Rutherford Morrison scar in RIF Nephrectomy scars Tenchkoff catheter **Smooth oval mass under scar** Dull percussion Can't get below it Doesn't move with respiration Renal bruit heard over transplant **Completion:** urine dip (haem/proteinuria), drug chart review, BP (HTN common post-transplant)

Answer 38

EPO ---\> **Polycythaemia** PTHrP ---\> **Hypercalcaemia** Renin ---\> **Hypertension** ACTH ---\> **Cushing's syndrome** **Amyloidosis**

Answer 39

**Drugs:** Ciclosporin, Phenytoin, Nifedipine **Familial** **AML** **Scurvy** **Pregnancy**

Answer 40

**Urine** Dip: haematuria, proteinuria MC+S **Bloods** FBC (infection), U+Es (GFR) LFTS: ciclosporin can cuase hepatic dysfunction Fasting glucose: tacrolimus is diabetogenic Drug levels: ciclosporin, tacrolimus **Renal biopsy**: if rejection suspected

Answer 41

**Diabetic nephropathy** **Glomerulonephritis** **Polycystic kidney disease** **Hypertensive nephropathy**

Answer 42

**Virology:** CMV, HIV, HZV, hepatitis **Co-morbities:** Cardiovascular disease **ABO group** **Anti-HLA antibodies** **Halotype** Importance: HLA-DR \> HLA-B \> HLA-A 2 alleles at each locus, 6 possible mismatches **Pre-implantation x-match:** recipient serum vs donor lymphocytes

Answer 43

Active infection Malignancy Severe co-morbidity Failed pre-implantation x-match

Answer 44

Cadaveric: brainstem death with CB support Non-heart beating donor: no active circulation Live-related Live unrelated

Answer 45

**Pre-operative:** Alemtuzumab (anti-CD52) **Post-operative** Short-term: prednisolone Long-term: **Basiliximab**, when used as part of an immunosuppressive regimen that includes a calcineurin inhibitor (**tacrolimus** or **ciclosporin**)

Answer 46

**Post-operative:** Bleeding Graft thrombosis Infection Urinary leak **Rejection** **Drug toxicity**

Answer 47

**Hyperacute rejection: minutes** ABO incompatbility --\> thrombosis and systemic inflammatory response **Acute rejection** Cell-mediated rejection Fever, graft pain, decreased urine putput, Increased creatinine Mx: immunosuppression **Chronic rejection** \>6 months Gradual increase in creatinine and proetinuria Interstitial fibrosis and tubular atrophy Mx: supportive, not responsive to immunosuppression

Answer 48

**Calcineurin inhibitor**: block **IL-2** production Nephrotoxic, may contribute to organ rejection Gingival hypertrophy Hypertrichosis Hepatic dysfunction

Answer 49

**Calcineurin inhibitor:** blocks **IL-2** production Less nephrotoxic vs ciclosporin **Diabetogenic** Cardiomyopathy **Neurotoxicity**: peripheral neuropathy

Answer 50

Cushing's syndrome

Answer 51

**Increase risk of infection** CMV PCP Fungi **Increased risk of malignancy** **Skin:** squamous cell carcinoma, basal cell carcinoma, malignant melanoma, kaposi's **Post-transplant lymphoproliferative disease** (secondary to **EBV**)

Answer 52

**GFR\<15ml/min AND Symptoms** Psychlogical preparation necessary Peritoneal vs haemodialysis is a multi-factor decision (med, social, psychological and personal factors)

Answer 53

20% annual **mortality** **Cardiovascular** disease **Malnutrition** **Infection**: uraemia --\> granulocyte dysfunction --\> increased risk of **sepsis** **Amyloidosis** Beta2-microglobulin accumulation **Carpal tunnel,** arthralgia Renal cysts --\> **RCC**

Answer 54

**Counter-current flow** Blood flows on one side of a semi-permeable membrane Dialysate flows in opposite direction on the other side of the semi-permeable membrane Solute transfer by diffusion **Ultrafiltration** Fluid removal by creation of a negative transmembrane pressure by decreasing the hydrostatic pressure of the dialysate

Answer 55

**Disequilibration syndrome** Usually only 1st dialysis Rapid change in plasma osmolarity --\> cerebral oedema Nause, vomiting, headache, decrease GCS **Fluid balance** Hypotension Pulmonary oedema **Electrolyte imbalance** **Aluminium toxicity** (in dialysate) --\> **dementia** **Psychological** trauma

Answer 56

Usually only in **ITU** Takes **longer** than haemodilaysis **Less haemodynamic instability** **Uses Vas Cath** Blood filtered across a highly permeable membrane by hydrostatic pressure Water and solutes are **removed by convection** Ultrafiltrate replaced with isotonic fluid

Answer 57

Dialysate introduced into peritoneal cavity by **Tenchkoff** catheter **Uraemic solutes diffuse into fluid across peritoneum** Ultrafiltration: addition of osmotic agent e.g. Dextrose 3L 4/day with 4 h dwell times **Types:** Continuous ambulatory peritoneal dialsysi (**CAPD**): fluid exchanged duringthe day with long swell at night Automated peritoneal dialsysis (**APD**): fluid exchanged throughout the night by machine with logn dwell during the day

Answer 58

**Advantages:** simple, can do it at home Less haemodynamic instability = great for patients with cardiovascular disease **Disadvantages** Inconvenience, Body image, Anorexia **Complications** Peritonitis Exit site infection Cathter malfunction Obesity: glucose in dialysate Mechanical: hernias and back pain

Answer 59

**AV fistula** Swelling with surgical scar over distal forearm or elbow Evidence of needle marks (cannulation of fistula) Evidence of infection Check if painful Check temperature Palpable trhill Audible bruit **Significant negatives:** evidence of infection, stenosis, aneurysm **Tunnelled Cuffed Catheter** **Tessio lines:** two lines tunnelled under skin entering internal jugular vein

Answer 60

= Surgically created connected between artery and vein **Radio-cephalic** at the wrist = **Cimino-Brescia** **Brachio-cephalic** at the elbow Brachial-basilic

Answer 61

**Advantages** High flow rates: low recirculation Low infection rates Less chance of stenosis compared with grafts **Disadvantages** Takes 6 weeks to develop Affects patients body images Need to be careful of area e.g. shaving, taking BP **Complications:** Thrombosis Stenosis Infection Bleeding Aneurysm **Steal syndrome**

Answer 62

Thrombosis Stenosis Aneurysm Infection Bleeding **Steal syndorme**

Answer 63

**Distal tissue ischaemia** Presenting as pallor, pain, and reduced pulses May lead to **necrosis** **Decreased wrist: brachial pressure index** **Mx:** banding of fistula

Answer 64

**Tesio Line**

Answer 65

**Disadvantges** Increased risk of recirculation compared with AV fistula Lower flow rates Increased risk of infection Increased risk of thrombosis **Complications** Adverse events at insertion: pneumothorax Line or tunnel infection Blockage Retraction

Answer 66

**Stage I: eGFR \>90** minus 30 Stage II: eGFR 60-89 minus 20 Stage III: eGFR 30-59 minus 15 Stage IV: eGFR 16-29 **Stage V: eGFR \<15**

Answer 67

**Common** _Diabetes melitus nephropathy_ Hypertensive nephropathy **Other** Renal artery stenosis Glomerulonephritis Connective tissue disease: rheumatoid, SLE, systemic sclerosis Polycystic kidney disease Drugs: analgesic nephropathy (aspirin, phenacetin, and paracetamol) Pyelonephritis seconday to vesicoureteral reflux Myeloma Amyloidosis

Answer 68

Kidney damage for more than **3 months** indicated by **decline in renal function**

Answer 69

**Urine** Dip: proteinuria, haematuria, glycosuria Protein:creatinine ratio: normal \<20, Nephrotic \>300mg/mM Bence Jones: Myeloma **Function** FBC (anaemia), U+E (eGFR), Bone (hypocalcaemia, phosphataemia, increased PTH, increased ALP) **Renal Screen** Fasting glucose, HbA1c: Diabetes ESR **Immune:** SLE (ANA, C3, C4) Goodpasture;s: Anti-GBM Vasculitis: ANCA Hepatitis: viral serology Serum protein electrophoresis **Imaging** CXR: pulmonary oedema Renal USS: usually small non-functioning, may be large of PCKD Bone x-rays: renal osetodystrophy CT KUD: Cortical scaring form pyelonephritis **Renal Biopsy** Histology Amyloid: apple green bifringence with congo red

Answer 70

**CRF HEALS** **C**ardiovascular disease **R**enal osteodystrophy **F**luid: oedema **H**ypertension **E**lectrolyte disturbance: hyperkalaemia and acidosis **A**naemia **L**eg restlessness **S**ensory neuropathy

Answer 71

**Freatures** **Osteoporosis:** decreased bone density **Osteomalacia:** decreased mineralisation of osteoid (matrix) Secondary an Tertiary hyperparathyroidism --\> **Osteitis fibrosa cystica** Subperiosteal bone resorption Acral osteolysis: short stubby fingers Pepperpot skull Osteosclerosis of the spine --\> Rugger Jersey spine (indicative of hyperparathyroidism) Sclerotic vertebral end-plate with lucent centre Extra-skeletal calcification e.g. band keratopathy

Answer 72

**Phosphate retention -**-\> Increases PTH directly **Decreased 1 alpha hydroxylase** --\> reduced vit D activation --\> Hypocalcaemia --\> increased PTH **Increased PTH** --\> activation of **osteoclasts** and **osteoblasts** Acidosis --\> bone rresorption

Answer 73

**General Mx** Treat reversible causes Stop nephrotoxic drugs Na, K, fluid and phosphate restriction **Optimise CV risk factors** Smoking cessation Exercise Atorvastatin Antiplatelet **Hypertension**: aim \<140/90 (130/80 if Diabetic) If diabetic, give ACE-I Oedema --\> **Frusemide** **Bone disease** Phosphate binders: calcichew, sevelamar Vitamin D anlogues: alfacalcidol (increased hydroxylated Vit D) Ca supplements Cinacalcet: Ca mimetic **Anaemia** Exclude IDA EPO to raise Hb to 11 **Restless legs:** clozapine

Answer 74

Commonest cause of ESRF \>20% Gloermulosclerosis and nephron loss Nephron loss --\> RAS activation --\> hypertension **Presentation** **Microalbuinaemia** albumin:creatinine ratio \>3, strong risk factor for CV disease Screen diabetics for microalbuminaemia every 6 months **Progresses to proteinuria** Mx **Good glycaemic control delays onset and progression** (UK prospective Diabetes Study UKPDS, Diabetes control and complications trial DCCT) Control BP: \<130/80mmHg ACE-inhibitor or ARB even if normotensive Stop smoking Combined kidney and pancreas transplant in selected patients

Answer 75

**Rheumatoid arthritis** NSAIDs --\> ATN Penicillamine and gold --\> membranous glomerulonephritis AA amyloidosis occurs in 15% **SLE** Involvement of glomerulus --\> ARF/CRF Immune complexes deposition --\> Type 3 hypersensitivity Proteinuria and hypertension Mx: ACE-inhibitor and immunosuppression **Systemic Sclerosis** Renal crisis: malignant HTN and acute renal failure = commonest cause of death Mx: ACE-inhibitor

Answer 76

Excess production of monoclonal antibodies and light chains Light chains block tubules and have direct toxic effects --\> Acute tubular necorsis Associated with hypercalcaemia Urinary Bence Jones protein Drink at least 3L / day to reduced ATN Dialysis may be required

Answer 77

**Causes** Atherosclerosis (80%) Fibromuscular dysplasia Thromboembolism External mass compression **Presentation** Refractory hypertension Renal bruits Worsening renal function after ACE-inhibitor / ARB Flash pulmonary oedema (with no LV impairment on echo) Other signs of peripheral vascular disease **Invx:** CT/ MR angio Renal angiography **Mx:** Treat CV risk factors Angioplasty and stenting Avoid ACE-inhibitors or ARB

Answer 78

**Ileostomy** **Inspection** Often young female patient Laparatomy scars Malnutrition or weight loss Cushingoid Pallor **Hands** Clubbing Leukonychia Beau's lines **Eyes** Pale conjunctivae Iritis Episcleritis **Mouth** Aothous ulcers Ginigval hypertrophy (ciclosporin) **Legs** Erythema nodosum Pyoderma gangrenosum **Abdomen** Scars: healed stoma sites, healed drains, midline laparatomy Stomas Enterocutaneous fistula Tender palpation, RIF mass +/- hepatomegaly **Completion:** inspect perineum, examine for extra-intestinal features Large joint monoarthritis Sacroileitis Bronchiectasis DDx: Crohns, UC Malabsorption: Coeliacs Midline lap: FAP

Answer 79

**Bloods** FBC, U+Es, LFTs, Clotting, Increased ESR, Increased CRP, Haematinics **Markers of activity** Hb ESR CRP WCC Albumin **Stool** Culture, MC+S Exlcude infectious causes **Imaging** AXR: toxic megacolon in UC, bowel obstruction secondary to strictures in Crohn's Contrast studies: Ba or Gastrograffin enema in UC MRI: peri-anal disease in Crohn's **?Endoscopy** Ileocolonoscopy + regional biopsy ?Not safe in acute disease Distinguishes UC from Crohn's Assess disease severity Witeless capsule endoscopy

Answer 80

**Toxic megacolon** Haemorrhage **Malignancy** Colorectal carcinoma Cholangiocarcinoma VTE

Answer 81

Fistulae Perianal abscess Strictures Malabsorption Toxic dilatation

Answer 82

**Severity of Acute Flare of Inflammatory Bowel Disease** **Symptoms** Bowel motions \>6/day Large PR bleed **Systemic Signs** HR \>90 Pyrexia \>37.8 **Lab Values** Hb \<10.5 ESR \>30

Answer 83

**Skin** Clubbing Eyrthema nodosum Pyoderma gangrenosum (esp. UC) **Mouth:** Apthous ulcers **Eyes** Anterior uveitis Episcleritis **Joints** Large joint arthritis Sacroileitis **Hepatic** Fatty Liver Chronic hepatitis --\> cirrhosis Gallstones (esp. Crohn's) Primary sclerosing cholangitis and cholangiocarcinoma (Esp. UC) **Other** Amyloidosis (AA) Oxalate renal stones