NMDE Flashcards

Question

Side effects of blood transfusions

Answer 1

Hypothermia as products stored at fridge temperature Hypocalcaemia - blood contains citrate which chelates calcium Hyperkalaemia

Answer 2

``` Haemorrhoids Fissures Carcinoma Polyps Proctitis Diverticular disease IBD Angiodysplasia Infection - E.coli, shigella, salmonella, campylobacter ```

Answer 3

``` FBC U&Es Clotting LFTs Colonoscopy or flexi sig Rectal exam Stool cultures ```

Answer 4

``` Coeliac disease Gastric cancer Peptic ulcer disease Colorectal cancer IBD ```

Answer 5

Treat underlying cause Replace iron stores if deficient Check blood count after 1 month to see if it improves

Answer 6

A - Night blindness D - Osteomalacia - Proximal limb weakness E - Anaemia K - Clotting deficiency - Bruising

Answer 7

B6 - Dermtitis, anaemia B12 - Pernicious anaemis - Tired/fatigue/pale/peripheral neuropathy Folate - megaloblastic anaemia - tired.fatigue.pale C - Scurvy - bruising, gingivitis

Answer 8

Secondary to pathological disease - raised metabolic demand Neglect - by patient or staff NBM

Answer 9

Consider in all - BMI < 18.5 - Unintentional weight loss >10% in 3-6 months - BMI < 20 and unintentional weight loss >5% in 3-6 months - Eaten little or nothing for 5 days and not likely to in next 5 days - Poor absorptive capacity

Answer 10

Oral - supplementation e.g, fortisips Tube feeding - NG tube if inadequate or unsafe oral intake Enterostomy feeding - if for over 4-6 weeks PEG tube - can get perforation, infection or peritonitis

Answer 11

- Only if other routes not suitable e.g. perforated GI tract If short term can use peripheral cannula <14 days If not the PICC line Complicated by thrombophlebitis

Answer 12

Complication from too rapid reintroduction of feeding following starvation. Low insulin levels secondary to starving. When feeding restarted, increased insulin. Insulin causes cellular uptake of phosphate Low phosphate causes respiratory/cardiac failure, muscle weakness, seizures, coma usually occurs in day 4 of refeeding

Answer 13

BMI < 16 History of alcohol abuse Little or no intake for 10 days Low levels of phosphate, potassium or magnesium prior to feed Unintentional weight loss of >15% in last 3-6 months

Answer 14

``` Diarrhoea Steatorrhoea Weight loss Fatigue Flatulence and abdominal distension Oedema from hypoalbuminaemia Bleeding disorders (vit K) Metabolic defects in bones Neurological manifestation (low Ca, Mg - tetany) ``` ``` Orthostatic hypotension Decreased subcut fat Signs of muscle loss or wasting Hyperactive bowel sounds Ascites Pallor Peripheral oedema Glossitis ```

Answer 15

Iron deficiency anaemia - blood loss, increased demand (growth and pregnancy), decreased absorption (post-gastrectomy, Crohn's), poor intake Thalassaemia Anaemia of chronic disease Sideroblastic anaemia

Answer 16

``` Acute blood loss CKD Anaemia of chronic disase Autoimmune rheumatic disease Endocrine disease Marrow infiltration Haemolytic anaemia ```

Answer 17

Vitamin B12 or folate deficiency B12 - gastrectomy, ileal disease, resection Folate - alcohol, coealiac, Crohn's, partial gastrectomy, cancer, drugs

Answer 18

``` Fatigue headache angina, breathlessness pallor palpitations tachycardia ```

Answer 19

Increased in females (2 to 1) Age peaks in early childhood and again 40-50 1-2% prevalence FHx - HLA DQ2 RF - other autoimmune disease

Answer 20

``` Tiredness, malaise GI symptoms may be absent or mild Diarrhoea or steatorrhoea Abdominal pain diffuse Weight loss ``` Mouth ulcers Angular stomitis Anaemia/pallor Dermatitis herpetiformis

Answer 21

Classic - 50% Typical symptoms Atypical Lacks GI symptoms but presents with deficiency state or extra intestinal features Silent - 20% No signs of symptoms Non-responsive Refractory - 1%

Answer 22

Proteins in wheat, barley, rye are broken down by tissue transglutaminase into GLIADIN Gliadin then presents to T cells via HLA class 2 DQ2 and DQ8 T cells produce inflammatory cytokines Over expression of IL 15

Answer 23

IgA anti-tissue transglutaminase antibodies - highly specific and sensitive. They become undetectable after 6 months of a gluten free diet FBC - microcytic anaemia from iron deficiency Howell-Jollie bodies (leukocytes) LFTs - raised transaminases Small bowel biopsy is gold standard - need to still be consuming gluten

Answer 24

GLUTEN FREE DIET! NHS can subsidise gluten free products Recommended to have 5 yearly pneumococcal vaccinations

Answer 25

``` Inguinal (indirect or direct) Femoral Umbilical and parumbilical Incisional Ventral and epigastric ```

Answer 26

Reducible - contents replaced completely back into peritoneal cavity Lump disappears lying down, not painful Cough impulse ``` Irreducible Adhesions to sac wall mass larger than neck not reducible Cough impulse ``` Strangulation Contents restricted by neck so circulation is cut off - gangrene inevitable Severe pain, central, colicky vomiting, distension, constipation (from obstruction) Tender,tense No cough impulse Noisy bowel sounds

Answer 27

1. Femoral 2. Indirect inguinal 3. Umbilical

Answer 28

``` Pass through internal ring Lateral to inferior epigastric vessels May be congenital Can be controlled by pressure over internal ring Commonly strangulates due to narrow neck Often extends to scrotum Does not readily reduce on lying ``` Hernia does not reach full size until the patient has been up for some time, does not reduce on lying

Answer 29

Pass through posterior wall of inguinal canal MEDIAL to inferior epigastric vessels Always acquired Not controlled by pressure over internal ring Rarely strangulate due to wide neck Reduces spontaneous on lying

Answer 30

Anterior - skin, external oblique aponeurosis Posterior - conjoint tendon forms posterior well medially, transversalis fascia laterally Above - internal oblique and transversus abdominis Below - inguinal ligament

Answer 31

passes through the femoral canal Medial to the femoral sheath Femoral sheath contains the femoral artery and vein ``` Occurs more commonly in women Usually seen in elderly and middle aged Non-strangulated swelling, BELOW and LATERAL to pubic tubercle Enlarges on standing and coughing Disappears on lying down ``` STRAGULATION COMMON due to narrow neck`

Answer 32

Rare condition | Failure of all or part of midgut to return to abdominal cavity in foetal life

Answer 33

Different types In more serious cases - present as respiratory distress shortly after birth and require urgent surgery Others e.g. large oesophageal hiatus = present as regurgitation, vomiting, dysphagia and progressive weight loss in the child

Answer 34

Sliding (90%) stomach slides through hiatus and is covered anteriorly with peritoneal sac, posterior = extraperitoneal. It disturbs cardio-oesophageal mechanism and produces the effect of a space occupying lesion Rolling (10%) Cardia remains in position, stomach rolls up anteriorly through volvulus - partial volvulus. No symptoms of regurgitation. Represents progressive weakening of hiatus muscles. Occur in obese, middle aged and elderly. 4x more common in women

Answer 35

``` cough dyspnoea palpitations hiccough burning retrosternal pain worse on lying and swooping occult bleeding from oesophagitis ```

Answer 36

Treat symptomatically | If not controlled then laparoscopic repair

Answer 37

``` 50 per 100,000 3rd most common malignancy Increases with age More common in men FHx is associated especially regarding HNPCC, FAP ``` ``` RFs UC or Crohn's Pelvic radiotherapy Smoking Alcohol Obesity Sedentary lifestyle High red meat in diet Type 2 diabetes aspirin/NSAIDs Cholecystectomy Low fibre diet ```

Answer 38

Dependent on site of cancer Left - fresh rectal bleeding, early obstruction, tenesmus, mucus (if rectal), early change in bowel habit, mass in LIF Right - anaemia from occult bleeding, altered bowel habit (alternating diarrhoea and constipation), mass in RIF ``` Colicky pain Weight loss Can present with obstruction or perforation SOB/fatigue (from anaemia) Hepatomegaly/ascites if mets Signs of peritonitis ```

Answer 39

Rock hard abdomen rebound tenderness absent bowel sounds

Answer 40

45% rectosigmoid 30% ascending colon 15% descending colon 10% transverse colon

Answer 41

Malignant transformation of benign adenomatous polyp Accumulation of multiple genetic mutations APC gene K-ras gene - failure leads to cell proliferation DCC gene - has a role in invasion and metastasis p533 gene - role in impaired apoptosis and cell proliferation

Answer 42

Hereditary non-polyposis colon carcinoma Also known as Lynch syndrome Occurs at a young age with family history - autosomal dominant Mean age 45, lifetime risk 80% It is the most hereditary syndrome Majority occur proximally Increased risk of other cancers: endometrium, ovary, urinary tract, stomach, small intestine, pancreas, CNS Regular colonoscopy every 1-2 years from 25 Criteria for diagnosis - 3+ relatives with colon cancer (1 must be 1st degree, must be across 2 generations) & 1 family member affected under 50, FAP excluded

Answer 43

Familial adenomatous polyposis Hereditary disorder causing numerous polyps and resulting in colon carcinoma before 40 Autosomal dominant Patients usually asymptomatic Diagnosis by colonoscopy (100+ polylps) and genetic testing (APC gene) Treated with colectomy Polyps present in 50% by 15 and 95% by 35 Extra intestinal manifestations: - osteoma of skull/mandible - sebaceous cysts - increase in cancer: small intestine, pancreas, thyroid, brain, liver and gastric cancer

Answer 44

surgery - without metastatic disease. Tumour + resection margins+ pericolic lymph nodes removed May reanastamose or stoma Adjuvant therapy = if lymph spread it can't be controlled with surgery alone Chemotherapy with 5-FU or carbecitabine or irinotecan

Answer 45

FBC - anaemia LFTs - for mets Colonoscopy for diagnosis + biopsy (GOLD STANDARD) CT colongraphy CT or MRI and liver US for staging PET for recurrent but not initial cancer CEA is raised in colon cancer but is not useful for screening. Good prognostic factor, better outcome if CEA negative,

Answer 46

Faecal occult blood | Every 2 years after 60

Answer 47

>40 + rectal bleeding + loose stools for over 6 weeks >60 with rectal bleeding OR loose stools >6 weeks regardless of other symptoms If right lower abdominal mass consistent with large bowel Palpable rectal mass (NOT pelvic - urology or gynae referral) Men with unexplained iron deficiency anaemia <11 Non-menstruating women with unexplained iron deficiency anaemia <10

Answer 48

``` Dukes A - tumour confined to bowel (10%) B - extension through bowel wall (35%) C - tumour involving lymph nodes (30%) D - distant mets (25%) ``` Or can use TNM T - 1 submuscosa, 2 muscularis propria, 3 pericolorectal tissues, 4A surface of visceral peritoneum, 4B directly invades

Answer 49

``` Abdominal pain ** Localised pain if contained, generalised after rupture Anorexia Nausea Vomiting Fever and chills Diarrhoea ```

Answer 50

High fever in early stages Rebound tenderness Absent bowel sounds Rock hard abdomen Guarding and rigid abdomen Hypotensive Signs of septic shock DRE increases abdominal pain

Answer 51

Spontaneous bacterial peritonitis is acute bacterial of infection of ascitgic fluid resulting from translocation ofbacteria across gut wall Complications of ascites 90% is mono-microbial 40% E.coli, 7% Klebsiella pneumonia, 15% strep 30% Predominantly gram negative

Answer 52

Pathogens depend on location in GI tract Mainly gram positive in upper HI tract Colon perforation generally multi-microbial and predominantly gram negative All caused by perforation

Answer 53

``` Malignancy Penetrating trauma Ulcer perforation Stone perforation Iscahemic bowel Bowel obstruction Crohn's Appendicitis Post-operative Peritoneal dialysis Pancreatitis ```

Answer 54

FBC - raised WBC, CRP LFTs, amylase and lipase for pancreatitis Blood cultures - sepsis Peritoneal fluid for culture Urinalysis to rule out urinary tract pathology Abdominal x=ray CT/MRI

Answer 55

Correction of underlying pathology Systemic antibiotics Supportive therapy to prevent organ system failure Antibiotics are dependent on the cause - usually 3rd generation cephalosporin Haemodynamic, pulmonary and renal support = fluid resuscitation, monitor renal function, blood gases, urine output, BP, HR Nutrition support - high requirement in sepsis Surgery to correct pathology

Answer 56

Foregut = stomach, duodenum, liver, pancreas. Pain described as upper abdominal pain. Midgut = small bowel, proximal colon and appendix. Pain felt in umbilicus Hindgut = distal colon and genito-urinary tract. Lower abdominal pain

Answer 57

``` Pancreatitis Diabetic ketoacidosis Early appendicitis Gastroenteritis Intestinal obstruction Mesenteric ischaemia Peritonitis Sickle cell anaemia crisis Spontaneous bacteria peritonitis Typhoid fever ```

Answer 58

``` Severe pain Tachycardia Hypotension Confusion Signs of peritonitis Abdominal distension ```

Answer 59

``` Appedicitis with gravid uterus Cholecystitis Biliary colic Congestive hepatomegaly Hepatitis Perforated duodenal ulcer ```

Answer 60

Appendicitis Caecal diverticulitis Merkel diverticulitis Mesenteric adenitis

Answer 61

``` Abdominal or psoas abscess Abdominal wall haematoma Cystitis Endometriosis Strangulated hernia IBD PID Renal stone Ruptured AAA Ectopic pregnancy Ovarian cyst torsion ```

Answer 62

Passage of >200g of stool per day | Can be acute or chronic

Answer 63

OSMOTIC - when unabsorbable water solutes remain in the bowel and retain water - Stops with fasting - Examples: sorbitol, malabsorption causing high concentration in lumen, absorptive defect e.g. lactase deficiency SECRETORY - Bowel secretes more electrolytes and water - Persists with fasting - Causes: infection, malabsorption. drugs (colchicine, quinine), endocrine tumours - Enterotoxins cause block of Na/H+ exchange or absorption of Cl- INFLAMMATORY - reduced surface area or contact time - Causes: bowel resection, IBD, Coeliac, shigella

Answer 64

Likely to be infective bacteria: salmonella, campylobacter, shigella, E.coli, C. Diff. bacillus cereus viral: norovirus, rotavirus, CMV, hep A parasite: giardia, Drugs: antibiotics, cytotoxic drugs, PPIs, NSAIDs Ask about recent travel abroad

Answer 65

``` IBS IBD Bowel resection Coeliac disease Pancreatic insufficiency Lactose intolerance Colon cancer Lymphoma Hyperthyroidism Diabetes ```

Answer 66

``` Blood Pus Fever Signs of dehydration Chronic Weight loss ```

Answer 67

1. Enquire about red flag symptoms 2. Assess for dehydration 3. Offer Oral rehydration therapy - 100ml per episode. if sever then IV 5% dextrose 4. Stool cultures 5. Faecal examinati0on for parasites and ova 6. Faecal alpha 1 antitrypsin levels - high in entroinvasive infections usually self-limiting Only requires supportive treatment

Answer 68

- lack of fibre or fluid intake - immobility - old age - bowel obstruction: volvulus, adhesions, hernia, faecal impaction, strictures - IBS - Drugs: opiates, anti-cholinergic, calcium antagonists, iron supplements, anatacids, antipsychotics, antispasmodics, general anaesthetics - Colon cancer - Obstruction: strictures, Crohn's, pelvic mass - Metabolic/endocrine: hypothyroid, hypercalcaemia, hypokalaemia - Neuromuscular: spinal or pelvic nerve injury, diabetic neuropathy - Parkinsonism - Diabetes - Pregnancy - Depression

Answer 69

``` Distended abdomen Vomiting Blood in stool Weight loss Severe constipation with recent onset or worsening Over 50 ```

Answer 70

Blood tests FBC, U&E, TFTs, calcium Blood glucose Abdominal X-ray for masses or obstruction PR exam barium enema or colonoscopy/sigmoidoscopy

Answer 71

Functional constipation. must include 2 or more of: - straining - lumpy/hard stools - sensation of incomplete evacuation - Sense of anorectal obstruction - Manual manoeuvres - Less than 3 per week Each symptom must be present >25%

Answer 72

1. Separate hard lumps 2. Lumpy sausage shape 3. Like sausage with cracks 4. Sausage, smooth and soft 5. Soft blobs with clear cut edges 6. Fluffy with ragged edges (mushy) 7. Watery, no solid pieces

Answer 73

INITIAL if no alarm - Patient education - High fibre diet - Increase fluids - Increase exercise - Bulk laxatives 1. Bulk laxatives e.g. ispaghula husk 2. Osmotic or stimulant laxatives 3. Refer

Answer 74

6 month history of either: abdominal pain or discomfort, bloating or change in bowel habit - Pain improves in defaecation - Altered passage of stool: straining, urgency, incomplete evacuation - Abdominal bloating - Distention - Symptoms aggravated by eating - Rectal mucus - lethargy - Nausea - Backache - Urinary frequency and urgency - Headaches and migraine

Answer 75

10-20% of population Increased in women (2:1) Peak between 20-40 RF Emotional stress Food poisoning or gastroenteritis Mental health condition

Answer 76

Rome III Criteria Recurrent abdominal pain for over 3 months, at least 3 days per month, PLUS 2 or more of: - Pain improves with defaecation - Change in stool frequency - change in stool form

Answer 77

Psychological factors, altered GI motility, altered visceral sensation 7-30% develop IBS following gastroenteritis

Answer 78

``` FBC, ESR, CRP Coeliac screen CA-125 if ?ovarian cancer Faecal calprotectin if ?IBD Colonoscopy or sigmoidoscopy Refer if any RED FLAGS ```

Answer 79

IBS-C - constipation - loose stool <25%, Hard stools >25% IBS-M - mixed - both hard and soft stools >25% of the time IBS-D - diarrheoa - loose stool >25%, hard <25%

Answer 80

Constipation - high fibre diet, bulk forming laxatives (ispaghula husk) or osmotic (but avoid lactulose) Diarrhoea - reduce fibre + loperamide, codeine, colestyramine Pain and bloating - use spasmolytic drugs e.g. amitryptiline Treat the symptoms of the patient CBT, hypnotherapy, psychotherapy

Answer 81

``` Dysphagia Affecting solids more than liquids Regurgitation in 80% Chest pain in 50% - occurs after eating, retrosternal Heartburn is common Weight loss suggests malignancy Nocturnal cough No signs! ```

Answer 82

Smooth muscle layer of oesophagus has impaired peristalsis and failure of the sphincter to relac causes functional stenosis or stricture Most have no underlying cause

Answer 83

CXR - vastly dilated oesophagus Barium swallow - usually precedes endoscopy when investigating dysphagia as can perforate malignancy with endoscope. Birds beak - narrow segment in distal oesophagus. Endoscopy Manometry - is GOLD STANDARD - can detect 90% of cases. High resting pressure in cardiac sphincter, incomplete relaxation on swallowing and absent peristalsis If no radiological evidence - it may be pseudoachalasia

Answer 84

Calcium channel blockers and nitrates - reduce pressure in lower sphincter. Only works in 10% Heller myotomy - divide muscles longitudinally (90% success) Pneumatic dilation - balloon inflated to rupture muscle, leaving mucosa intact Enodscopic injection of botulinum but recurs in the majority. Endoscopic stent insertion

Answer 85

``` benign stricture: schataki ring, GORD Malignant stricture: SCC, adenocarcinoma Stroke Achalaisa Parkinson's Motor neurone disease Myasthenia gravis ```

Answer 86

13th most common in the UK, 8th most common worldwide Increased in age - most are over 60 Increased in men High in East African and Asia Increasing prevalence of adenocarcinoma, decreasing SCC ``` RF Adenocarcinoma - Caucasian - Barrett's oesophagus - Obesity ``` SCC - Achalasia - Corrosive strictures - Coeliac - African Both - Smoking - Alcohol - Radiation to area - Genetics - Diet (high sat fat)

Answer 87

``` Dysphagia (initially liquids then solids) Vomiting Anorexia Weight loss Blood loss/ melaena Odynophagia (painful swallowing) Hoarseness Retrosternal or epigastric pain Persistent cough Lymphadenopathy ```

Answer 88

Adenocarcinoma - more common in lower oesophagus. Mainly progression from Barrett's oesophagus Squamous cell carcinoma - can be anywhere along the oesophagus

Answer 89

FBC - anaemia U&Es, LFTs for baseline CRP - can be raised Glucose Urgent endoscopy and biopsy CXR for mets and spread Double contrast barium swallow Staging - FDG PET/CT or MRI Endoscopic Ultrasound

Answer 90

50% have mets at diagnosis presents late as 75% of lumen needs to affected around the circumference before difficulties present 20-25% 5 year survival rate AC and SCC have the same prognosis

Answer 91

Primary = surgery +/- chemo +/- radiotherapy Surgery - antibiotic and antithrombotic prophylaxis given - If early, endoscopic muscosal resection - If late: oesophagectomy endoscopically if possible - Abdominal lymphadenectomy is beneficial - Chemo and radiotherapy shrink tumour prior to resection Palliative - Can use chemo/radiotherapy to decrease bulk - Fit stent to allow swallowing - PEG for feeding - ANALGESIA

Answer 92

25% of adults, 5% have daily symptoms More common in men RFs - Obesity - Pregnancy - Systemic sclerosis - Drugs: nitrates, TCAs, anticholinergics, calcium channel blockers - Hiatus hernia - Increased intra abdominal pressure - Smoking - Alcohol - Large meals

Answer 93

``` Heartburn worsened on lying or bending down Retrosternal discomfort Regurgitation Pain on swallowing Nocturnal cough Excessive salivation Chronic hoarseness Acid brash Pain relieved by antacids ``` No signs

Answer 94

60-70% have normal endoscopy (non-erosive reflux disease) 20-30% erosive oesophagitis 6-10% Barrett's oesophagus Can show basal hyperplasia, inflammation, Goblet cell metaplasia, thinning of squamous layer or dysplasia

Answer 95

Spectrum of disorders from endoscopy negative GORD to oesophageal damage 3 main causes: - Poor oesophageal motility - Dysfunction of lower oesophageal sphincter (permanent or intermittent relaxation or increase in abdominal pressure) - Delayed gastric emptying

Answer 96

FBC to exclude anaemia H.pylori stool test (stool antigen test) Endoscopy +/- biopsy (must be drug free for 2 weeks) Barium swallow

Answer 97

Assess for possibility of GI bleed Simple lifestyle advice: healthy eating, weight reduction, smoking cessation. Avoid precipitants: smoking, alcohol, coffee, chocolate, fatty foods, acidic foods e.g. tomatoes, oranges Raised head of bed Avoid eating late at night If H.pylori positive, treat Full dose PPI for 4 weeks. Can offer H2 receptor agonist therapy as alternative. Antacids as required If very severe and uncontrollable, can fit magnetic band around LOS to aid closure.

Answer 98

``` Dysphagia Dyspepsia + weight loss/anaemia Dyspepsia new onset in over 55s Dyspepsia plus one of: - FHx of upper GI cancer - Barrett's - Pernicious anaemia - upper abdominal mass - known dysplasia ```

Answer 99

``` Oesophagitis Ulceration Anaemia Stricture Barrett's oesophagus ```

Answer 100

Premalignant condition Normal squamous lining is replaced by columnar cells Adaptive response to GORD

Answer 101

Savary-Miller Grading system 1. single or multiple erosions on single fold 2. multiple on multiple folds 3. multiple circumferential erosions 4. ulcers, stenosis or oesophageal shortening 5. Barrett's Can use Los Angeles Grades A-D

Answer 102

Of the 1% with reflux receiving endoscopy, 13% will have peptic ulcer disease 1 per 1000 (0.1%) Decreasing in Western populations Increased in males RFs - Smoking - Alcohol - NSAID or steroid use

Answer 103

``` Post-prandial epigastric pain Relieved by food Nausea Oral flatulence Bloating Intolerance of fatty foods Heartburn Pain can radiate to the back if ulcer is posterior Fatigue or dyspnoea if anaemia melena ``` Signs Epigastric tenderness

Answer 104

``` H. pylori Bile acids NSAIDs Steroids pepsin Stress Smoking Changes in mucus consistency Alcohol ```

Answer 105

``` Gram negative spiral Lives deep beneath mucus layer Closely adheres to epithelial surface Uses an adhesin (BabA) Any acidity is buffered by urease ```

Answer 106

1. Depletion of somatostatin 2. increase gastrin release from G cells 3. Increased acid secretion 4. Increased acid load in duodenum will cause metaplasia

Answer 107

FBC - iron deficiency anaemia H. pylori test - 13C breath test or stool antigen test Endoscopy if there are any warning signs

Answer 108

Lifestyle advice: stop smoking and alcohol If H.pylori positive treat If taking NSAIDs = STOP If neither is positive (rare), endoscopy for ? Zollinger-Ellison syndrome Endoscopic ablation if actively bleeding

Answer 109

Perforation (more common in duodenal) Gastric outlet obstruction Bleeding Anaemia

Answer 110

TRIPLE therapy for 7 days Clarithromycin PPI Amoxicillin or metronidazole

Answer 111

Chronic discomfort in the upper abdomen without any organic disease (as seen in GORD) Drug treatment not useful. Prokinetic drugs e.g. metoclopramide may be helpful

Answer 112

Formation of gall stones within the gall bladder | Choledocholithiasis - stones in the common bile duct

Answer 113

10-15% of Western population but only 10-25% of these become symptomatic Increases with age Increased in women increased in middle age Fair, fat, fertile, female and 40 ``` RF FHx Obesity Pregnancy Sudden weight loss Haemolysis (sickle cell) Loss of bile salts (ileal resection) Drugs (oestrogens, fibrates, somatostatin) Diabetes Oral contraception Crohn's ```

Answer 114

70% are asymptomatic Pain in RUQ or epigastrium, can radiate to the back Pain begins post-prandially Pain is intense and dull Subsides spontaneously, after analgesia, vomiting, antacids, defaecation, flatus or positional changes Sporadic and unpredictable episodes Persists from 5 minutes to 24 hours Nausea or vomiting can accompany pain Intolerances to fats Abdominal distension Can have diaphoresis (excessive sweating)

Answer 115

No findings if asymptomatic Tachycardia (due to pain) No peritoneal signs If complications: can have jaundice, positive Murphy's sign or pancreatitis

Answer 116

Cholesterol stones (80%) Large, solitary and radiolucent Increased with increased cholesterol Pigment stones (20%) Small, black and friable, irregular radiolucent RFs - haemolysis and cirrhosis Occurs with high levels of unconjugated bilirubin Calcium bilirubinate can crystalise to form stones Mixed stones - calcium salts, pigment and cholesterol, 10% are radio-opaque Brown pigment stones <5%, due to stasis and generally present with E.coli or Klebsiella infection

Answer 117

1. Lithogenic state in which conditions favour gall stones: high cholesterol, low bile sales 2. Asymptomatic gallstones 3. Symptomatic gallstones with episodes of biliary colic 4. Complicated cholethiasis

Answer 118

Blood tests: FBC, LFTs, amylase and lipase If uncomplicated or simple biliary colic, will be normal Abdominal x-ray to rule out obstruction US - best way to see stones. They are usually echogenic, mobile and cast an acoustic shadow. ERCP - can be used to see and remove stones in CBD MRCP - using MRI, reserved for suspected choledolithiasis.

Answer 119

Manage with pain with morphine Laparoscopic cholecystectomy If unfit for surgery can surgical drain the gallbladder (cholecystotomy) If stones in bile duct then - cholecystectomy and CBD exploration and stone extraction Consider mechanical or shock wave lithotripsy If asymptomatic watch and wait.

Answer 120

``` stone > 2cm high risk of GB carcinoma Non-functioning GB Sensory neuropathy of abdomen Sickle cell anaemia Cirrhosis or portal hypertension Children Transplant candidates Diabetics ```

Answer 121

``` Cholangitis if in biliary tree GB empyema Gallstone ileus Fibrosis of gallbladder Loss of gallbladder function GB carcinoma ```

Answer 122

``` 10% have gallstones 1/3 get cholecystitis Increases with age increased in females Although acalculus is more common in men ``` ``` RFs Gallstones Trauma Obesity Rapid weight loss Pregnancy Crohn's Hyperlipidaemia ``` ``` RF for acalculus Major surgery Long term parenteral nutrition Sepsis Prolonged fasting ```

Answer 123

Upper abdominal pain may radiate to right shoulder or scapula Pain begins in epigastrium and localises to RUQ Starts colicky but becomes constant in all cases nausea and vomiting Fever

Answer 124

``` Raised WCC Positive Murphy's sign Local peritonism Fever Tenderness in epigastrium/RUQ Tachycardia Jaundice Guarding/rebound tenderness palpable GB ```

Answer 125

90% are calculous Stone obstructs cystic duct causing distension of GB Blood flow and lymph drainage of the gallbladder are compromise and can cause ischaemia and necrosis Acalculous 10% Cause unclear. If fasting GB has no CKK stimulus and so bile remains stagnant

Answer 126

GALLSTONES ``` Acalculus MI Sickle cell Salmonella Diabetes AIDS CMV pregnancy ```

Answer 127

Blood tests - Raised WCC Raised ALT and AST Check amylase and lipase for pancreatitis Urinalysis to rule out pyelonephritis and renal stones Pregnancy test CXR to rule out lower lobe pneumonia or see radiopaque stones US - thickened gall bladder wall >3mm, pericholecystic fluid or air on GB or GB wall CT with IV contrast

Answer 128

``` Rest IV hydration Bowel rest - no intake Correct electrolyte imbalance Analgesia IV antibiotics (tazocin/metronidazole) Laparoscopic cholecystectomy ERCP ```

Answer 129

Charcot's triad RUQ pain Jaundice Fever Reynold's pentad adds confusion and hypotension

Answer 130

Infection of biliary tract Majority of cases are due to gall stones 10-30% are due to benign strictures, post-op damage, tumours, bacteria (anaerobes) and parasites Carries significant risk of death due to shock or multi organ failure

Answer 131

``` Raised CRP or WCC Increased LFTs (ALP, AST, ALT, GGT) ```

Answer 132

8th most common cancer Increases in Asia and South America Increases with age More common in men 50% in pylorus, 25% in lesser curve, 10% cardia, 2-8% lymphomas ``` RFs H.pylori infection Smoking Diet: rich in pickles, salt, smoked meats and fish FHx Poor socioeconomic status Previous gastric surgery Obesity ```

Answer 133

Correa's cascade - Chronic non-atrophic gastritis - Atrophic gastritis - Intestinal metaplasia - Dysplasia - Cancer Can spread to ovaries 2 main types: - Intestinal (type 1) with well formed glandular structures. Ulcerating lesions with heaped rolled edges. Strong environmental association - Diffuse (type 2) poorly cohesive cells. Poorer prognosis. Loss of expression of E=cadherin molecule

Answer 134

FBC for anaemia LFTs Rapid access flexible endoscopy: Gastroscopy and biopsy Endoscopic US for local staging and depth Chest/Abdo/Pelvis CT 18F PET/CT

Answer 135

Surgery is treatment of choice If distal then subtotal gastrectomy, if proximal then total If curable remove D2 lymph nodes Perioperative chemotherapy is standard with 5-FU, but can be palliative Blood transfusion if anaemia Corticosteroids for management of anorexia

Answer 136

Overall survival rate 15% 11% live 10 years Younger patients have a better prognosis Poorer prognosis if paraneoplastic syndrome

Answer 137

150 per million 3% of all abdominal pain in hospital High in USA & Scandinavia Equal gender distribution RF - Alcohol abuse - Some family history (alpha 1 antitrypsin deficiency) - Hyperlipidaemia - Gallstones - CF - Smoking - Oestrogens - Hypothermia - Congenital abnormalities - Vasculitis

Answer 138

``` Severe upper abdominal pain Decreases steadily over 72 hours Pain focused in LUQ or epigastrium Penetrates tot he back Sudden onset vomiting ```

Answer 139

``` Mild pyrexia (common), rare but can have hypothermia Hyperlipidaemia Tachycardia Jaundice Abdominal tenderness and rigidity Bowel sounds in early phase Paralytic ileus causes absent bowel sounds Hypoxaemia ``` ``` In severe: Gross hypotension Pyrexia Tachypnoea Ascites Pleural effusion Body wall staining around umbilicus (Cullens sign) or Grey Turner's (flanks) ```

Answer 140

Body wall staining around the umbilicus

Answer 141

Body wall staining on the flanks

Answer 142

90% are caused by gallstones, alcohol, post-ERCP or idiopathic ``` Idiopathic Gallstones Ethanol Trauma Steroids Mumps/malignancy Autoimmune Scorpion bite Hyperlipidaemia ERCP Drugs ``` Viral causes - Coxsackie B, hepatitis, mumps Drugs - thiazides, valproate, azathioprine IBD Alpha 1 antitrypsin deficiency Sclerosing cholangitis Vasculitis Hyperparathyroidism

Answer 143

Occurs as a consequence of premature activation of zymognes releasing proteases that digests surrounding tissues. Severe is dependent on balance between proteases and anti-proteolytic factors (Alpha anti-trypsin_ Occurs because of one of: - Defective intracellular transport and secretion of pancreatic zymogens - Pancreatic duct obstruction - Hyperstimulation of pancreas (alcohol/fat) - Reflex of infected contents into CBD

Answer 144

FBCs, U&Es, LFTs, CRP, glucose - Amylase 3x normal - Lipase is more sensitive and specific - Hypocalcaemia is common Abdominal x-ray - rule out perforation and obstruction CXR - at show pleural effusions or ARDS CT + contrast is bloods unclear After 4 days can assess for complications - pancreatic swelling, fluid collection, change in density of gland US - poorly visualised in 25-50% of cases See swollen pancreas, dilated CBD, free peritoneal fluid MRI for acute abdominal wall oedema Laparoscopy if inconclusive results

Answer 145

MILD - Manage on general ward - Pain relief with pethidine +/- benzos - NBM - IV fluids - Nasogastric tube if severe vomiting - Antibiotics for specific infections - resume oral fluids once symptoms resolve and normal blood tests MODERATE - Treat in HDU or ITU - If pancreaitic necrosis - IV antibiotics and peritoneal fluid culture - Enteral nutrition via NG below Ligament of Treitz - Surgery only if infection and necrosis = open surgical debridement - Early ERCP for co-existing cholangitis

Answer 146

Pancreatic necrosis (if infected then 3x mortality) - confirmed by CT. Infected necrosis - fatal without intervention (Infection in 30-70% of necrosis) - IV antibiotics and agrressive surgical debridemnt Fluid collections Pancreatic abscess - occurs several months after the attack, requires surgery Acute pseudo-cyst - occurs 4 weeks after the attack. Can rupture/haemorrhage, requires surgery Pancreatic ascites from collapsed pseudocyst Acute cholecystitis Systemic complications - pulmonary oedema, pleural effusions, consolidation, hypovolaemia, shock, renal dysfunction, hypocalcaemia, hypomagnesaemia, hyperglycaemia, GI haemorrhage, Weber-Christian disease

Answer 147

80% have mild and recover without complications 5% mortality in mild 30% mortality in severe

Answer 148

Glasgow Prognostic Score Ranson's criteria (very similar) 3+ = severe pancreatitis Can also use APACHE II = 8 or more is severe

Answer 149

``` Pancreatitis Renal failure Ectopic pregnancy Diabetic ketoacidosis Perforated duodenal ulcers Mesenteric ischaemia ```

Answer 150

``` Episodes of exacerbation with intervening remission or continuous pain Abdominal pain Epigastric and radiating to the back Nausea and vomiting Decreased appetite Weight loss Steatorrhoea ```

Answer 151

Exocrine dysfunction - Malabsorption - Diarrhoea/steatorrhoea - Protein deficiency Endocrine dysfunction - diabetes mellitus Abdominal tenderness

Answer 152

``` Alcohol abuse Smoking Genetics (PRSS1, CFTR, SPINK1) Male Black ```

Answer 153

Obstruction OR reduction of bicarbonate excretion These lead to the activation of pancreatic enzymes - causing pancreatic necrosis Alcohol causes proteins to precipitate in pancreatic ducts leading to pancreatic dilation and fibrosis. It leads to ductal plugging and obstruction - Alcohol most common cause - Increased protein secretion, decreases fluid, decreased bicarbonate production 2 pathological subtypes: - LARGE DUCT: dilation and dysfunction of large ducts visible on imaging. - Occurs more in men, steatorrhoea common, requires surgery to alleviate symptoms - SMALL DUCT: occurs more in women, no diffuse pancreatic calcification. Imaging normal - hard to diagnose. - Patients respond to pancreatic enzyme replacement

Answer 154

Rare Similar to chronic Genetic mutation in PRSS1 This increases autoactivation of chymotrypsin C Presents at a young age with epigastric pain Exocrine and endocrine dysfunction High incidence of pancreatic carcinoma

Answer 155

Developing countries Associated with type 1 diabetes Associated with CFTR and SPINK1 genes Similar to alcoholic pancreatitis presentation

Answer 156

``` High prevalence in Japan Elevated IgG and serum gammaglobulins Autoantibodies may be increased Steroid responsive. Reversible ```

Answer 157

Blood tests - FBC - U&Es - LFTs - Calcium (hypocalcaemia) - Amylase (raised) - Glucose and HbA1c Secretin stimulation test - positive if pancreatic exocrine function damaged Serum trypsinogen, urinary D-xylose Faecal elastase All seen in malabsorption US - first line then CT -> ERCP - See pancreatic calcification MRCP Pancreatic biopsy - chronic inflammation, irregularly placed fibrosis, Rarely performed as high risk Tests of pancreatic function: - GOLD standard is collection of pure pancreatic juice after secretin injection (rarely used due to invasive nature) - Pancreolauryl test or PABA test - Faecal pancreatic elastase

Answer 158

Supportive measures Lifestyle advice - smoking cessation, alcohol abstinence Pain relief - opiates ERCP may reduce pain Malabsorption is treated by pancreatic enzyme replacement - Lipase treatment of choice Octreotide (somatostain analogue) inhibits pancreatic enzyme secretion and CCK levels Surgery - pseudocyst decompression, ERCP + lithotripsy - If large duct dilation: pancreaticojejunostoy - Pancreatoduodenectomy

Answer 159

``` Cobalamin Deficiency (B12) Diabetes Pericardial, peritoneal and pleural effusions Pseudocysts Pancreatic carcinoma ``` Increased risk of morbidity and mortality. 1/3 die in 10 years

Answer 160

Very common in developing countries, particularly in early life Most common viral hepatitis High risk: India, Africa, South and Central America, Middle Esat ``` RFs - Personal contact - Occupation - residential home staff, sewage worker - Travel to high risk areas - ```

Answer 161

``` Small unenveloped RNA virus Enterovirus in picornaviridae family Incubation period 2-6 weeks Spread through faecal oral route Can be vaccinated with ```

Answer 162

More severe in older patients, children can be asymptomatic - Mild-flu like symptoms - Anorexia, nausea, fatigue, malaise, joint pain, mild headache - Following this: jaundice - Icteric phase: dark urine, pale stools, jaundice, abdominal pain, pruritus, arthralgia, skin rash

Answer 163

1. Receptor binding 2. RNA uncoating 3. Tranlocation and proteolytic processing. Host ribosomes bind to form polysomes 4. RNA replication. Genome copied by viral RNA polymerase 5. Virion assembly 6. maturation and release. Shed via biliary tree into faeces Shedding greatest between 14-21 days after infection

Answer 164

Specific antibody tests - IgM antibody to Hep A (positive for 3-6 months) IgG occurs after and persists for many years LFTs - ALT>AST. Raised ALP Levels return to normal over several weeks Raised bilirubin Modest decrease in albumin Mild lymphocytosis common

Answer 165

Mainly supportive - fluids, antiemetics, rest Avoid alcohol until liver enzymes return to normal For immediate protection can give immune serum globulin

Answer 166

Excellent Self limiting No long term sequale No carrier state. No chronic liver disease Complications - cholestatichepatitis, autoimmune hepatitis, relapsing hep A infection 4-15 weeks after first illness.

Answer 167

High prevalence in sub-Saharan Africa, most of Asian and Pacific Islands 1 in 350 in UK Starting to decline due to vaccinations RFs - Homosexual males - Sex workers - IV drug users - HIV + patients - Sexual assault victims - Healthcare workers/needle stick injuries

Answer 168

Double stranded DNA Hepadnoviridae family Incubation period 40-160 days (average 60-90) Can be e antigen positive or negative (positive = increase rate of replication) Transmission: vaginal or anal intercourse, blood to blood contact, vertical transmission

Answer 169

HBsAg - hep B surface antigen Indicator of active infection If present after 6 months then chronic infection HBcAg - Hep B core antigen Detected by its antibody IgM then IgG HBeAg - Hep B e antigen Indicator of viral replication Chronic infection = HbsAg and anti-HBcAg (IgG)

Answer 170

Blood tests - HBsAg (only detected in first 3-5 weeks after infection - unless chronic infection) - HBsAg antibodies - in vaccinated people - HBeAg - if positive, active infection - HBcAg antibodies - past infection - Dane particles are Hep B virions, can have anti-Dane antibodies - Quantitative Hep B DNA - FBC, bilirubin, LFTs, clotting, ferritin, lipid profile, caeruloplasmin - Test for Hep C and HIV - Alpha fetoprotein and liver US for hepatocellular carcinoma screen

Answer 171

Avoid unprotected intercourse Notify HPA Supportive treatment - fluids, antiemetics, rest Avoid alcohol. Stop unnecessary medications ``` Give antiviral agents if - Fulminant hepatitis - HBeAg positive - Pregnancy with high HBV DNA Give: peginterferon alpha-21 or tenofovir ``` - Monitor ALT every 24 weeks, more often if cirrhosis - Test for HCC (US and alpha fetoprotein) Can give hepatitis B immunoglobulin to baby to reduce risk of vertical transmission or just after infection to decrease risk

Answer 172

Cirrhosis 20% Faster progression in Hep C or HIV positive as well

Answer 173

``` Flu like illness - nausea, anorexia, mlaise, ache in RUQ Jaundice Disinclination to drink alcohol Dark urine Pale stool ``` Fever In decompensated - ascites, encephalopathy, Gi haemorrhage

Answer 174

Acute - asymptomatic, often diagnosed on routine blood testing 20-30% get jaundice Chronic - malaise, weakness, anorexia, abdominal pain Symptoms are worse with increased alcohol intake

Answer 175

Large number undiagnosed 214,000 in UK RF - Drug misuse - Blood transfusion pre-1991 - Sexual intercourse - Infected pregnant mother - Healthcare worker - Needlestick injury - Tattoo, body piercing - Sharing razors/toothbrushes

Answer 176

Enveloped RNA virus Flavivirdae family Incubation period 6-9 weeks Hep C RNA can be found after 2-4 weeks, antibodies at 6-12 weeks Transmission - Parenteral, blood born, sexual contact, vertical transmission 6 genotypes - 1 = most common - 2, 3, 4, 5, 6

Answer 177

- Anti HCV serology - HCV RNA quantitative PCR - HCV antibody positive for life regardless of treatment - US: focal lesions, splenomegaly, cirrhosis - Liver biopsy to assess severity - Measures of severity: macroglobulin, haptoglobulin, apolipoprotein A1, GGT, total bilirubin, transient elastography - Test for Hep B and HIV

Answer 178

Advice - counselling, barrier contraception, alcohol abstinence, implications of being positive Drugs effectiveness is related to genotype Better response in type 2 and 3 - Weekly subcut peginterferon alpha2a

Answer 179

50-85% become chronic carriers 15% will clear virus completely Cirrhosis in 20-30% of chronic 1-4% get HCC, 2-5% get liver failure Co-infection with Hep B or HIV = worse prognosis Type 1 more likely to clear spontaneously

Answer 180

``` Single stranded RNA virus Enveloped spherical deltavirus Requires presence of Hep B to replicate Patients must be HBsAg positive Delta virus Blood bourne Clinically indistinguishable from Hep B infection ``` Replicated only in liver cells Increases risk of fulminant hepatic failure, chronic liver disease, cirrhosis and HCC with B+D Chronic in 30-50% Incubation 3-20 weeks

Answer 181

Hepeviridae Non-enveloped single stranded RNA Spread via faecal oral route Self-limiting with no chronic infections Incubation 2-9 weeks Fulminant disease in 10% Mild flu like symptoms

Answer 182

HBsAg antibody - positive HBsAg - negative HBcAg antibody - negative

Answer 183

HBsAg - positive HBcAg antibody - positive HBcAg IgM - positive HBsAg antibody - negative

Answer 184

HBsAg - positive HBcAg IgG - positive HBsAg antibody - negative

Answer 185

HBsAg antibody - positive HBcAg antibody - positive HBsAg - negative

Answer 186

Occurs when liver loses the ability to regenerate or repair so that decompensation occurs. Characterised by - - Hepatic encephalopathy - Abnormal bleeding - Ascites - Jaundice Fulminant hepatic failure - when failure takes place within 8 weeks of the onset of underlying illness Late onset/subacute fulminant - when it occurs during 8-26 weeks Chronic decompensated hepatic failure - after 6 months

Answer 187

``` Chronic alcohol abuse Poor nutritional status Female Chronic Hep B/C infection Chronic pain and narcotic use Pregnancy Paracetamol Antidepressant therapy Medications Illicit drug use ``` FHx - Wilson's disease, haemochromatosis

Answer 188

Toxins - alcohol, Paracetamol, Reye's syndrome, drugs (co-amoxiclav, ciprofloxacin, doxycycline, erythromycin), ectasy, cocaine Infections - viral hepatitis, EBV, CMV, viral haemorrhagic fevers Cancer - HCC or mets Pregnany related - acute fatty liver of pregnancy Autoimmune liver disease Metabolic - Wilson's disease, alpha 1 antitrypsin deficiency Vascular - ischaemia or veno-occulsive disease. Budd-Chiari syndrome

Answer 189

``` Nausea and vomiting Malaise Abdominal pain RUQ tenderness Drowsiness and possibly confusion Jaundice Abdominal distension - ascites, hepatomegaly Papilledema,, hypertension, bradycardia (from cerebral oedema) Asterixis Palmar erythema Hepatic encephalopathy ```

Answer 190

FBC - thrombocytopaenia, leucocytosis, anaemia LFTs - Very raised transaminases, raised ALP Raised INR, Raised bilirubin, raised ammonia, low glucose May have: raised lactate, raised creatinine Blood cultures - very susceptible to infection Viral serology Free copper (Wilson's), Paracetamol levels for OD ABG - metabolic acidosis Dopper US, CT or MRI Avoid contrast

Answer 191

Intensive care management Mannitol to decrease ICP Lactulose + neomycin to reduce ammonia AKI may require haemodialysis or haemofiltration FFP, platelets and anti-fibrinolytic drugs for abnormal bleeding Replace glucose as required

Answer 192

Infection - Spontaneous peritonitis common Cerebral oedema Haemorrhage Bleeding, sepsis, cerebral oedema, AKI, respiratory failure High morbidity and mortality Cause depends on outcome Higher survival if Paracetamol, hep A, pregnancy

Answer 193

Yellow discolouration caused by accumulation of bilirubin in tissue Not apparent until serum bilirubin is over 35 It can be pre-hepatic, hepatocellular, post-hepatic

Answer 194

Haemoglobin broken down in spleen to biliverdin. Biliverdin in plasma converted to unconjugated bilirubin and bound with bilirubin Unconjugated becomes conjugated in liver by glucaronic acid Secreted into bowels where converted to urobilinogen by bacteria, secreted in stool as stercobilin

Answer 195

``` Any prodromal flu like illness may suggest viral hepatitis Pain suggest gallstones painless suggests cancer Change in colour of urine and stools Pruritus Weight loss Alcohol or drug use medication history! amitriptyline, erythromycin, COCP, rifampicin, salicylates ```

Answer 196

``` Jaundice - skin and sclera Spider naevi Palmar erythema Gynaecomastia Testicular atrophy Flapping tremor Ascites Splenomegly Finger clubbing Peripheral oedema ```

Answer 197

Gilbert's syndrome - unconjugated hyperbilirubinaemia Haemolytic anaemia - spherocytosis, pernicious anaemia Thalassaemia Trauma Crigler-Najjar syndrome

Answer 198

``` Viral hepatitis HCC Alcoholic hepatitis Autoimmune hepatitis Drug induce hepatitis (Paracetamol) Decompensated cirrhosis ```

Answer 199

``` Gall stones Bile duct strictures Common duct stone Head of pancreas cancer Tumour at ampulla of Vater Pancreatitis GB cancer Primary biliary cirrhosis Primary sclerosing cholangitis ```

Answer 200

Raised unconjugated bilirubin Normal AST, ALP, GGT Raised reticulocytes Normal INR, PT

Answer 201

``` Raised bilirubin ** Raised AST ALT>AST Raised ALP Raised GGT Raised INR and PT Raised urobilinogen with raised or normal bilirubin ```

Answer 202

``` Very high bilirubin Raised AST ** Raised ALP ** Raised GGT Rasied INR and PT ALT>AST Raised urine bilirubin ```

Answer 203

``` FBC - reticulocytes and blood smear LFTs Hepatitis viral serology Serum ANA and anti-smooth muscle antibody for primary biliary cirrhosis Ferritin for ?haemochromatosis Alpha 1 antitrypsin levels Abdominal US MRI/MRCP Liver biopsy ```

Answer 204

Primary biliary cirrhosis

Answer 205

Autoimmune hepatitis

Answer 206

Hepatocellular carcinoma

Answer 207

Serum iron Transferrin Ferritin

Answer 208

Serum and urine copper | Serum caeruloplasmin

Answer 209

Antinuclear cytoplasmic antibody

Answer 210

Growing incidence More common in males Increases with age RFs Alcohol consumption - prolonged and heavy Hep C infection Female - more rapid progression, requires lower dose of alcohol to achieve Smoking Obesity Over 65 Hispanic Genetic predisposition - alcohol metabolising enzymes

Answer 211

3 stages: steatosis (fatty liver) --> alcoholic hepatitis --> alcoholic liver cirrhosis Alcohol converted to acetaldehyde by alcohol dehydrogenase. At thee same time NAD converted to NADH NADH inhibits gluconeogenesis and increases fatty acid oxidation Uses other pathways to metabolise alcohol and this generates free radicals

Answer 212

``` Abdominal pain Weight loss/gain Anorexia Fatigue Jaundice Nausea and vomiting If severe - peripheral oedema, abdominal distension ```

Answer 213

``` Hepatomegaly Palmar erythema Ascites Asterixis Telangiectasia Pruritus Fever Dupytren's contracture Gynaecomastia Hypogonadism Dementia Peripheral neuropathy ```

Answer 214

FBC - anaemia, leucocytosis, thrombocytopaenia, raised MCV LFTs - Raised AST and ALT - AST>ALT - Raised or normal ALP - Raised GGT and bilirubin - Normal or prolonged PT and INR U&Es Hepatic US - Hepatomegaly, fatty liver, liver cirrhosis, liver mass, splenomegaly, ascites, portal hypertension Consider - hepatic virology, iron, ferritin, transferrin, copper, caeruolplasmin, AMA, ANA, AMSA, alpha 1 antitrypsin Biopsy

Answer 215

Removal alcohol Thiamine for Wernicke-Korsakoff syndrome Diazepam for DTs Decrease weight, smoking cessation Nutritional supplements and multivitamins Immunisation - influenza, pneumococcal, hep A and B Corticosteroids - if hepatic encephalopathy Sodium restriction and diuretics Liver transplant

Answer 216

Improves with alcohol cessation With abstinence 5 year survival = 90%, without = 60% If advanced liver disease (jaundice, ascites, haematemesis = 35%

Answer 217

``` 40-60 years NAFLD is equal in both sexes More prevalent in Hispanics NAFLD 20-30% of population Non-alcoholic steatohepatitis - 5% Fatty liver is found in 50% of heavy alcohol users and 94% of obese individuals ```

Answer 218

Steatosis - accumulation of fat in liver Steatohepatitis - fatty liver causing inflammation Can be divided into: - Alcoholic fatty liver disease - NAFLD - non alcoholic fatty liver disease Only difference is alcoholic consumption When inflammation is present can get NASH non-alcoholic steatohepatitis which can progress to cirrhosis and HCC

Answer 219

Metabolic syndrome - T2DM, impaired glucose tolerance, central obesity, dyslipidaemia, hypertension PCOS Alcohol exceess Starvation, rapid weight loss, gastric bypass surgery Total parenteral nutrition and re-feeding syndrome Hep B, C, HIV Medication - Amiodarone, tamoxifen, steroids, tetracycline, oestrogens, methotrexate Wilson's disease

Answer 220

Accumulation of triglycerides and other lipids in hepatocytes Result of defective fatty acid metabolism, mitochondrial damage (alcohol), insulin resistance or impaired receptors and enzymes Histologically undistinguished from alcoholic hepatitis Mallory's hyaline neutrophil inflammation and pericellular fibrosis

Answer 221

Most do not have symptoms picked up on routine blood tests May have fatigue, malaise or RUQ pain If advanced - ascites, oedema, jaundice

Answer 222

Definitive diagnosis only from biopsy + histology - LFTs: mildly raised ALT relative to AST, reverses as disease progresses - If raised GGT then alcohol likely cause - Fasting lipids and glucose - FBC - Viral serology - US - hyperechoic bright imaging - Elastography can be used to determine degree of fibrosis - CT or MRI can show extent of disease - SteatoTest, NAFLD fibrosis score - BIOPSY

Answer 223

Alcohol related fatty liver is managed with abstinence and diet - Weight loss - Control co-morbidities: BP, diabetes, cholesterol - Exercise - medications: statins, fibrates,, metformin - Bariatric surgery - Regular follow up

Answer 224

Steatosis - 1-2% develop cirrhosis in 202 years | Steatohepatitis - 10-12% have cirrhosis in 8 years

Answer 225

Loss of normal hepatic architecture due to fibrosis with nodular regeneration. Implies irreversible liver disease and is the final stage of chronic disease from a variety of causes 80-90% of liver parenchyma needs to be destroyed before signs appear

Answer 226

``` Alcohol Hep B Hep C Unknown cause NAFLD NASH Primary biliary cirrhosis Autoimmune Primary sclerosing cholangitis Wilson's disease Haemochromatosis Alpha 1 antitrypsin deficiency Chronic R heart failure Budd-Chiari syndrome Drugs - methotrexate ```

Answer 227

Chronic injury to the liver results in inflammation, necrosis and eventually fibrosis Fibrosis is initiated by activation of stellate cells and upregulation of receptors for proliferative and fibrogenic cytokines Normal matrix replaced by collagens Loss of endothelial fenestrations --> impaired liver function Fibrosis causes distortion of hepatic vasculature and can lead to increased intrahepatic resistance and portal hypertension Portal hypertension can lead to oesophageal varices, hypoperfusion of kidneys, salt and water retention, Micronodular - caused by alcohol damage and biliary tract disease Macronodular - chronic hepatitis

Answer 228

Vague symptoms: anorexia, nausea and weight loss In a long period of compensate cirrhosis, patient is well. Decompensation leads to: - Hepatocellular failure - Ascites - Portal hypertension - HCC - Osteoporosis - Increased infections - particularly spontaneous bacterial peritonitis

Answer 229

Dependent on clinical suspicion of aetiology - Hypoalbuminaemia - FBC: anaemia, thrombocytopaenia, macrocytosis - U&E: hyponatraemia, poor renal function would indicate hepatorenal function - Raised ferritin in haemochromatosis Imaging - US of liver +/- CT/MRI to detect complications - CXR: elevated diaphragm and pleural effusion - BIOPSY: gold standard

Answer 230

Delay progression and prevent or treat any complications - Cholestyramine for pruritus - Preventative for osteoporosis - Prophylactic antibiotics in upper GI bleeding - Stop alcohol - Regular exercise

Answer 231

``` Anaemia Thrombocytopaenia Coagulopathy Oesophageal varices Ascites Spontaneous bacterial peritonitis HCC Cirrhotic cardiomyopathy Hepatopulmonary syndrome Portopulmonary hypertension ```

Answer 232

Calculated by Childs-Pugh-Turcotte Classification | Raised score has decreased prognosis

Answer 233

Abnormally high pressure in the hepatic portal vein | Hepatic venous pressure gradient >10mmHg

Answer 234

Veins that enter portal hepatic vein - Superior mesenteric vein (from small intestine) - Splenic vein - Inferior mesenteric vein (from large intestine)

Answer 235

Pre-hepatic - Portal vein thrombosis - Splenic vein thrombosis - Extrinsic compression (tumours) Hepatic - Cirrhosis - Chronic hepatitis - Myeloproliferative diseases - Idiopathic - Toxins - Nodular Post-hepatic - Budd-Chiari syndrome - Constrictive pericarditis - R heart failure - Anti-leukaemic drugs/radiation from veno-occlusion of small veins

Answer 236

Increased vascular resistance in portal venous system - liver damage activates stellate cells and myofibroblasts contributing to abnormal blood flow patterns Increased blood flow in portal veins - Splanchnic arteriolar vasodilation caused by excessive release of endogenous vasodilators Increased portal pressure opens up collaterals connecting to portal and systemic venous system

Answer 237

Gastro-oesophageal junction - producing varices Rectum Left renal vein Diaphragm Anterior abdominal wall via umbilical vein (caput medusae)

Answer 238

Occlusion of hepatic vein leading to collateral opening up within the liver with blood diverting though caudate lobe whose short hepatic veins drain directly into IVC

Answer 239

``` Haematemesis or melaena Lethargy, irritability and changes in sleep (encephalopathy) Increased abdominal girth, weight gain Abdominal pain, fever (SBP) Pulmonary involvement Caput medusae Splenomegaly Ascites Jaundice Spider naevi Palmar erythema Confusion, asterixis Gynaecomastia Testicular atrophy Hyperdynamic circulation - bounding pulse, low BP, warm peripheries ```

Answer 240

LFTs, U&Es, glucose, FBC, clotting screen Abdominal US - liver and spleen size, ascites, portal blood flow and thrombosis Doppler for direction of flow in vessels Elastography for fibrosis Measure hepatic venous pressure gradient Liver biopsy

Answer 241

Difficult to treat = treat underlying cause - Beta blockers +/- nitrates or shunt procedure - Salt restriction and diuretics - Terlipressin and octreotide can assist control of variceal bleeding - TIPS: transjugular intraheptatic portosystemic shunt Connects portal and hepatic veins using stent. Decompresses portal system Prevents re-bleeding and ascites Has a role in: hepatorenal syndrome, hepatic hydrothorax, hepatopulmonary syndrome, Budd-Chiari syndrome

Answer 242

``` Bleeding from gastric or oesophageal varices (90% get varices, 33% of these bleed) Ascites (SBP, hepatorenal syndrome) Portopulmonary hypertension Liver failure hepatic encephalopathy Cirrhotic cardiomyopathy ```

Answer 243

Vague symptoms: weight loss, reduced appetite, lethargy May have jaundice, ascites etc. Smooth hepatomegaly: hepatitis, CHF, sarcoid, early cirrhosis Craggy hepatomegaly: HCC or 2y tumours

Answer 244

Apparent - low lying diaphragm, early cirrhosis Venous congestion failure - viral hepatitis, EBV, CMV, malaria, constrictive pericarditis, hepatic vein obstruction Autoimmune liver disease Biliary disease - extrahepatic obstruction, primary biliary cirrhosis, primary sclerosing cholangitis 2y cancers, HCC Amyloidosis, sarcoidosis Sickle cell, thalassaemia, haemolytic anaemia, myeloma, leukaemia, lymphoma Haemochromatosis, Wilson's disease, porphyuria, NAFLD Drugs - alcohol, drug induced hepatitis In children - TORCH (toxoplasmosis, other, rubella, CMV, herpes simplex)

Answer 245

``` Cirrhosis (transudate) Malignancy (exudate) Heart failure Nephrotic syndrome - hypoproteinaemia Protein losing enteropahty TB Pancreatitis Hypothyroidism Iatrogenic Budd-Chiari syndrome ```

Answer 246

Malignancy Ruptured ectopic pregnancy Abdominal trauma Acute pancreatitis

Answer 247

Only if not affected and not associated with hepatorenal syndrome - Grade 1: MILD, only detected on US - Grade 2: MODERATE: moderate symmetrical distension of abdomen - Grade 3: LARGE - marked abdominal distension

Answer 248

Transudates are the result of increased pressure in hepatic portal vein e.g. due to cirrhosis Exudates are actively secreted due to inflammation - raised protein, LDH and WCC, low pH and glucose Sodium and water retention occurs due to peripheral arterial vasodilation and consequent reduction in effective blood volume - NO, ANP and prostaglandins vasodilation - Decrease blood volume leads to increase RAAS Portal hypertension - exerts a local hydrostatic pressure and leads to increase production of lymph and transudate into peritoneal cavity Low serum albumin - may contribute to low plasma oncotic pressure

Answer 249

Abdominal distension and discomfort Weight gain - due to water retention Nausea Appetite suppression - due to compression of bowels and stomach Increased dyspnoea due to limited venous return from legs and impaired lung expansion Stigmata of liver disease and cirrhosis Virchow's node - if peritoneal carcinoma

Answer 250

- Confirm presence of ascites - Find cause - Assess complications - FBC, U&Es, LFTs, TFTs, clotting US - can detect small amounts and show causative pathology CXR - pleural effusion, pulmonary mets, heart failure Aspiration of fluid - Neutrophils > 250 = SBP - Measure protein - transudate or exudate - Cytology for malignant cells

Answer 251

Salt and water intake restriction Regular weights 1. Spironolactone (monitor for hyperkalaemia) 2. Loop diuretics (Monitor for hyponatraemia) 3. Paracentesis - if large or refractory ascites - TIPS if > 3 per month - Catumaxamab

Answer 252

Spectrum of neuropsychiatric abnormalities in patients with liver disease after exclusion of other known brain disease. Can be covert or overt Grades 0-4 0 - subclinical, normal mental status (minimal changes in memory, co-ordination or concentration) 1 - mild confusion, euphoria or depression 2 - drowsiuness, lethargy, gross defects in performing mental tasks 3 - rousable, unable to perform mental tasks, disorientated in time and place. incomeprehensible speech 4 - coma +/- response to painful stimuli

Answer 253

``` high dietary protein GI bleeding Constipation Infection, including SBP Diuretic therapy TIPS Surgery Progressive liver damage Development of HCC Sedative drugs ```

Answer 254

``` Personality changes Intellectual impairment Decreased level of consciousness Reversal of sleep rhythm Nausea and vomiting Confusion Irritability Weakness Coma Hyper-reflexia Increased tone Fetor hepaticus - sweet smell to breath Asterixis Constructional apraxia Decreased mental function ```

Answer 255

``` Diagnosed clinically Will have deranged LFTs - Psychometric tests - Increased ammonia levels - EEG (decreased alpha waves) - Visual evoked response ```

Answer 256

Early diagnosis Management of precipitating factors - Lactulose - decreased nitrogen load from gut - Antibiotics - lower amino acid production by decreasing concentration of ammonia forming colonic bacteria (neomycin, vancomycin, metronidazole) - IV fluids as required

Answer 257

Ammonia is by product of colonic bacteria catabolism of nitrogenous sources such as ingested protein and secretion of urea nitrogen Impaired liver function leads to impaired ammonia clearance Cirrhosis leads to portosystemic shunting which also decreased ammonia clearance increased ammonia = alteration of cerebral concentration of aminio acids and this affects neurotransmitter synthesis

Answer 258

Phase 1 - oxidation reactions catalysed by enzyme's of which P450 is the most important Phase 2 - conjugation Formation of covalent bond between drug and endogenous substrate - usually in hepatic cytoplasm, makes it water soluble for excretion

Answer 259

No general rules for modifying drug doses in liver disease Changes in metabolism alters efficacy and toxicity If hypoalbuminaemia then protein bound drugs may be present in toxic amounts Decreased clotting - increased sensitivity to anticoagulants Fluids overload can worse ascites Avoid hepato-toxic drugs

Answer 260

Decreased BP = decreased renal perfusion at juxtaglomerular apparatus = RENIN secretion from kidneys Angiotenisogen -- renin --> angiotensin I Angiotensin I --ACE (lungs --> angiotensin II

Answer 261

1. Increased sympathetics 2. Na+ and water retention 3. Aldosterone secretion 4. Arteriolar vasoconstriction 5. ADH secretion from posterior pituitary (increase water absorption) 6. Increased thirst

Answer 262

``` 7% of over 65s increases with age FHx of CV or renovascular disease More common in younger women (fibromuscular dysplasia) and older men (atherosclerosis) Increased in Caucasians ``` ``` RFs Obesity Hyperlipidaemia Hypertension Renal impairment Other vascular disease Diabetes Smoking ```

Answer 263

``` Renal artery atheroma Fibromuscular dysplasia Prolonged hypotension Embolic renal disease Renal artery or aortic dissection Neurofibromatosis Renal AV malformation Takayasu's arteritis ```

Answer 264

Atherosclerosis is most common Normally develops at renal artery ostium on luminal surface of aorta/proximal renal artery Atheroma obstructs blood flow Chronic renal ischaemia In India and Far East - Takayasu's arteritits most common Fibromuscular dysplasia affects distal renal artery

Answer 265

Patients are often asymptomatic Hypertension - Abrupt severe onset in middle or older aged patients Biochemical or clinical evidence of renal impairment during treatment ARB or ACEi Decompensation of congestive heart failure - recurrent episodes of acute pulmonary oedema

Answer 266

``` U&Es Blood glucose 24 hour urine protein excretion Urinalysis for RBCs and casts Serology to rule out SLE or vasculitis Lipid profile - likely to have atherosclerotic disease Renal US ``` If thought to be amenable to intervention - angiography

Answer 267

Optimise vascular profile - smoking cessation, diabetes, statins, hypertensive therapy Avoid ACEi and ARBs Avoid nephrotoxic drugs Angioplasty and stenting is first line (indicated in pulmonary oedema, severe for refractory hypertension) Open/endovascular surgery to reconstruct stenosed artery

Answer 268

``` End organ damage from uncontrolled hypertension CKD AKI Decreased renal function Refractory angina ```

Answer 269

80-100 ml/min

Answer 270

``` Stage 1 - normal GFR with renal disease Stage 2 - GFR 60-90 Stage 3a - GFR 45-60 Stage 3b - GFR 30-45 Stage 4 - GFR 15-30 Stage 5 - <15 or renal replacement therapy ```

Answer 271

True hypovolaemia (diarrhoea, bleeding, burns, haemorrhage) Relative hypovolaemia (HF, septic shock, hepatorenal failure) Renovascular disease Shock

Answer 272

``` Glomeruli - glomerulonephritis Tubules - ischaemic tubular necrosis, nephrotoxic acute tubular necrosis, intra-tubular obstruction Pylelonephritis Acute interstitial nephritis Malignant HTN Scleroderma Vasculitis ```

Answer 273

Need bilateral obstruction for kidney failure - Bilateral pelvicourtetic junction (rare) - Bilateral ureteric - tumour, retroperitoneal fibrosis, stones - BOO - BPH, stones, tumour, neurogenic bladder - Urethra tumour, valves, stricture, foreign body

Answer 274

Prostaglandins dilate afferent NSAIDs constrict afferent ACEi dilate efferent Angiotensin II constricts efferent

Answer 275

Presence of protein in urine Suggestive of glomerular disease Measured by protein:creatinine ratio

Answer 276

Measured by albumin:creatinine ratio | indicator of early diabetic nephropathy and capillary injury secondary to hypertension or vascular disease

Answer 277

- Maintain acid base balance - Potassium excretion - Excretion of waste produces - Sodium and water balance - Hormone production: - anaemia - bone disease

Answer 278

``` Anorexia Change in taste Nausea and vomiting Pruritus Neuropathy Pericarditis Confusion Encephalopathy Coma ```

Answer 279

Kidney failure causes decreased production of 1,25-dihydroxyD3 - This decreases calcium absorption - Decreased calcium and increased phosphate causes raised PTH - Secondary hyperparathyroidism - This causes renal osteodystrophy and vascular calcification

Answer 280

Rapid deterioration of renal function resulting in an inability to maintain fluid, electroryes and acid base balance Decreased urine output Decreased GFR

Answer 281

``` Over 65 Heart failure Liver disease CKD PMH of AKI Diabetes Hypovolaemia Oliguria Haematological malignancy Urological obstruction Sepsis Iodinated contrast Nephrotoxic drugs Emergency surgery Reliance of carer for fluids ```

Answer 282

Volume depletion - haemorrhage, severe D and V, burns Oedematous state - Heart failure, cirrhosis, nephrotic syndrome Hypotension - cardiogenic shock, sepsis, anaphylaxis CV - severe cardiac failure, arrhythmias Renal hypoperfusion - NSAIDs, COX2 inhibitors, ACEi, ARBs, AAA, renal artery stenosis, hepatorenal syndrome

Answer 283

Glomerulonephritis Thrombosis Haemolytic uraemic syndrome Acute tubular necrosis - prolonged ischaemia, nephrotoxins Acute interstitial nephritis - drugs, autoimmune, infection Vascular - vasculitis, polyarteritis nodosa thrombotic microangiography, cholesterol emboli Eclampsia

Answer 284

``` Calculus Blood clot Papillary necrosis Urethral stricture BPH Prostate cancer Bladder tumour Radiation fibrosis pelvic malignancy Retroperitoneal fibrosis ```

Answer 285

Decreased urine output nausea and vomiting Dehydration Confusion

Answer 286

Hypotension/ hypertension Large painless bladder if BOO Can be dehydrated with postural hypotension OR fluid overloaded - raised JVP, pulmonary oedema, peripheral oedema Pallor, rash, bruising

Answer 287

Raised creatinine >26 in 48 hours Over 50% increase in creatinine in 7 days Decreased urine output <0.5ml/kg/day for 6 hours

Answer 288

Determine cause - Urinalysis and dipstick (if blood or protein consider acute nephritis) - Bloods - FBC - eosinophilia in acute interstitial nephritis, cholesterol embolic and vasculitis - U&E with creatinine (raised creatinine, raised potassium, metabolic acidosis) (If urea:creatinine over 2x then pre-renal - Coagulation studiues - CK, myoglobin for rhabdomyolysis - CRP - WCC for infection - ANA in SLE - ANCA in vasculitis - anti-GBM in Goodpasture's - US if obstruction suspected - CXR for pulmonary oedema

Answer 289

Pre-renal has decrease urine sodium | Renal has increased urine sodium

Answer 290

Largely supportive Treat cause Stop nephrotoxic drugs Monitor U&Es, creatinine, sodium, potassium calcium, phosphate, glucose - Identify and treat any complications (hyperkalaemia, acidosis, pulmonary oedema, bleeding - Loop diuretic for treating fluid overload - RRT if not responding to medical management with complications

Answer 291

RIFLE stage 1 - creatinine 1.5-2x normal Stage 2 - 2-3x normal Stage 3 - >3x or RRT

Answer 292

Volume overload Metabolic acidosis Hyperkalaemia Spontaneous haemorrhage

Answer 293

Give IV volume expansion - sodium bicarbonate and 0.9% NaCl | PLUS vitamin B1 and B2 to mop up free radicals

Answer 294

Abnroaml kidney function and/or structure Presence of kidney damage (albuminuria) OR Decreased kidney function (GFR<60 for 3 months)

Answer 295

``` Very common Frequently undiagnosed Increases with age Mildly increased in females Increased in Blacks and Asians Approximately 10% of adult population ``` RFs - CV disease - AKI - Hypertension - Diabetes - Smoking - Untreated BOO - Chronic NSAID use

Answer 296

``` Diabetes (most common) Hypertension (2nd most common) Arteriopathic renal diseases Glomerulonephritis Infective or obstructive nephropathies hereditary renal disease e.g. PCKD Multi system disease with renal involvement e.g. SLE Neoplasms Myeloma Hypercalcaemia ```

Answer 297

Regardless of method of renal injury the cascade of events is the same 1. Renal injury = increased intraglomerular injury and glomerular hypertrophy (kidney attempts to adapt to nephron loss to maintain GFR) 2. Increased permeability to macromolecules. Toxicity to the mesangial cells. Mesangial cell expansion, inflammation, fibrosis and scarring 3. Injury causes increased angiotensin I, raised TGF-beta and increased collagen and scarring 4. Progressive renal scarring and loss of function - All CKD is associated with tubulo-interstitial disease thought to be secondary to decreased blood supply

Answer 298

``` Only in severe anorexia nausea and vomiting fatigue weakness pruritus dyspnoea peripheral oedema insomnia muscle cramp pulmonary oedema headache nocturia/polyuria (usually first due to loss of concentrating ability) then oliguria/anuria ```

Answer 299

``` Skin pigmentation Excoriations Pallor Postural hypotension HTN Peripheral oedema Peripheral vascular disease Pleural effusion Peripheral neuropathy Restless leg syndrome ```

Answer 300

AKI CV disease Structural renal disease e.g. renal stones or BPH Multisystem disease with renal involvement e.g. SLE FHX of end stage renal disease Hereditary renal disease Haematuria

Answer 301

Gold standard is isotropic GFR, mainly eGFR Bloods - Urea and creatininie - Electoryles (raised potassium, decreased bicarb_ - Albumin (low - Calcium (can be normal, low or high) - ALP raised if bone disease - PTH raised - Cholesterol - FBC (normocytic normochromic anaemia) - ANA, ANCA and anti-GBM antibodies (Good pasture's) Urine - Dipstick = proteinuria - RBC or casts = proliferative glomerulonephritis - Pyuria = UTI, pyelonephritis - protein electrophoresis = myeloma ECG and echo for cardiac function Renal US - Small echogenic kidneys in CKD - Hydronephrosis in BOO CT for masses and cysts (be aware of implications of contrast) Renal biopsy

Answer 302

``` Monitor regularly Lifestyle: control HTN and diabetes Review meds Avoid nephrotoxins Immunisation of pneumococcus and influenza ```

Answer 303

``` Anaemia Bone disease (renal osteodystrophy) Acidosis Hyperkalaemia Fluid overload Uraemia ```

Answer 304

Erythropoetin deficiency Other causes: bone marrow fibrosis (2y to raised PTH), haemotinic deficiency, increased RBC destruction, increased blood loss (GI bleed, haemodialysis), ACEi Give recombinant human EPO Target Hb = 110-120 Iron replacement if required increases exercise tolerance Can casue HTN avoids HLA antigens from blood products

Answer 305

``` Decreased 1,25-D3 Decreased bone mineralisation Decreased calcium absorption from fut Decreased calcium Raised ALP and phosphate Leads to osteomalacia ``` Low calcium also causes raised PTH Secondary hyperparathyroidism = increase osteoclastic activity OR iatrogenic bone disease. Transplant patients receive steroids post-transplant causing osteoporosis

Answer 306

Bisphosphonates to prevent osteoporosis Vitmain D supplements if required Calcium and phosphate control and suppression of PTH - Dietary restriction of phosphate - Oral calcium carbonate - Phosphate binders

Answer 307

``` Keep BP <120/80 ACEi Add ARB] Add diuretic to prevent hyperkalaemia Add CCB (verapamil or diltiazem) ``` Statins for cholesterol Stop smoking Treat diabetes Normal protein diet

Answer 308

``` Hyperprolactinaemia Decreased testosterone (increased ED) Increased LH Amenorrhoea Abnormal thyroid levels ```

Answer 309

Equal in gender Within lumen - Blood clot - Calculi - Tumourof renal pelvis or ureter Within Wall - Ureteric, urethral stricture - Congential urethral valves - Bladder neck obstruction - neurogenic bladder - Pinhole meatus - Functional failure from denervation - MS, spinal trauma Pressure from outside - Tumours - BPH - Retroperitoneal fibrosis - Pancreatitis - Chronic granulomatous disease - Retrocaval ureter - Crohn's

Answer 310

Urine flow depends on - pressure gradient from glomerulus to Bowman's capsule - Peristalsis of renal pelvis and ureters - Effects of gravity Obstruction causes increased intraluminal pressure Decreased pressure gradient Decreased GFR Increased hydrostatic pressure on nephrons Body tries to maintain dropping GFT by decreasing renal blood flow, causing ischaemia, causing nephron loss

Answer 311

Pelvi-ureteric junction (PUJ) Where urters cross pelvic brim (level of iliac vessels) Vesico-ureteric junction

Answer 312

Upper urinary tract - Pain (especially if acute) Flank pain, dull, sharp or colicky. Often radiated to iliac fossa, testes or labrum - Ipsilateral back pain - Loin tenderness - Nausea and vomiting - Anuria - Polyuria if chronic or partial obstruction due to impairment of tubule concentrating capacity - Increased pain with alcohol, diuretics or high fluid intake Lower urinary tract - pain (suprapubic) - abdominal distension - IF chronic - urinary hesitancy, weak and narrow stream, dribbling, incomplete emptying

Answer 313

U&Es and GFR - Raised urea, raised potassium - Metabolic acidosis - FBC: anaemia of chronic disease or evidence of infection - PSA if ?prostate Ca Urinalysis, microscopy and culture Cystoscopy if haematuria US - first choice imaging If abnormality then CT (CT gold standard for stones) Post void US to assess residual volume

Answer 314

Symptom relief and relieving the obstruction - Analgesia and hydration - Relieve blockage

Answer 315

Benign prostatic hyperplasia Increase in the size of the prostate without malignancy Failure of apoptosis Begins in the transitional zone which is periurethral

Answer 316

Increased with age 90% at 90 years Increased severity in Blacks Weak RFs - FHx - Smoking - Male pattern baldness - metabolic syndrome

Answer 317

Prostate enlargement depends on potent androgen - DIHYDROTESTOSTERONE Thought to be due to age related hormonal factors with androgen imbalances Hyperplasia of epithelial cells in transitional zone and increased muscle tone Increased stromal:epithelial ratio

Answer 318

``` IPSS International Prostate Symptoms Score Mild 0-7 Moderate 8-19 Severe 20-35 ``` For each symptom 0 = not at all, 1 = less than 20% of the time, 2 =

Answer 319

``` Urinary frequency Urgency Hesitancy Terminal dribbling Poor stream Incomplete emptying Intermittent stream Staining nocturia ```

Answer 320

Palpable bladder of chronic obstruction or neurogenic bladder DRE: anal sphincter tone, prostate size - enlarged, texture and contour, firm, not hard and smooth Clear median sulcus

Answer 321

``` DRE Urine dip and MSU FBCs, U&Es, LFTs PSA - cut off depends on age US may assist choice of treatment Post-void residual volume US Urine flow rate as baseline - Qmax Cystoscopy if ?urethral stricture or bladder cancer ```

Answer 322

- Wathc and wait if minimla symptoms and cancer excluded - Advise weight loss, healthy diet and exercise MEDICAL - alpha adrenergic antagonists to decrease tone in bladder neck TAMSULOSIN (alpha 1) or DOXASOZIN (if HTN and BPH) - 5 alpha reductase inhibitors - block conversion of testosterone of dihydrotestosterone FINASTERIDE - less side effects - Combination therapy if one fails - trial treatment for at least 1 year SURGICAL - TURP - shave prostate with diathermy - Complications: increased erectile dysfunction, retrograde ejaculation, can cause urethral stricture - Open prostectomy if over 8-0g

Answer 323

``` Urinary retention Recurrent UTIs Bladder calculi Impaired renal function (CKD) Haematuria ```

Answer 324

3 cell types: - Endothelial cells - Epithelial cells - Mesangial cells

Answer 325

Diffuse - all glomeruli are affected Focal - some glomeruli are affected Global - all parts of the glomeruli are affected Segmental - some parts of the glomeruli are affected

Answer 326

Protein Loss | Haematuria

Answer 327

``` Minimal change GN Membranous GN Mesangial proliferative GN Focal segemental GN Focal segmental glomerulosclerosis Crescenteric GN Diffuse proliferative GN Mesagniocapillary GN ```

Answer 328

Peripheral pitting oedema - decreased capillary oncotic pressure from hypoalbuminaemia Proteinuria Hypoalbuminaemia Hypercholesterolaemia - liver overworking to create albumin and increases production of cholesterol Most also have secondary hyperaldosteronism due to perceived hypovolaemic state as fluids in periphery - activates RAAS and increased aldosterone

Answer 329

1. Minimal change GN | 2. Focal segmental glomerulosclerosis

Answer 330

1. Membranous GN 2. IgA nephropathy Diabetic nephropathy SLE Amyloidosis

Answer 331

Light microscopy is normal. Podocyte effacement Most common cause of nephrotic change in children Treat WITHOUT biopsy = can only be diagnosed with biopsy Most will respond to steroids Some children will relapse when steroids stopped

Answer 332

Not all glomeruli are involved and only parts are affected

Answer 333

Most common cause of nephrotic syndrorme in adults Capillary loop thickened on light microscopy Silver staining will show spikes Presents with proteinuria and can cause progressive renal impairment 1/3 spontaneous recovery, 1/3 persistent proteinuria, 1/3 end stage renal failure Vast majority are autoimmune Treated with immunosuppression Common associations: adenocarcinoma (GI and bronchial), hep B, SLE, drugs (gold and penicillamine)

Answer 334

GI and bronchial adenocarcinoma Hepatitis B SLE Drugs - gold and penicillamine

Answer 335

Common glomerulonephritis Presents with haematuria Presence of IgA in mesagium Presents with visible haematuria 1-2 days post URTI 1/3 will progress to end stage renal failure over 20 years Prognosis worse if associated proteinuria, hypertension or abnormal scarring

Answer 336

Also known as IgA nephropathy Common glomerulonephritis Presents with haematuria Presence of IgA in mesagium Presents with visible haematuria 1-2 days post URTI 1/3 will progress to end stage renal failure over 20 years Prognosis worse if associated proteinuria, hypertension or abnormal scarring

Answer 337

``` Presents with non-visible haematuria Most commonly X-linked recessive More common in males Haematuria Proteinuria Progressive renal failure Sensorineural deafness Anterior lenticonus (eye lense issue) ``` Female carriers present with microscopic haematuria, normal renal function. They have a good prognosis

Answer 338

``` Haematuria Hypertension AKI Often oliguria Often some proteinuria Oedema may be present but due to oliguria Red cell casts in urine ```

Answer 339

Post-streptococcal glomerulonephritis Haemolytic uraemic syndrome Henoch-Schonlein purpura

Answer 340

Goodpasture's syndrome ANCA associated vasculitis SLE Primary or secondary mesangiocapillary glomerulonephritis

Answer 341

10-14 days post streptococcal sore throat Nephritic - haematuria, hypertension, AKI Antisreptolysin I titre positive No treatment Spontaneous recovery - supportive therapy Diffuse proliferative GN

Answer 342

Characteristic red rash on buttocks and extensor surfaces of the legs Skin or renal biopsy Would stain for IgA

Answer 343

Causes of nephritic syndrome in adults Presents with AKI developing over days-weeks Histology would show crescenteric glomerulonephritis and vascular necrosis Serology would show ANCA - cANCA in Wegeners - pANCA in microscopy polyangiitis Early diagnosis and treatment gets better outcome Treat with immunosupprerssion - steroids and cyclophosphamide

Answer 344

Antibodies to glomerular basement membrane Presents with AKI and pulmonary haemorrhage Crescenteric glomerulonephritis with linear IgG deposition Anti-GBM antibodies VASCULITIS - ANCA positive Goodpasture's syndrome = any disease causing AKI and pulmonary haemorrhage

Answer 345

There are 3 different types and can present at any age Can be due to: - infection (Hep C or endocarditis) - Monoclonal gammopathy (myeloma or lymphoma) - Collagen vascular disease - Genetic and acquired complement disorders

Answer 346

Seen in diabetic nephropathy

Answer 347

Similar lesions to diabetic nephropathy But stain positive with Congo red Often present with nephrotic syndrome and progressive deterioration

Answer 348

Chronic inflammation- RA, AS, psoriasis, Crohn's Hereditary familial Mediterranean fever Chronic pyogenic infection Multi-organ involvement

Answer 349

Serum amyloid A component Causes: lymphoma, myeloma, MGUS, Waldeenstroms Paraprotein in blood or urine

Answer 350

``` Diabetic nephropathy Amyloidosis AA amyloid AL amyloid - lymphoma, myeloma, MGUS Cryoglobulinaemia Subacute bacterial endocarditis SLE Shunt nephritis ```

Answer 351

Renal stones | Renal calculi are formed when urine is supersaturated with salt and minerals

Answer 352

Lead to the production of stone formation Calcium oxalate precipitates in GBM It accumuilates in subendothelial space of papillae leading to Randall's plaques causing calculus

Answer 353

``` 1/10 Most are asymptomatic 1/1000 - renal colic Increased in males Peak age 30-50 years Recurrence is common ``` Risk factors - Anatomical abnormality - FHx of renal stones - HTN - Gout - Immobilisation - Hyperparathyroidism - Dehydration - Hot climates - Cystinuria - Diuretics, calcium supplements - Metabolic disorders: chronic metabolic acidosis, hypercalcinuria

Answer 354

Hypercalcaemia - hyperparathyroid, sarcoidosis Hypercalciuria - hypercalcaemia, increased dietary calcium, excessive resorption of calcium in immobilisation Hyperoxaluria - ingestion of high oxalate foods (spinach, rhubarb, tea), dietary calcium restriction, GI disease Hyperuricaemia - myeloproliferative disorders, gout, dehydration UTI - mixed stones (staghorn calculi) - mostly proteus Cystinuria - polycystic kidney disease, renal tubular acidosis Drugs = loop diuretics, steroids, antacids, theophylline

Answer 355

``` 65% calcium oxalate 15% calcium phosphate alone 10-15% magnesium ammonium sulphate 3-5% uric acid stones 1-2% cystinuria ```

Answer 356

Many are asymptomatic and are picked up during investigations for something else. - Renal colic: sudden severe pain in loin, moving to groin - Can have tenderness in loin or renal angle - Moving stone is more painful than static stone - Pain can radiate to testes, scrotum, labia or anterior thigh - More constant than biliary colic, short periods of relief or background dull ache - Dysuria - Fever - Rigors - Haematuria - Urinary retention - nausea and vomiting - Writing in agony - Decreased bowel sounds - Can be hypotensive

Answer 357

- Dipstick: red cells, leukocytes and nitrates (infection) ph >7 = proteus - MSU for culture, microscopy and sensitivities - Bloods: FBC, CRP, U&Es, calcium, phosphate, urate - Non-enhanced CT is imaging of choice - US is good for determining if any obstruction - Plain AXR for determining passage of stones - Stones analysis: all first time stone formers, patients with recurrent stones on preventative pharmacology, early recurrence after stone clearance, late recurrence after long stone free period (stone composition may change)

Answer 358

Hospital admission if: fever, solitary kidney, inadequate pain relief, inability yo take fluids, anuria, pregnancy ACUTE - NSAIDs: diclofenac, more effective than opioids - Provide antiemetics and rehydration therapy - Most stones will pass in 1-3 weeks - Conservative management for 3 weeks unlesds unable to manage pain, infection or obstruction - Medical expulsive therapy - nifedipine, tamsulosin - Surgical management: insert JJ stent. - To remove stones: extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy - Open surgery in rare severe cases

Answer 359

20% if symptoms in over 4 weeks - Complete blockage, decreased GFR - irreversible renal damage if over 48 hours - Infection/ pyelonephritis - Ureteric stricture

Answer 360

- Increased fluid intake - Decreased salt, oxalate and urate intake - Cranberry juice - Normal calcium intake - if stones are URIC acid stones: allopurinol - if stones OXALATE stones: calcium citrate - If stones CALCIUM stones: thiazide diuretics

Answer 361

Lower UTI = cystitis Upper UTI = pyelonephritis Uncomplicated = infection by usual pathogen in normal urinary tract Complicated = anatomical, functional or pharmacological factors predisposing to persistent or recurrent infection

Answer 362

1-3% of GP consultations 1/3 of women have one before 24 50% will have one in their lifetime 2nd most common clinical indication for antibiotics Risk factors - Incomplete bladder emptying: prostatic obstruction, urethral stricture, uterine prolapse, MS, spina bifida, diabetic neuropathy - Recent instrumentation of renal tract - Antibiotic use - Abnormality in renal tract - Sexual activity - new sexual partner - Use of spermicide - Diabetes - presence of catheter - Pregnancy - Immunocompromised - Vaginitis

Answer 363

- Most care caused by E.coli - Other common organisms: protues mirabilis, enterococci, staph saprophyticus - Less common: Klebsiella, proteus vulgaris, candida albicans, pseudomonas - Less common organisms are more common in underlying pathology, immunosuppressed, catheterised or frequent infections

Answer 364

Can be asymptomatic and only diagnosed on dipstick - Urinary frequency - Dysuria - Haematuria - Foul smelling urine - Cloudy urine - Urgency - Suprapubic/loin pain - Rigors - Urinary incontinence - Nausea and vomiting - Pyrexia - Confusion

Answer 365

- Dipstick: positive nitrites and leukocytes - Urine culture: should be done in all men and in pregnancy or failed to respond to initial treatment - FBCs, U&Es, urea, creatinine (if complicated) - Blood cultures (if complicated) - US of upper tract to exclude obstruction or urolithiasis in pyelonephritis - Men = PR exam, women = pelvic exam - Refer for cystoscopy if: haematuria, men with >2 UTIs, renal tract disease, not responding to treatment

Answer 366

Avoid risk factors, cranberry juice, increase fluids, avoid delaying urination, wipe front to back, no douching - 3 days of nitrofurantoin or trimethoprim - 7 day course for men - In pyelonephritis: ciprofloxacin 7-10 days - Topical oestrogen can decrease recurrence in post-menopausal women - If recurrent infections can use prophylactic antibiotics - TRIMETHOPRIM (if related to sex, within 2 hours of intercourse, or 6 months low dose) - Paracetamol or NSAIDs for symptom relief

Answer 367

``` Pyelonephritis Perinephritic abscess Intrarenal abscess AKI Hydronephrosis Pyonephrosis Sepsis Prostatits Prostatic abscess ```

Answer 368

TRIAD: LOIN PAIN, FEVER, TENDERNESS OVER KIDNEYS - Can be caused by the same organisms that ascend - Can be associated with papillary necrosis causing obstruction and AKI - More common in: chronic urinary obstruction, diabetics, sickle cell and analgesic nephropathy - Emphysematous pyelonephritis: necrotising producing gas - Xanthogranuloamtous pyelonephritis: chronic infection that resembles renal cancer causing obstruction

Answer 369

Symptoms plus one of: - Random glucose conc >11.1 - Fasting glucose > 7 - 2 hour glucose concentration after 75g of glucose (OGTT) >11.1

Answer 370

Diagnosis should not be based on single glucose measurement Requires confirmatory plasma venous concentration At least one additional test on another day with a value in diabetic range 2 positive tests on 2 different days - random glucose>11/1 - Fasting glucose >7 - 2 hour OGTT >11.1

Answer 371

Can be used to diagnose HbA1c >48mmol or 6.5% Cannot use in: - Children - If suspecting type 1 diabetes - <2 months of symptoms - High risk patients who are currently ill - Taking medications that can rapidly increasing glucose (steroids, antipsychotics) - Patients with acute pancreatic damage - Pregnancy

Answer 372

body failure to produce sufficient insulin | Characterised by deranged metabolism and vascular sequale

Answer 373

``` 15% of diabetes 40% concordance in identical twins Increased in Caucasians, particularly Scandinavia Increased in women Incidence increasing ```

Answer 374

Can be split into 2 types: 1A proven autoimmune aetiology and IB no autoimmune component - T cell mediated autoimmune disease involving destruction of insulin secreting beta cells in islets of langerhan's - Progressive loss of beta cells takes months-years - Symptoms when loss of 80-90% functional loss - Damage beta cell specific - Autoantibodies can be found in blood prior to diagnosis - It is associated with other autoimmune diseases: thyroid disease, coeliac, Addison's, pernicious anaemia, vitiligo - Genetic: HLA DR3 or DR4 - Autoantibodies: anti-glutamic acid decarboxylase (GAD), islet cell and islet antigen 2 antibodies - Some thoughts about environmental factors

Answer 375

``` Thyroid disease Pernicious anaemia Vitiligo Coeliac disease Addison's disease ```

Answer 376

HLA DR3 or DR4

Answer 377

Hyperglycaemia with one or more of: - Ketosis - Rapid weight loss - Under 50 - BMI <25 - Personal or family history of autoimmune disease Usually in childhood and early adult life Abrupt onset of symptoms Prone to ketoacidosis - Polyuria - Polydipsia - Lethargy - Increased thirst - Extreme hunger - Weight loss - Boils - Frequent and prolonged infection - Increased blood glucose, - Glycosuria - DKA

Answer 378

- Fasting blood glucose >7.0 - Random blood glucose >11.1 - Raised plasma or urine ketones - Can do antibody screen for: GAD (anti-glutamic acid decarboxylase), islet cell antibodies, islet cell antigen 2 antibodies

Answer 379

Early care plan - Diabetic education - Management of CV risk factors - Guidance on insulin - Support and indivualised care - Carbohydrate counting training - Advice on weight control and CV risk management - Increase exercise - Self monitoring at least 4 times per day (before each meal and before bed) - Aim fasting glucose 5-7 - Increase if many hypos, during illness, before, after or during sport, planning pregnancy, not achieving target - Regular follow up. HbA1c every 3-6 months - Inform patients of values at each consultation, aiming for HBa1c of 48 Insulin therapy - twice daily long acting INSULIN DETERMIR - Additional rapid acting insulin BEFORE meals - Teach injection technique, avoid repeating injection sites - Consider islet or pancreas transplant if recurrent severe hypoglycaemia not responding to treatments - Assess awareness of hypoglycaemia (using Gold or Clarke score) - If impaired awareness consider insulin pump (continuous subcut insulin infusion) Manage renal disease - Start ACEi - Maintain BP <130/80

Answer 380

All 3 of: - Blood glucose >11 (or known diabetic) - Blood ketones > 3 or urine ketones +++ - Bicarbonate <15 or ph<7.3

Answer 381

4% of type 1 diabetics each year Normally only seen in T1DM Increased in under 45s 10% new diabetics, 15% interruption of insulin therapy, 30% intercurrent illness

Answer 382

``` Infection Discontinuation of insulin Pregnancy Surgery Trauma Inadequate insulin CV disease e.g. stroke or MI Drugs - thiazides, steroids, SGLT2 inhibitors ```

Answer 383

State of uncontrolled catabolism associated with insulin deficiency Insulin deficiency leads to lipolysis, increase breakdown of free fatty acids, ketone build up, causes acidosis Hyperglycaemia causes glycosuria, leading to electrolyte losses and dehydration - renal failure Free fatty acids would normally enter Kreb's cycle In DKA, body not utilising glucose and so glucagon is released to cause gluconeogenesis and glycogenolysis This further increases blood sugar As gluconeogenesis is taking place, shortage of oxaloacetate leading to ketones not entering Kreb cycle Acidosis from raised ketones

Answer 384

``` Usually develops within 24 hours Polyuria Polydipsia Nausea and vomiting Dehydration Blurred vision Weight loss Abdominal pain Leg cramps Weakness Altered mental state ``` ``` Kussmaul breathing Acetone smell on breath Hypothermia Reduced GCS Dehydration - dry mucous membranes, sunken eyes, long cap refill Tachycardia Hypotension ```

Answer 385

Capillary blood glucose and plasma glucose (++) Urine dipstick - glycosuria and ketonuria Urine for microscopy and culture Assay of blood ketones Bloods - glucose (++), FBC (can have raised WCC), U&Es ABG - metabolic acidosis (raised anion gap) Screening for suspected causes - Troponins, ECG - CK - Amylase - CXR, AXR - Blood cultures, - LP - CT/MRI Plasma osmolarity - raised in DKA

Answer 386

``` 2 x (Na + K) + urea + glucose Raised in DKA Very raised in HONK ```

Answer 387

Immediate resuscitation Cannula and catheter 1. Fluid administration 2. Insulin therapy - IV insulin infusion (don't stop long acting insulin), continue until pH normal or ketones normal 3. Aim for ketones <0.5mmol/hr decrease Aim for glucose drop by 3mmol/hr 4. IV glucose when glucose <12 with 5% dextrose 5. Replace lost K+ to prevent hypokalaemia 6. Regular monitoring Post event management - review usual glycaemic control - review injection technique - assess need for handheld ketone monitors at home - education

Answer 388

Cerebral oedema - More common in children than adults - headache, behavioural changes, urinary incontinence Pulmonary oedema - Rare, usually within a few hours of treatment Iatrogenic hypoglycaemia Iatrogenic hypokalaemia VTE Hypophosphataemia ARDS

Answer 389

mortality <2% Prognosis worse in elderly and increased severity of precipitant Main cause of death in children is cerebral oedema

Answer 390

Lab grown in E.coli Genetically recombinant DNA technology More rapid and uniform

Answer 391

Insulin aspart = Novorapid Insulin glulisine = Apidra Insulin lispro = Humalog

Answer 392

Insulin detemir = Levemir Insulin glargine = Lantus Insulin degludec = Tresiba

Answer 393

Humulin S Actrapid Takes 30 minutes after injecting Peaks at 2-3 hours

Answer 394

Insulin lispro | 30% short acting, 70% long acting

Answer 395

Direct SC injections - abdomen, upper arm, buttock, outer thigh More injection site every 1-2 weeks Continuous SC insulin infusion therapy / insulin pump - Hard to access and expensive - Continuously delivers rapid acting via needle under skin to decrease number of injections Injection ports - alternative to daily injection, port connected to needle under skin, can remain in place for a few days Insulin pens - one shot devices. dial to adjust dose

Answer 396

Rests of 3 criteria: Whipple's triad - Plasma hypoglycaemia (<3) - Symptoms attributable to decreased blood sugar level - Resolution of symptoms with correction

Answer 397

``` Tight glycaemic control Malabsorption Alcohol Injection in lipohypertrophy site Insulin prep error Long duration of diabetes Renal dialysis Drug interactions - SSRIs Decreased renal function Addison's Hypothyroid ```

Answer 398

- Alcohol is most common non-iatrogenic cause - diabetes treated with insulin or sulphonyureas - Ketotic hypoglycaemia - Drugs and toxins - quinines, Paracetamol - Pancreatic insulinomas - Starvation - Self inflicted

Answer 399

``` Shaking/trembling Sweating Pins and needles in lips and tongue Hunger Palpitations Headache Double vision Confusion Difficulty concentrating Slurred speech Stupor/Coma ```

Answer 400

- Blood glucose - LFTs, TFTs - if ? insulinoma, 72 hour fast

Answer 401

Oral glucose/hypostop/glucogel - Repeat CBG after 15 minutes - If unconscious IV 75ml of 20% glucose - If pre-hospital and unconscious IM glucagon - If caused by oral antihyperglycaemics, admit for effects - If prolonged and associated cerebral oedema then IV mannitol, dexamethasone and glucose

Answer 402

``` Very common 4-6% 85% of diabetes Increases with age More common in South Asian and Blacks FHx associated ``` RFs - Obesity - Decreased exercise - Hyperlipidaemia - HTN - Smoking

Answer 403

50% identical twin concordance - strong inherited component - Poor nutrition in early life - Sub clinical inflammatory changes - Insulin resistance and beta cell dysfunction Cause of insulin resistance unknown Theory = central adipose tissue is metabolically active and releases large quantities of FFS and induce insulin resistance Pancreatic beta cell failure - amyloid deposition - raised glucose levels are toxic to beta cells

Answer 404

``` Polyuria and nocturia Thirst Weight loss Blurred vision Low energy Nausea Headache Hyperphagia Mood change Irritability Difficulty concentrating Itchy vulva ``` Can present with complications

Answer 405

Diagnosed with usual blood testing - Fasting >7 - Random >11.1 - HbA1c > 48 Screen for complications at time of diagnosis Urine dip: positive glucose, negative ketones

Answer 406

- Patient education - Dietary advice - Encourage weight loss - Increase physical activity - BP management - Glucose control 1. Metformin, gradually increase dose over weeks to decrease GI symptoms 2. If HbA1c over 58 Consider: DDP-4i, pioglitazone, sulfonylurea, SGLT2i 3. If still over 58, add another. Triple therapy 4. Insulin

Answer 407

Low sugar diet Increase low glycaemic index carbohydrates Increase fibre Low fat Low salt Alcohol in moderation Regular meals, 3 times a day, avoid skipping

Answer 408

Measure 3-6 monthly until stable then 6 monthly Target 48mmol/L if managed with diet and exercise Target 53 mmol/L if managed with oral medications

Answer 409

``` gastroparesis Autonomic neuropathy Erectile dysfunction Retinopathy Neuropathy Nephropathy Increased CV risk ```

Answer 410

``` Retinopathy, blindness Nephropathy Peripheral neuropathy - ulcers, difficulty walking Autonomic neuropathy Foot disease ```

Answer 411

Coronary circulation - MI Cerebral circulation - Stroke Peripheral circulation - claudication/ischaemia

Answer 412

Diabetes control and complications trial - Study of type 1 diabetes - Lasted 9 years - If strict glycaemic control (rather than conventional) then decreased complications - High rates of severe hypoglycaemia

Answer 413

UK Prospective Diabetes Study - Study of type 2 diabetes - Decreased complications and slower progression with good glycaemic control

Answer 414

Action to Control Cardiovascular Risk in Diabetes - Increased mortality in aggressively lowered HbA1c - Not beneficial in older patients or those in long disease course - ACEi decreased complications

Answer 415

One of the most common causes of blindness in 30-65 years Risk increases with duration of diabetes Present in almost all after 20 years

Answer 416

``` Increased duration of diabetes Poor glycaemic control Pregnancy Hyperlipidaemia Hypertension Obesity Smoking Nephropathy ```

Answer 417

Hyperglycaemia increases retinal blood flow and disrupts intracellular metabolism in retinal endothelial cells and pericytes Impaired vascular auto regulation, increased production of vasoactive substances and endothelial proliferation Results in capillary hypoperfusion and closure Chronic retinal hypoperfusion Increased VEGF Increased vascular permeability and new vessel formation

Answer 418

1. Non-proliferative Microaneurysm, dot and blot haemorrhages (retinal haemorrhages) 2. Pre-proliferative Cotton wool spots, venous beading, inter-retinal vascular abnormalities 3. Proliferative Growth of new vessels on retina/optic disc New vessels bleed causing vitreous haemorrhage and fibrosis Retinal detachment At any stage can develop clinically significant macular oedema which increases vascular permeability and deposition of hard exudates in central retina

Answer 419

``` Good glycaemic control When glucose lowered - it can cause hyperglycaemia induced hyperperfusion Control BP <130/80 Screen annually Digital photography symptoms Refer to ophthalmology ```

Answer 420

Ranibizumab - monoclonal antibody for VEGF-A used in macular oedema Retinal photocoagulation - in severe proliferation - Destroys areas of retinal ischaemia - Treat leaking micro aneurysm - Decreases risk of recurrent haemorrhage Usually argon laser under topical anaesthesia

Answer 421

``` Poor glycaemic control Increased duration of diabetes South Asians HTN FHx of HTN FHx of nephropathy Presence of other microvascular complications ```

Answer 422

Thickening of GBM and accumulation of matric material in mesangium - Microalbuminuria - Characteristic nodular deposits - Glomerulosclerosis worsens as heavy proteinuria develops - Glomeruli progressively lost and decreased renal function

Answer 423

Type 1 - annually 5 years after diagnosis Type 2 - annually from diagnosis early morning mid stream urine for albumin creatinine ratio - microalbuminuria is not detected on dipstick In overt nephropathy - macroalbminuria

Answer 424

Prompt vigorous attempt to decrease risk of progression - Decreased BP - Start ACEi - Decreased constriction of efferent, which decreases hyperfiltration and decreased protein leak RRT can be beneficial earlier in diabetics Renal transplant changes lives, recurrence is slow

Answer 425

Affects 50-90% of diabetics Increases morbidity and mortality Axonal degeneration of myelinated and unmyelinated nerves Thickening of Schwann cells basal lamina

Answer 426

``` Decreased vibration perception Glove and stocking pattern Reflex loss in lower limbs Feet paraesthesia Burning soles Wide based gait Weakness and atrophy in muscles Slower sensory and motor conduction Increased pressure on plantar aspects of metatarsal heads ```

Answer 427

``` Wasting of proximal leg muscles Weight loss Severe anterior leg pain Decreased reflexes Hyperaesthesia and paraesthesia Due to infarction of lower motor neurons of lumbrosacral plexus ```

Answer 428

``` Motor or sensory dysfunction in single cranial/peripheral nerve Severe rapid onset 3rd and 6th cranial nerve most common Femoral or sciatic nerve most common Median nerve compression - carpal tunnel Due to thickened connective tissue ```

Answer 429

``` Parasympathetic or sympathetic Postural hypotension Fixed HR Tachycardia Gastroparesis Dysphagia Nausea and vomiting Sweating Erectile dysfunction Nocturnal incontinence Oedema Delayed light reflexes ```

Answer 430

Occurs due to trauma, neuropathy or peripheral vascular disease Ulcers develop at site of plaque, necrosis underneath, breaks surface

Answer 431

``` Progressive condition affecting the feet Early inflammation Joint dislocation Pathological fractures Deformity ```

Answer 432

Low risk = foot care advice Moderate risk = refer to foot protection services, reassess 3-6 monthly High risk = refer to services, reassess 1-2 monthly ``` Podiatrist led. Give advice - Daily inspect and wash feet, change socks - Cut and file nails regularly - wear suitable well fitting shoes - check footwear for foreign bodies - cover cuts with dressings - do not burst blisters - stress importance of foot care ```

Answer 433

Document severity using SINBAD Site Ischaemia Neuropathy Bacterial infection Area Depth - Offloading - Control of infection/ischaemia - Wound debridement - Wound dressings - Foot x-ray if ?osteomyelitis - Treat infections with antibiotics

Answer 434

1. Thyroglobulin synthesised and secreted into colloid 2. Inorganic iodine actively transported into follicular cell "trapping" via Na/I symporter 3. Iodine transported onto colloidal surface via pendrin and organified by THYROID PEROXIDASE ENZYME. It is incorporated into amino acid TYROSINE on surface of thyroglobulin to form MIT and DIT 4. Iodinated tyrosines couple to form T3 and T4 5. Tg is endocytosed 6. Tg is cleaved by proteolysis to free iodinated tyrosine and thyroid hormones 7. Iodinated tyrosine dehalogenated to recycle iodine 8. T4 converted to T3 in tissues

Answer 435

Hypothalamus - releases thyroid releasing hormone - TRH This stimulates the pituitary gland Pituitary gland releases thyroid stimulating hormone - TSH This stimulates thyroid gland to produce T4 and T3 In peripheral tissues T4 converted to T3 This has negative feedback on hypothalamus and pituitary gland

Answer 436

``` More common in women Highest in 40-60 group Increased in Caucasians and Asians More common in women Thyrotoxicosis 1/2000 ``` RFs - FHx - High iodine intake - Smoking - Trauma to thyroid gland - Toxic multinodular goitre - Child birth - HAART - HLA CTLA4 (grave's)

Answer 437

``` 75% GRAVE's DISEASE 14% Toxic nodular goitre 5% solitary thyroid adenoma Thyroiditis 3% De Quervain's thyroiditis 1% Drug induced 0.1% Follicular carcinoma ``` Factitious (excessive levothyroxine) ``` 2Y causes: TSH secreting pituitary adenoma Thyroid hormone resistance syndrome hCG secreting tumour Gestational thyrotoxicosis ```

Answer 438

Most common cause of hyperthyroidism Autoimmune disease mediated by antibodies that stimulate the TSH receptor. Leading to excess secretion of thyroid hormones and hyperplasia of follicular cells Diffuse goitre

Answer 439

Transient hyperthyroidism resulting from a viral infection Presents with features of hyperthyroidism with pyrexia and neck pain Often after an infection with Coxsackie, mumps or adenovirus Initially hyperthyroidism then hypo Painful thyroid, radiating to the jaw and ear, worse with swallowing and movement Usually in 20-40 years old Damage to fascicular cells causing release of stored thyroid hormones and impaired synthesis of new.

Answer 440

AMIODARONE Contrast agents Lithium Exogenous iodine - Should check TFTs prior to starting Amiodarone. - Can cause hypo or hyperthyroidism - in 6-10% of people on Amiodarone, more common in iodine deficient areas Type 1 - thyrotoxicosis in patient with thyroid disease Type 2 - thyrotoxicosis from destructive thyroiditis without underlying disease STOP drug

Answer 441

Consuming excessive amounts of levothyroxine It the suppresses TSH secretion and iodine uptake, serum thyroglobulin and release of endogenous thyroid hormones T4:T3 ratio is 70:1 Usually in thyrotoxicosis 30:1

Answer 442

``` Low TSH Normal T3 and T4 2% of elderly Look for signs of low TSH and normal T3/T4 - glucocorticoids, dopaminergic drugs, Amiodarone Recheck TFTs regularly Most common cause = toxic nodular goitre ```

Answer 443

``` Weight loss with increased appetite Irritability Weakness and fatigue Diarrhoea +/- steatorrhoea Sweating Tremor Mental illness Heat intolerance Loss of libido Oligomenorrheoa, amenorrhoea ```

Answer 444

``` Palmar erythema Fine tremor Hyper-reflexia Tachycardia Hair thinning or diffuse alopecia Urticaria Goitre Proximal myopathy Gyanecomastia Lid lag Thyrotoxic periodic paralysis ```

Answer 445

``` Exophthalmos Opthalmoplegia Conjunctival oedema Papilloedema Pretibial myxoedema Clubbing Splenomegaly ```

Answer 446

1-2% patients with hyperthyroidism Hyperthermia + mental disturbance + thyrotoxic symptoms Assocaited with precipitating events: withdrawal of anti-thyroid drug, radioiodine therapy, infection, surgery Manage with IV fluids, Beta blockers, anti thyroid drugs, steroids 20-30% mortality due to arrhythmias and hypothermia

Answer 447

TFTs - High T4 (mainly) and T3 (5% have T3 thyrotoxicosis) - Low TSH Autoantibodies (GRAVES) - thyroid peroxidase antibodies - antithyroglobulin antibodies - TSH receptor antibodies ** Bloods - AST, GGT and ALP raised - mild hypercalcaemia Thyroid US scan CRP and ESR raised in thyroiditis ECG for sinus tachy or AF

Answer 448

Raised T3 Raised T4 Undetectable TSH

Answer 449

Raised T3 Normal T4 Undetectable TSH

Answer 450

Normal T3 Normal T4 Low TSH

Answer 451

Raised T3 Raised T4 Raised TSH

Answer 452

Beta blockers (propranolol) for symptom control Carbimazole or propylthiouracil - Inhibit production of thyroid hormones - Takes 2-3 weeks to work - 1st line: carbimazole - Use propylthiouracil in pregnancy or thyroid storm - Block and replace with levothyroxine - Repeat TFTs every month and adjust dose according to T4 level - Remission achieved after 18-24 months and can attempt to stop drugs - IF THEY DEVELOP SORE THROAT = FBC = BONE MARROW SUPPRESSION Can use radioactive iodine - 1st choice = teenagers, relapsed Grave's, toxic nodular hyperthyroidism Surgery - Infrequently used - Euthyroid state prior to surgery to avoid thyroid storm - Subtotal or near total thyroidectomy has 98% cure rate

Answer 453

Radioactive iodine taken up by thyroid and destroys the gland - Inexpensive and definitive - Must stop antithyroid drugs for 5-7 days before - not in pregnancy, breastfeeding or planning to get pregnant in next 6 months - Avoid close contact with children and pregnant women

Answer 454

Haemorrhage Hypoparathyroidism Vocal cord paralysis

Answer 455

Nodules secrete thyroid hormone autonomously and suppressing TSH dependent growth If very large = retrosternal Mediastinal compression, stridor, dysphagia, SVCO

Answer 456

Growth hormone stimulates production of insulin like growth factor (IGF-1) IGF-1 is the main mediator of the action of growth factor. Acromegaly is caused by excessive secretion of growth hormone by pituitary tumour Overgrowth of all organ systems, bones, joints and soft tissues,

Answer 457

1 per 250,000 Most commonly diagnosed in 40s Equal in men and women Often diagnosed 10 years after onset due to insidious onset and slow progression

Answer 458

Headaches Visual defect: bilateral hemianopia Gradual change in appearance due to effects on cartilage and soft tissues - Enlargement of hands and feet - Frontal bossing - Thickening of nose - Enlarged tongue (macroglossia) - Growth of jaw - Coarsening of facial features ``` Excessive sweating Development of skin tags Thickened skin Some have sleep apnoea from enlarged tongue Women have mild hirsuitism Widespead osteoarthritis Visceral hypertrophy Carpal tunnel syndrome HTN, LVH, cardiomyopathy ``` Galactorrhoea, amenorrhoea

Answer 459

Visual field tests - Random GH - often not diagnostic - Glucose tolerance test: GH normally inhibited by glucose. If glucose fails to suppress GH level and IGF1 is raised then diagnose acromegaly Assess other pituitary hormones; prolactin, thyroid, FSH, LH MRI of pituitary and hypothalamus CT for lung, pancreatic, adrenal or ovarian tumours that secrete GH Cardiac assessment: ECG, echo Screen for bowel cancer - increased prevalence in acromegaly

Answer 460

Somatostatin analoge - OCTREOTIDE Dopamine agonists - bromocriptine, cabergoline - Increases risk of fibrosis - tumours that secrete GH and prolactin will have better response to dopamine agonists Pegvisomant - Highly selective GH receptor antagonist. Used as 2nd line Trans-sphenoidal surgery is treatment of choice Patients with residual disease can be offered adjunct treatment Radiotherapy is used in refractory disease or when surgery contraindicated.

Answer 461

``` HTN, IHD, HD, cerebrovascular disease Diabetes Acromegalic arthropathy Obstructive sleep apnoea Increased colon cancer and polyps Hypopituitarism post op ``` Increased mortality Better prognosis with smaller tumour

Answer 462

Excessive activation of glucocorticoid receptors Most commonly iatrogenic due to excessive glucocorticoid treatment Endogenous rare - excessive ATCH from pituitary tumour to ectopic ACTH by other tumours

Answer 463

10 per million Higher incidence in diabetes, obesity, hypertension, osteoporosis If due to tumour: more common in women (5:1) Peak incidence for tumour is 25-40 years Ectopic ACTH production due to lung cancer occurs late in life

Answer 464

Exogenous glucocorticoids Endogenous - Corticotropin-dependent causes (80-85%) 80% pituitary adenoma 20% are due to ectopic corticotropin syndrome from small cell lung cancer (other endocrine tumours: phaeochromocytoma, medually thyroid) - Corticotropin independent causes 60% adrenal adenoma 40% adrenal carcinoma RARE: macronodular adrenal hyperplasia, primary pigmented nodular adrenal disease, McCune-Albright syndrome Pseudo-Cushing's - Alcohol excess - Major depressive illness - Primary obesity

Answer 465

``` Hypertension Central obesity Buffalo hump Weight gain Thin skin Striae Wasting and weakness of proximal thighs Bruising Poor wound healing Osteoporosis Fractures Hyperglycaemia Peptic ulcer Moon face Thinning hair Hirsutism Cataracts Psychosis Gondal dysfunction or reduced libido ```

Answer 466

Testing should not be done in times of stress - acute illness activates HPA axic 1. Establish whether the patient has Cushing's - 24 hour urinary free cortisol ideally 3 collections, cortisol should be >3x upper limit on 2+ tests - 1mg overnight dexamethasone suppression test At 11pm given 1mg dex, measure serum cortisol at 8am - Late night salivary cortisol - FBC: raised WCC - U&Es: hypokalaemia - Metabolic alkalosis 2. Determine the cause - Plasma ACTH (highest at 8am, lowest at midnight) diurnal pattern - Undetectable ACTH + increased cortisol = ACTH independent Cushing's - High ACTH = ACTH dependent cushing's If ACTH undetectable - High dose dexamethasone suppression test - Inferior petrosal sinus sampling - MRI of pituitary - Chest and abdo CT - Plasma corticotropin releasing hormone

Answer 467

Tumour resection Medical therapy: - Prepping for surgery - Unfit for surgery - Persistent raised cortisol post-op - Metyrapone, ketoconazole, mitotane - inhibits synthesis and secretion in adrenal gland - not effective long term. Surgery: - trans-sphenoidal surgery - surgical removal of tumours or ectopics

Answer 468

``` Metabolic syndrome Hypertension Impaired glucose tolerance and diabetes Obesity Hyperlipidaemia Coagulopathy: thrombophilia Osteoporosis perforated viscera Nelson's syndrome Impaired immunity Opportunistic infections ``` 5x mortality risk

Answer 469

Has medulla and cortex Cortex is split into: - Zona glomerulosa (releases aldosterone) - Zone fasciculata and reticularis (releases cortisol and androgens)

Answer 470

Released from zona fasciculata and reticularis Levels are highest in the morning on waking and lowest in the middle of the night Rapidly rises with stress and illness 95% is protein bound - principally cortisol binding globulin which is increased by oestrogens It is the free 5% that is biologically active - Regulates the cell function by binding to glucocorticoid receptors that regulate the transcription of genes - Can activate mineralocorticoid receptors, - They do not do it normally as mineralocorticoid receptors as they contain an enzyme (11beta HSD2) that inactivates cortisol by converting to cortisone - 11 beta HSD2 inhibitors is in liquorice which causes hypertension, sodium and water retention.

Answer 471

Aldosterone is most important binds to mineralocorticoid receptors in the kidney and causes sodium retention Increased excretion of K+ and H+ Principal stimulus to aldosterone is angiotensin II

Answer 472

NA, adrenaline Only a small proportion is derived from adrenal medulla - the rest for sumpathetic nerve endings Conversion of NA to adrenaline is catalysed by catechol-o-methyltransferase (COMT) which is induced by glucocorticoids Blood flow in adrenals is centripetal so medulla is bathed in high concentrations of cortisol and is the major source of circulating adrenaline

Answer 473

Insidious onset Significant morbidity Often wrongly attributed to other illnesses particularly in post-partum and elderly Initially increase in TSH with normal T3 and T4 Then decrease T4 causing symptoms

Answer 474

More common in women Overt 2% women, 0.2% men Subclinical 7% women, 3% men 2.5% of pregnant women - Risk increases with age, most common in 60s - Autoimmune thyroiditis more common in Japan

Answer 475

Insufficient secretion of thyroid hormones - PRIMARY - Autoimmune: Hashimoto's thyroiditis - Iatrogenic: radioiodine treatment, surgery, radiotherapy - Iodine deficiency (most common worldwide) goitre present - Drugs: Amiodarone, contrast media, iodide, lithium, anti thyroid medication - Iodine: very high concentrations - Congenital defects: absence of thyroid cells - Infiltration of thyroid: amyloidosis, sarcoidosis, hemochromatosis

Answer 476

``` Autoimmune Associated with goitre Painless goitre Rubbery consistency Irregular surface Increased risk of thyroid lymphoma Positive thyroid peroxidase antibodies In under 20s - can be antinuclear factor positive ```

Answer 477

Spectrum of hypothyroidism end stage of autoimmune hypothyroidism Patients are overtly hypothyroid

Answer 478

The structure is analogous to T4 and contains a huge amount of iodine Thyrotoxic on thyroid follicular cells and inhibits conversion of T3 to T4

Answer 479

Isolated TSH deficiency Hypopituitarism - cancer, infiltrative, infection, radiotherapy Hypothalamic disorders - cancer or trauma

Answer 480

- Withdrawal of thyroid suppressive therapy - Postpartum thyroiditis 5-7% of pregnancies in the first 6 months - Subacute/chronic thyroiditis with transient hypothyroidism - De Quervain's thyroiditis - initially hyperthyroid then become hypo

Answer 481

Insidious onset ``` Tiredness, lethargy, fatigue Low mood Dry skin, hair loss Slowing of intellectual activity, poor memory, difficulty concentrating Constipation Decreased appetite with weight gain Deep hoarse voice Menorrhagia Impaired fluid due to fluid in middle ear Reduced libido Depression ```

Answer 482

``` Dry coarse skin Hair loss Cold peripheries Myxoedema (puffy face, hands and feet) Bradycardia Delayed tendon reflex Carpal tunnel syndrome Pallor Effusions - pericarditis, pleural effusions ``` AKI Female sexual dysfunction Hypercholesterolaemia

Answer 483

Expressionless dull face with periorbital puffiness, swollen tongue, sparse hair Pale, cool skin with rough doughy texture Enlarged hart Megacolon, intestinal obstruction Cerebellar ataxia Psychosis Encephalopathy

Answer 484

Low T3 Low T4 Raised TSH

Answer 485

Normal T3 Normal T4 Raised TSH

Answer 486

Low T3 Low T4 Low TSH

Answer 487

TFTs Anti-thyroid peroxidase antibodies (anti-TPO) Or antithyroglobulin antibodies Antibodies are found in 95% of autoimmune thyroiditis Anaemia FBCs, U&Es, LFTs US if asymmetrical goitre to rule out cancer.

Answer 488

Levothyroxine (T4/tetraiodothyronine) - Initial dose of 50-100 mcg then adjusted up by 25-50mcg every 3-4 weeks depending on response - Start lower (50mcg, up by 25mcg) if over 50, severe hypothyroidism or cardiac disease Once stable check TSH annually. T3 therapy has risks - osteoporosis, cardiac arrhythmias. Symptom relief can take up to 6 months after TSH levels have normalised Drugs that can interfere with absorption - ferrous sulphate, calcium supplements, rifampicin, Amiodarone

Answer 489

TSH high but normal T4 If TSH very high then may benefit from levothyroxine Treat patients if history of radio-iodine treatment or positive thyroid antibody test as they will always progress to overt.

Answer 490

Seen in elderly Mortality of 20-50% Major precipitating factors: stop thyroid medication ro infection ``` Reduced level of consciousness Seizures Hypothermia Features of hypothyroidism Hypoventilation causing hypoxia and hypercapnia Hyponatraemia Hypoglycaemia ``` Treat with IV levothyroxine Supportive therapy - correct metabolic disturbances, warming if hypothermic May need to be intubated if severe hypoventilation IV hydrocortisone as impaired adrenal function if often present in profound hypothyroidism

Answer 491

Potentially fatal and mainly associated with acute deficiency of cortisol and to a lesser extent aldosterone It occurs in long term adrenal insufficiency and 8%of people with Addison's disease will need annual hospital admission for crisis

Answer 492

Occurs when physiological demand exceeds ability of adrenal glands to produce them Generally with intercurrent illness or stress ``` Major illness or infection - most commonly GI Injury Surgery Burns pregnancy GA MI Acute allergic reactions Acute hypoglycaemia in diabetics ``` Abrupt cessation of steroids Sudden loss of adrenal function in bilateral adrenal haemorrhage

Answer 493

``` Malaise Fatigue Nausea or vomiting Abdominal pain Low grade fever Muscle cramps and pains ``` ``` Followed by: Dehydration Hypotension Hypovolaemic shock Confusion Loss of consciousness Coma ```

Answer 494

``` Low sodium, high potassium May have raised creatinine Hypoglycaemia Hypercalcaemia Cortisol and ACTH levels - treat before results Test for precipitating causes ```

Answer 495

Urgent admission Start treatment ASAP without results Immediate IV or IM hydrocortisone - do not need to give fludrocortisone in acute Rehydration with normal saline Continuous cardiac and electrolyte monitoring After rehydration and hydrocortisone = 5% glucose Treat underlying disorder Gradually reduce steroid dose back to oral

Answer 496

Don't stop steroids suddenly Alter doses of steroids for illness or surgery Educate patients Medical emergency identification bracelet or similar steroid cards Educate treatment for crisis

Answer 497

Adrenal insufficiency Destruction of adrenal cortex and subsequent reduction in amount of adrenal hormones - glucocorticoids - mineralocorticoids (aldosterone) ``` Primary insufficiency (Addison's disease) Inability of the adrenal glands to produce enough steroid hormones Most common cause is autoimmune disease ``` Secondary - inadequate pituitary of hypothalamic stimulation of adrenal glands

Answer 498

Primary is rare 1 in 10,000 Most common age is 30-50 years More common in women Secondary is more common More common in women peak in 50-60 years

Answer 499

``` Addison's disease (85%) autoimmune Surgical removal of adrenals Trauma Infections e,g, TB, histoplasmosis, HIV, syphilis Haemorrhage ``` Enzyme inhibition - ketoconazole, fluconazole Congential adrenal hyperplasia Accelerated hepatic metabolism of cortisol - phenytoin, barbituates, rifampicin ACTH or glucocorticoid resistance ACTH blocking antibodies Mutation in ACTH receptor gene Familial adrenal insufficiency

Answer 500

Hypothalamic related - Congenital - CRH deficiency - Trauma (fracture of school base) - Radiotherapy/surgery - Cancer Suppression of HPA - Exogenous steroids - antipsychotics e.g. chlorpromazine - steroid production from tumours Pituitary - tumours - panhypopituitarism - Isolated ACTH deficiency

Answer 501

``` Sepsis Severe pneumonia ARDS Trauma HIV infection ```

Answer 502

Can present acute or chronic ``` Fatigue and weakness Anorexia Nausea and vomiting Weight loss Abdominal pain Diarrhoea/constipation Cravings for salty food or liquorice Muscle cramps and joint pain Confusion Syncope or dizzy Personality change Irritability Loss of pubic or axillary hair in women ```

Answer 503

``` Hyperpigmentation - only in primary Buccal mucosa, lips, palmar creases, new scar, pressure areas Due to ACTH excess Hypotension Postural hypotension ```

Answer 504

Bloods - Low sodium - High potassium - Raised calcium - FBC: may be anaemia, mild eosinophilia, lymphocytosis - Hypoglycaemia - Reduced cortisol (get expert advice if shift worker, pregnant or taking oestrogen) - ACTH (high in primary, low in secondary) - Renin often high - Aldosterone low Synacthn test - measure cortisol levels after ACTH given. No rise in cortisol = adrenal insufficiency Adrenal antibodies - 2l-hydroxylase antibodies CXR - rule out lung cancer CT of adrenals if antibody negative

Answer 505

``` Thyroid disorders Diabetes mellitus Pernicious anaemia Vitiligo Premature ovarian failure 40-50% will develop an associated endocrine abnormality ```

Answer 506

Type 1 in children Type 2 in adults Type 1: adrenal insufficiency, hypoparathyroidism and chronic candidiasis Type 2: adrenal insufficiency, autoimmune thyroid disease,, +/- diabetes mellitus

Answer 507

Done by endocrinologist Medical emergency identification card patient education on not missing steroids - Glucocorticoid replacement - hydrocortisone - Highest dose in the morning but TDS - Increase dose in any illness (3x in minor, 10x in major) - Mineralocorticoid - fludrocortisone in primary insufficiency - Annual check

Answer 508

``` Adrenal crisis Reduced quality of life Loss of libido Frequent admissions for crisis Osteoporosis Untreated can be fatal ```

Answer 509

``` Papillary thyroid carcinoma (70%) Follicular thyroid carcinoma (10%) Medullary thyroid carcinoma (5-8%) Thyroid lymphomas (5%) Hurthle cell carcinoma (4%) Anaplastic thyroid carcinoma ```

Answer 510

Most common (70%) Presents between 35 and 40 years 3x more common in women Presents as micropapillary thyroid carcinoma <1cm with excellent prognosis Tends to spread locally to the neck, compressing the trachea and can involve recurrent laryngeal nerve Mets to lung and bone

Answer 511

``` 2nd most common (10%) Tends to occur in areas of low iodine 3x more common in women presents between 30 and 60 may infiltrate the neck as papillary cancer but has a greater propensity to metastasise to lung and bone ```

Answer 512

Arises from parafollicular calcitonin producing C cells 5-8% of thyroid cancers Female preponderance less marked Malignant C cells produce and secrete large amounts of peptides including: CEA, calcitonin, serotonin, ACTH and prostaglandins 75% occur sporadically 23% familial - part of MEN 2A or 2B Multiple endocrine neoplasia

Answer 513

Almost always Non-Hodgkins Mainly women over 50 Associated with Hashimoto's thyroiditis Presents with rapidly growing mass in neck which can cause symptoms of obstruction - dysphagia or dyspnoea Occurs in 70-80% of those with hypothyroid

Answer 514

3-10% 75-100% Hurthle cell components More common in females Most common 50-60 years Impossible to distinguish from benign using FNA - should be treated with surgical resection Behaves more aggressively than well differentiated cells High rate of mets and lower survival rate

Answer 515

``` Most aggress thyroid tumour One of the most aggressive human cancers Arises from follicular cells but does not retain any biological features Peaks in 60-70years develops from pre-existing well-differentiated thyroid cancer with additional mutations Hard mass Invading the neck causing compression 50% have mets at presentation mean survival is less than 6 months ```

Answer 516

``` More common in women 1% of all cancer Rare in children peaks at 35-39 and again in 70s More common in Asians ``` RFs - Exposure to ionising radiation - Hisotry of goitre, thyroid nodule or thyroiditis - FHx of thyroid disease - Genetics: medullary cancers associated with mutations in RET proto-oncogene causing MEN2 - Cowden's syndrome - macroencephaly, LD, carpet pile tongue, breast disease - FAP - Obesity

Answer 517

``` Presents as thyroid nodule Solitary nodule can be soft to hard Hard and fixed = malignancy Usually non-tender to palpation Vocal cord paralysis (recurrent laryngeal nerve) ```

Answer 518

``` FHx of thyroid cancer Previous irradiation Child Unexplained hoarseness or stridor with goitre Painless thyroid mass, rapidly enlarging Palpable cervical lymphadenopathy ```

Answer 519

TFTs - most will be euthyroid Serum calcitonin - for meduallary US - extremely sensitive for thyroid nodules. Hypogenicity, microcalcifications, absence of peripheral halo, irregular borders, solid aspect, increased blood flow, more tall than wide. FNA - on any nodule >1cm or <1cm if ?malignancy Radionuclide imaging to distinguish functioning toxic nodules and thyroid mets from follicular and papillary carcinomas. - Unreliable to confirm cancer - 4% of hot contain tumour, 16% cold CT and MRI to detect local and mediastinal spread

Answer 520

Refer urgently Surgical removal - total thyroidectomy if >4cm, multifocal, mets - Recurrent laryngeal nerves are close and are at risk during surgery - lymph node removal Can use radio-iodine remnant ablation Radiotherapy if high risk of recurrence, local invasion at surgery or residual tumour If anaplastic - no treatment due to poor prognosis Most has good prognosis - 90% survival at 10 years With the exception of anaplastic - 5% at 5 years

Answer 521

Small bowel - Adhesions - Strangulated hernia - Malignancy - Volvulus - Cancer - Paralytic ileus - Bowel surgery (post-op) - Congenital malformations - Hirschsprung's - Gallstone ileus - Severe constipation - Crohn's - Bezoar

Answer 522

Bowel ceases function and there is no peristalsis - Pneumonia - Acute MI - Trauma - Pueperuim - Stroke - Severe hypothyroidism - Electolyte disturbance - AKI - DKA

Answer 523

``` Diffuse central colicky abdominal pain Vomiting (first in high level) Retrograde peristalsis can cause faeculent material to come up. Faster presentation in upper GI Abdominal distension Absolute constipation ``` ``` Dehydration Pyrexia if perforation or bowel infarction Massive peristalsis may be visible Distended bowel resonant to percussion Very active bowel sounds - TINKLING ```

Answer 524

AXR - supine and erect - Ladder like series of small bowel loops - Fluid levels in upright views - Distended loops - Large bowel distension - Gas under diaphragm = perforation

Answer 525

Fluid monitoring AXR FBC, U&Es, LFTs, cross match CT

Answer 526

Uncomplicated = fluid resuscitation, electrolyte replacement, intestinal decompression, bowel rest Endoscopy for decompression - stents, dilate strictures if ischaemia, perforation or peritonitis - SURGERY

Answer 527

Hereditary disease Autosomal recessive Excessive intestinal absorption of dietary iron resulting in pathological increase in total iron body stores Excess iron accumulates in tissues - Liver, adrenals, heart, skin, gonads, joints present with cirrhosis, polyarthropathy, adrenal insufficiency, heart failure or diabetes. - Fatigue - malaise - Joint and bone pain - Insulin resistance - Erectile dysfunction Most common in Northern Europeans

Answer 528

Liver cancer Cirrhosis Diabetes Congestive heart failure Arrhythmias Pigment changes: bronze or grey discolouration in skin due to increased melanin deposition

Answer 529

Free iron Transferrin Ferritin All high

Answer 530

Also known as primary biliary cholangitis Autoimmune disease of the liver Slow, progressive destruction of the small bile ducts in the liver. Causes cholestasis, scarring, fibrosis then cirrhosis Symptoms: - Tiredness - itching - Jaundice Increased in females (x9)

Answer 531

Anti mitochondrial antibody | Elevated ALP and GGT

Answer 532

Disease of the bile ducts that causes inflammation and obliterative fibrosis of bile ducts and liver Most commonly associated with IBD - mainly UC - Pruritus - Severe fatigue - Episodes of acute cholangitis - Dark urine - Malabsorption - Hepatomegaly IDIOPATHIC Beading on ERCP

Answer 533

Raised ALP C 80% have anti-neutrophil cytoplasmic antibodies (not specific to PSC) ANA and anti-smooth muscles (neither are specific to PSC)

Answer 534

MINIMAL CHANGE Focal segmental

Answer 535

Membranous glomerulonephritis Diabetic nephropathy SLE Amyloidosis

Answer 536

Adenomas - bronchial Penacillamine Gold hepatitis B

Answer 537

Amyloid protein deposition in tissues. Primary AA amyloidosis AmyloidA-amyloidA Secondary AL amyloidosis amyloidA-light chains Seen in plasma cell dyscrasia or myeloma

Answer 538

Chronic inflammation - RA, Crohn's | Chronic infection - Bronchiectasis, osteomyelitis

Answer 539

Haematuria Hypertension AKI (Oedema)

Answer 540

Perinuclear Anti Neutrophil Cytoplasmic Antibdoies - UC - Primary sclerosing cholangitis - RA - Microscopic polyangiitis - Focal necrotising and crescentic glomerulonephritis

Answer 541

Granulomatosis with polyangiitis | Wegner's

Answer 542

Anti ds-DNA is highly specific | ANA - sensitive but not specific

Answer 543

Tented t waves Broad QRD Lose p waves Sine wave

Answer 544

Na + K+ - Cl - HCO3 High anion gap > 16 Low anion gap < 16

Answer 545

``` Ketoacidosis Uraemia Salicylic acid (aspirin) Methanol/ethylene glycol Alcohol Lactic acidosis ``` KUSMAL

Answer 546

Renal tubular acidosis | Diarrhoea

Answer 547

Antibiotics (penicillin) PPIs NSAIDs

Answer 548

Glomerular - causes of nephritic syndrome Interstitial - drugs Tubular - acute tubular necrosis Tubule obstruction - uric acid, myeloma, acyclovir, adanovir

Answer 549

Occurs in renal ischaemia or nephrotoxins - tubular necrosis with sloughing of epithelial cells - Occlusion of tubular lumen by cellular debris

Answer 550

Wegner's ``` Rhinitis Rapidly progressive glomerulonephritis --> CKD Upper airway and ear disease - Oral ulcers - Purulent or bloody discharge Pulmonary nodules - coin lesions Haemoptysis Arthritis Skin - nodules on elbows, purpura ``` Rarely affects heart, GI tract and brain

Answer 551

``` Bleeding Infection Tearing of the GI tract Aspiration Reactions to sedative medications if given ```

Answer 552

After first diagnosis (type 1) for the first few months to year there is a lower insulin requirement due to some insulin still being produced Make parents aware as otherwise control will go off for unknown reason

Answer 553

GAD antibodies - glutamic acid decarboxylase autoantibodies | Islet cell antibodies