Past papers Flashcards
Differential diagnoses of a solid liver mass
Pyogenic liver abscess Amoebic liver abscess Hyatid disease Benign liver tumours - Haemangioma, liver cell adenoma, focal nodular hyperplasia Malignant liver tumour - HCC, mets
Approach to a liver mass
Radiological imaging is the cornerstone of diagnosis for focal liver lesions. Various algorithmic approaches have been described, all starting with an ultrasound scan. The initial questions to determine are whether lesion(s) are single or multiple, or solid or cystic. Cystic lesions of the liver are considered later in this chapter. The solitary or potentially resectable liver ‘tumour’ is best evaluated by CT and, when appropriate, MRI scanning. Each of the benign and malignant tumour types has typical but seldom diagnostic appearances. The CT evaluation of the tumour appearance and behaviour during the various phases of contrast injection may be helpful. It should be possible to distinguish most cavernous haemangiomas from other tumours by this means, though some vascular tumours may create difficulty. It is important to remember that chest radiographs (and possibly CT scans of the lungs) may avoid unnecessary investigations by demonstrating that the patient has metastatic disease, rendering further investigation and surgery futile.
The objectives in assessing a liver mass are:
· to establish a diagnosis · to determine whether surgery is indicated · to judge whether resection is possible (i.e. the extent of the lesion and relation to vascular and biliary anatomy)
Two scoring systems used to assess liver function prior to surgery
Child’s grading system modified by Pugh Model for end stage liver disease (MELD) [INR, bili, creatinine]
Treatment options for primary liver malignancy
Large tumour - Transarterial embolisation. Iodised oil and cytotoxic drugs injected into hep artery -> cleared by normal cells not malignant ones Ressection
Which HCC occurs in non-cirrhotic livers without HepB/C
Fibrolammelar carcinoma [favourable prognosis]
How to classify renal artery stenosis
Anatomical (ostial, parostial, truncal, accessory, segmental, mixed, renal artery occlusion)) Pathological (Atherosclerotic vs non-atherosclerotic [fibromuscular dysplasia, takayasus, dissection, developmental, aneurysm, trauma, radiation, anastomotic]) Severity (mild, moderate, severe)
Diagnostic appraisal of severe, medically refractory HPT
Endocrine screen (cortisol, Aldosterone, renin assay, metanepharines/catecholamines[urine and plasma], TFTs, PTH, serum calcium and phosphate) Imaging (CT abdo, chest, brain. US thyroid. Radioisotope scan adrenal, MIBG[pheo]) MAG3 renogram for single GFRs Duplex US kidneys Captopril renogram Vascular imaging
Why not togive ACEi in RAS
Angiotensin ll vasoconstricts the efferent arteriole maintaining glomerular pressure. ACEi prevent this and decrease GF pressure.
Treatment modalities for RAS
Medical Percutaneous transluminal renal angioplasty Percutaneous transluminal renal angioplasty and stenting Surgical revascularisation Nephrectomy
Atherosclerotic RAS manifests clinically in which two ways
Severe HPT Ischaemic nephropathy
Causes of secondary HPT
- Endocrine disorders · Cushing’s syndrome · Conn’s syndrome · Phaeochromocytoma · Hyperthyroidism · Hyperparathyroidism · Adreno-genital syndrome 2. Renal parenchymal disorders · Nephroblastoma (Wilm’s tumor) 3. Renovascular disorders · Renal artery stenosis (RAS) · Coarctation of the aorta · The middle aortic syndrome
Differential diagnosis for rectal bleeding
· Diverticulosis · Angiodysplasia · Colitis · Neoplasia · Haemorrhoids and other anorectal disorders · Drug related (anti-coags, NSAIDS)
Investigations for LGIB
Bloods Radiology (AXR, CT [w mesenteric angiography], technetium labelled RBC scan, selective mesenteric angiography) Endoscopy/ colonoscopy
Breast lump differentials
Physiological lumpiness Fibroadenoma Cyst Infection Fat necrosis Cancer
Major risk factors for breast Ca
Female, age, contralateral disease, fam hx, Irradiation, BRCA1/2
Minor risk factors for breast Ca
Wide estrogen window, few/late/no children, HRT, OCP, smoking
Treatment options for oesophageal varices
- Pharmacological (Vasopressin, terlipressin, somatostatin, octreotide) 2. Endoscopic (banding, injection sclerotherapy) 3. Balloon tamponade 4. TIPS (transjugular intrahepatic portosystemic shunt) 5. Surgery (shunt, oesophageal transection)
Classify causes of portal HPT
- Increased resistance to flow A. Prehepatic (portal/splenic thrombosis, exrinsic compression) B. Hepatic (cirrhosis, ALD, schistosomiasis, portal fibrosis etc. C. Post hepatic (Budd-chiari, veno-occlusive disease, constrictive pericarditis) 2. Increased portal blood flow A. A-P-V fistula B. Increased splenic flow
Long term management of variceal bleeding
- Endoscopic Therapy - Injection Sclerotherapy - Variceal band ligation 2. Pharmacotherapy - b-blockers 3. Surgery a. Shunt i) DSRS ii) Portacaval b. Non-Shunt i) Oesophageal transection and gastric devascularisation ii) Splenectomy for gastric varices due to splenic vein thrombosis 4. Liver Transplantation
What to test in ascites if TB suspected
Adenosine deaminase
Pathogenesis of DVT
Virchows triad Coagulation (antithrombotics vs prothrombotic state)
Diagnostic work up for DVT
Risk factors D-dimer Duplex ultrasound (compressability) Wells score
Prophylaxis for DVT
General (hydration, analgesia, ambulate, elevate) Mechanical (compression) Pharmacologic (Unfractionated heparin, LMWH, vitK antagonists) - INR 2-3 If knee/hip give warfarin
