1
Q
Complications of fistula
A
- Clotting
- Ulceration/poor healing
- Failure (up to 40% before ever used)
- Steal syndrome in 10% (blood stolen from artery = cold/numb hand)
- High output cardiac failure (is L to R shunt. May have up to 2L flow/min)
2
Q
RIF mass differential
A
- Renal transplant
- Caecal carcinoma
- Ovarian tumour
- Ileocaecal mass (amoebic, TB, appendicular mass, ileal carcinoid or lymphoma)
3
Q
LIF mass differential
A
- Carinoma of sigmoid
- Diverticular mass/abscess
- Faeces
- Ovarian tumour
- Renal transplant
4
Q
Epigastric mass differential
A
- Left (caudate) lobe of liver (HCC, alcoholic hepatitis)
- Carcinoma of stomach or pancreas
- Lymphoma
- AAA
5
Q
Nail signs for CKD
A
- Leukonychia
- Half-and-half nails
- Absent lunulae
- Mees’ and Beau’s lines (transverse lines)
6
Q
Causes of leukonychia
A
- Hypoalbumin (malabsorption, nephrotic syndrome)
- Familial
- Sulphonamides
- Heavy metal poisoning
- Idiopathic
7
Q
Causes of koilonychia
A
- IDA
- Poor peripheral circulation
- Exposure to solvents
- Altitude
- Familial
8
Q
Causes of clubbing
A
- IBD
- Cirrhosis
- Coeliac
- Hyperthyroidism (thyroid acropachy)
- Idiopathic/familial (autosomal dominant) are most common!
9
Q
Cause of unilateral clubbing
A
- Arteriovenous fistula
- Other vascular malformations
10
Q
GI cause of Virchow’s node
A
- Stomach adenocarcinoma
11
Q
Causes of acanthosis nigricans
A
- Paraneoplastic (stomach cancer)
- Insulin-resistant T2DM
- Hypo/hyperthyroid
- Cushing’s
- Obesity
12
Q
Drug causes of gynaecomastia
A
DISCO
- Digoxin
- Isoniazid
- Spironolactone
- Cimetidine
- Oesotrogens
13
Q
Causes of gynaecomastia
A
- Drugs (DISCO)
- Liver disease
- CKD
- Thyrotoxicosis
- Secretory malignancies (hCG)
14
Q
Causes of abdominal distension
A
5 F’s
- Fat
- Fluid
- Flatus,
- Faeces
- Fetus
15
Q
How much fluid needed to diagnosed ascites clinically
A
- 1500ml (USS can detect 500ml)
16
Q
Signs of portal hypertension
A
- Splenomegaly
- Caput medusae (dilated superior epigastric veins)
- Oesophageal varices
- Ascites
17
Q
Sites of portosystemic anastomoses
A
(In brackets = which portal vein joins which systemic vein)
- Oesophageal (left gastric vein –> azygos vein)
- Rectal (superior rectal vein –> middle/inferior rectal veins)
- Umbilical (paraumbilical vein –> superior epigastric vein)
18
Q
3 most common causes of chronic liver disease
A
- Alcohol
- Hep B (abroad), Hep C (IVDU)
- Non-alcoholic hepatic steatosis (overweight)
19
Q
Types of hepatorenal syndrome
A
Due to liver not breaking down vasoactive substances (e.g. prostaglandins)–> excess renal vasoconstriction
- Type 1: doubling in Cr/halve in Cr clearance in 2 weeks –> 50% mortality after 1month. Should improve with vasoconstrictors and volume expanders
- Type 2: slower progression - starts with ascites and then diuretic-resistant ascites (kidneys can’t secrete enough sodium)
- May need combined liver-renal transplant if pre-morbid eGFR <30 (as immunosuppression post-transplant will reduce eGFR…)
20
Q
What is hepatopulmonary syndrome (with diagnosis and treatment)
A
- Liver failure
- Unexplained hypoxaemia
- Intrapulmonary vascular dilation (liver does not excrete NO)
- Diagnosis: contrast echo (microbubbles pass through dilated pulmonary vessels into left atrium)
- Treatment: liver transplant
21
Q
Features of decompensated liver disease
A
- Ascites
- Encephalopathy
- Hepatorenal/hepatopulmonary syndrome
(won’t come up in exam!)
22
Q
Grades for hepatic encephalopathy
A
- Grade 0: normal (mild changes on psychometric tests)
- Grade 1: mild confusion; short attention span; disordered sleep
- Grade 2: disorientated to time/place occasionally; lethargy; personality change
- Grade 3: very disorientated; somnolent but rousable to speech; amnesia
- Grade 4: comatose (no response to pain)
Test for it with constructional apraxia (ask pt to draw a 5-pointed star)
23
Q
How to grade severity of cirrhosis
A
Modified Child-Pugh Score- based on ABCDE
- Albumin
- Bilirubin
- Clotting (INR)
- Distension (ascites)
- Encephalopathy
(Modify bilirubin scores in PSC/PBC as expect high bilirubin)
24
Q
Management of ascites due to Chronic Liver Disease
A
Aim weight loss 1kg/day
1. No-added salt diet (5.2g a day/90mmol)
2. Spironolactone 100-400mg OD (if not getting hyperkalaemia)
3. Add furosemide 40-160mg OD
4. Ascitic drain (PleurX drain for malignant ascites)
5. Transjugular intrahepatic portosystemic shunt (TIPSS) = shunt from portal vein to hepatic vein, giving another route for portal blood to go to systemic circulation- increases encephalopathy risk as nitrogenous waste bypasses liver
25
Causes of ascites
Transudative
- Cirrhosis with portal HTN = commonest cause in PACES
- CCF
- Nephrotic syndrome (reduced oncotic pressure)
- Portal vein thrombosis
- Budd-Chiari Syndrome (occlusion of hepatic vein which drains liver to IVC)
Exudative
- Malignancy (metastatic GI, liver, ovarian, peritoneal mesothelioma)
- TB peritonitis
- Pancreatitis
26
Budd-Chiari Syndrome is triad of
- Abdo pain
- Ascites
- Hepatomegaly
27
Types of Budd-Chiari Syndrome
Primary (75%) = thrombosis of hepatic vein
- Polycythaemia
- Pregnancy
- COCP
Secondary (25%) = occlusion of hepatic vein
- Tumour
28
Cause of ascites in Chronic Liver Disease
1.
- Renal hypoperfusion --> renin from juxtaglomerular apparatus --> aldosterone
- Liver failure means aldosterone not broken down--> salt/water retention
2.
- Hypoalbumin reduces oncotic pressure--> increased portal pressure
1+2 = ultrafiltration of fluid into abdominal cavity
29
How differentiate between exudative and transudative cirrhosis
- Exudate: low serum:ascites albumin gradient (SAAG) <11g/L = loss of protein from serum into ascites
- Transudate: high serum:ascites albumin gradient (SAAG) >11g/L
30
Causes of hepatomegaly
DINMCO
Drug-induced
-Alcohol/drugs
Infective
- Hepatitis
- Tropical (malaria, leishmaniasis)
- Infectious mononucleosis
Neoplastic
- Hepatocellular carcinoma
- Lymphoma
Metabolic
- NAFLD
- Haemochromatosis
Cardiac
- CCF
Other
- Sarcoidosis
31
Scoring systems to assess severity of acute alcoholic hepatitis
- Modified Maddrey’s discriminant function test
- Mayo End Stage Liver Disease (MELD) score
- Glasgow Alcoholic Hepatitis score - do on Day 1
32
Treatment for acute alcoholic hepatitis
- Adequate nutrition
- Maddrey's discriminant function test >32 = pred 40mg for 4/52 and then taper
- IV NAC if severe
33
Histological stages of alcoholic liver disease
- Hepatic steatosis (fat in liver cells)- reversible
- Alcoholic hepatitis (inflammation liver cells--> necrosis) - reversible
- Hepatic cirrhosis
34
Hepatic amyloidosis affects which clotting factors
- Factor IX and X
35
Differentiate been palpable spleen and palpable left kidney
- Spleen cannot be balloted, is dull to percussion, has a notch and you should not be able to ‘get above’ it
36
Causes of isolated splenomegaly
Massive (>8cm)
- Myeloproliferative (CML, myelofibrosis)
- Tropical (chronic malaria = p. vivax/ovale, visceral leishmaniasis a.k.a kal-azar)
Moderate (4-8cm)
- Infiltrative (amyloid)
Tip (<4cm)
- Portal hypertension
- Acute infection (EBV, CMV, endocarditis)
- Felty's Syndrome (rheumatoid arthritis)
- Haemolytic anaemia
37
Features of Felty's Syndrome
SANTA
- Splenomegaly
- Anaemia
- Neutropenia
- Thrombocytopaenia
- Arthritis (rheumatoid)
Unknown cause
38
Presenting symptoms for hepatosplenomegaly
- Anaemia: fatigue/SOB
- Thrombocytopaenia: easy bruising
- Abdo pain referred to left shoulder
- Constitutional symptoms
- Febrile illness
39
Causes of hepatosplenomegaly
- Cirrhosis with portal HTN
- Infection (chronic malaria, visceral leishmaniasis, schistosomiasis)
- Myeloproliferative (CML, polycythaemia, myelofibrosis)
- Lymphoproliferative (CLL, lymphoma)
- Metabolic (Wilson's, haemochromatosis)
40
Important differential for hepatosplenomegaly
- Bilateral large kidneys (PCKD)!
41
Cause of Wilson's Disease (inc chromosome)
- Autosomal recessive
- Mutation of the adenosine triphosphatase 7B ( ATP7B) gene on chromosome 13
- Copper accumuates in liver --> blood --> urine
42
Tests for Wilson's Disease
- Low serum caeruloplasmin (acute phase protein so may be raised abnormally!) = protein which binds to copper in serum
- High 24hr urine copper
43
Features of Wilson's Disease
Present in 2nd decade of life
- Gastro: chronic liver disease and cirrhosis
- Neuro: Parkinsons, tremor, dysdiadochokinesia
- Renal: Fanconi Syndrome
- Cardiac: cardiomyopathy
- Psych: emotion labile, psychotic
44
Signs of Primary Biliary Cirrhosis
- Middle aged female with CLD --> always include PBC in differential!
- Scratch marks
- Orbital xanthelasma
- Hepatosplenomegaly
- Jaundice
- Most asymptomatic and diagnosed incidentally at cholecystectomy!
45
Antibody in Primary Biliary Cirrhosis
- Anti-mitochondrial antibodies
46
Antibodies in autoimmune hepatitis
- ANA
- Anti-smooth muscle
- Anti-dsDNA
47
Differential for Primary Biliary Cirrhosis
- Autoimmune hepatitis
- Primary Sclerosis Cholangitis
- Cholestatic sarcoidosis (-ve anti-mitochondrial antibody)
48
Management of Primary Biliary Cirrhosis
- No alcohol
- Fat-soluble vitamins (ADEK)
- Ursodeoxycholic acid: reduced cholestasis/liver function decline
- Cholestyramine: less itchy
49
Prevalence of haemochromatosis
- 1 in 200
50
Symptom triad for haemochromatosis
- Fatigue
- Arthralgia
- Sexual/gonadal dysfunction
51
Complications of haemochromatosis
GI
- Increased liver cancer risk
Endo
- T1DM (pancreatic failure)- 2/3 of patients
- Anterior pituitary dysfunction--> hypothyroid (TSH, ACTH)
Cardio
- Dilated cardiomyopathy (+/- arrhythmia)
Skin
- Bronze skin
52
Cause of haemochromatosis (inc mode of inheritance)
- Autosomal recessive
- Mutation in genes regulating iron metabolism (HFE gene on chromosome 6)
53
What speeds up iron overload in haemochromatosis
- Excess alcohol consumption
54
Management of haemochromatosis
- Weekly venesection (1unit a week until iron deficient, then 4x a year)
- Desferrioxamine (binds to free iron--> excreted in urine)
55
Complications of liver transplantation
- Infection: typical (LRTI) and atypical (PCP, CMV, varicella)
- Malignancy: solid organ (bowel), lymphoproliferative (post-transplant lymphoproliferative disease), skin (SCC or BCC)
- Metabolic: post-transplant diabetes and hyperlipidaemia
- Cardiovascular: IHD
56
Palpable mass in left loin for liver transplant patient
- Simultaneous liver-kidney transplant (paracetamol overdose)
57
Survival following liver transplant
- Over 60% over 15yrs
58
King's College criteria for liver transplant in paracetamol overdose
- pH <7.3 after 12hrs resuscitation
- Or all 3 of: INR > 6.5, creatinine > 300, encephalopathy (grade III or IV)
59
King's College criteria for liver transplant in non-paracetamol overdose
- Arterial lactate >3.5 4h after resuscitation
- Or INR > 6.5
- Or any 3 of: INR > 3.5, age<10 or > 40 years, bilirubin
>300, jaundice > 7 days, caused by drug reaction
60
Types of liver support system
- Bio-artificial: Extracorporeal Liver Assist Device (ELAD) = remove blood--> pass through ultrafiltration generator which separates blood from plasma--> pass through semi-permeable membrane to remove toxins
- Artificial: Molecular Absorbents Recirculation System (MARS) = in 1st circuit, blood exposed to albumin, which binds to toxins --> in 2nd circuit, remove bound toxins from albumin
61
Prevalence of IBD
- 250 per 100,000 in West
62
Extra-abdominal signs of IBD
- Clubbing = extensive small bowel Crohn's
- Uveitis
- Sacroiliitis
- Skin: pyoderma gangrenosum, erythema nodosum
63
Palpable mass in RIF in IBD
- Could be acute exacerbation
64
Differences between Crohn's and UC
Crohn's
- Non-bloody diarrhoea
- Mouth-to-anus skip lesions
- Full thickness wall inflamed
- Granulomas
- Fat malabsorption (affecting ADEK vitamins) - because affects small bowel
- Peri-anal disease (ulceration, fistulas)
UC
- PR bleeding + tenesmus (feeling incomplete defecation)
- Colon continuous inflammation
- Partial thickness wall inflamed
- Crypt abscesses
- Dilated terminal ileum ("backwash ileitis")
65
Truelove and Witt's criteria for IBD exacerbation
- Mild: <4 poos a day, normal ESR, no systemic symptoms
- Moderate: >4 poos a day, mild systemic symptoms
- Severe: >6 bloody poos a day, ESR >30 or fever/tachy/anaemic
66
Management of Crohn's
- Ileocaecal: budesonide if mild and pred is more severe --> move on to immunosuppressants (azathioprine) or biologics (infliximab or adalimumab = anti-TNF)
- Colonic disease but non-fistulating: prednisolone if mild and pred + azathioprine if more severe --> consider biologics
- Perianal fistulae: surgery and infliximab
67
Management of UC
Acute = induce remission
- Mild: topical mesalazine if proctitis --> oral mesalazine if more extensive colitis
- Moderate/severe: oral prednisolone (or can do azathioprine + infliximab)
- Severe: IV hydrocortisone 100mg QDS --> add on infliximab if no response within 3 days
Maintain remission
- Proctitis: topical mesalazine
- More extensive: azathioprine +/- infliximab
68
Indications for surgery in acute IBD
- Toxic megacolon (colon >6cm or caecum >9cm)
- Stools >8/day or CRP >45 after 3 days of IV hydrocortisone
- Fistula/perforation/obstruction
69
Which IBD is more commonly associated with Primary Sclerosis Cholangitis
- UC
70
Management of Primary Sclerosis Cholangitis
- ADEK vitamins
- Stent fibrotic bile duct
- Liver transplant
71
Presenting features of Adult Polycystic Kidney Disease
- Asymptomatic (proteinuria, blood tests)
- Recurrent UTIs
- Abdo pain
- Subarachnoid haemorrhage
72
Signs of Adult Polycystic Kidney Disease
- Large kidneys with bruit over them (increased perfusion or vascular tumour e.g. angiomyolipoma)
- Hepatomegaly- irregular (cysts)
- Anaemia/HTN/CKD/dialysis signs
73
Causes of unilateral kidney enlargement
- Polycystic Kidney (other not palpable because had nephrectomy - look for scar!)
- Tumour
- Hydronephrosis
- Horseshoe kidney
74
Types of Adult Polycystic Kidney Disease
- Type 1 and Type 2 (milder)
75
Mechanism of Adult Polycystic Kidney Disease (including mode of inheritance and chromosomes affected)
- Autosomal dominant mutation --> abnormal cilia function --> cysts form and replace kidney tissue
- Type 1 = PKD1 gene on Chromosome 16 (85%)
- Type 2 = PKD2 gene on Chromosome 4 (15%)
- Type 2 is less severe/later onset
76
Ultrasound diagnostic criteria for Adult Polycystic Kidney Disease
- 15–39yrs: 3+ cysts in the kidneys (unilaterally or
bilaterally).
- 40–59yrs: 2+ cysts in each kidney.
- >60yrs: 4+cysts in each kidney.
77
Complications of Adult Polycystic Kidney Disease
- Mitral valve prolapse (also MR, TR, AR)
- Cysts elsewhere (liver, pancreas, arachnoid)
- Intracranial berry (saccular) aneurysm
- HTN (excess renin)
- Polycythaemia (excess EPO)
78
Causes of new abdominal pain in Adult Polycystic Kidney Disease
- Infected cyst
- Haemorrhage into cyst
(also diverticulitis, kidney stones, AAA rupture)
79
Complications of chronic immunosuppression (e.g. transplant)
- Infection (PCP, CMV, EBV, BK virus)
- Malignancy (solid organ, lymphoproliferative, skin)-- look for surgical/radiotherapy scars
- Metabolic (diabetes, anaemia, HTN)
- CVD
- CKD (ciclosporin/tacrolimus)
80
Cause of end-stage renal failure if no signs
- Glomerulonephritis
81
Patient wearing hearing aids in Abdominal station
- Alport's disease (glomerulonephritis, hearing loss, vision changes)
- Aminoglycoside (gentamicin) induced nephrotoxicity and ototoxicity
82
Things to check when assessing functional status of renal transplant
- HTN
- Fluid overload
- Ongoing dialysis
83
Complications of CKD
- Anaemia (EPO)
- Renal osteodystrophy (secondary hyperparathyroidism)
- CVD
- Hyperkalaemia
- Pulmonary oedema
84
Causes of end-stage renal failure
- Diabetes
- Adult Polycystic Kidney Disease
- Chronic glomerulonephritis
- HTN in blacks only! (association in other races less established)
85
Issue with renal transplant in Alport's Syndrome
- Defect in type IV collagen --> transplant exposes to new antigens --> develop anti-GBM antibodies (Goodpasture's!)
86
Complications of specific immunosuppressants
- Seborrheic wart (azathioprine)
- Fine tremor (tacrolimus)
- CKD (tacrolimus, ciclosporin)
87
Presenting features of Hereditary Haemorrhagic Telangiectasia
- Epistaxis
- Anaemia (not melaena/UGI bleeding)
- Telangiectasia on fingers, face, lips, tongue, buccal
mucosa, conjunctiva and nose
- High-output cardiac failure due to large AVM
- Stroke (cerebral AVM) and lung haemorrhage (lung AVM)
88
Difference between Hereditary Haemorrhagic Telangiectasia and Peutz-Jeghers syndrome
- HHT = telangiectasia
- Peutz-Jeghers = macules
89
Difference between Hereditary Haemorrhagic Telangiectasia and Systemic Sclerosis
- Systemic Sclerosis has thickened skin
90
Common sites for AVM in Hereditary Haemorrhagic Telangiectasia
- Brain, lung, liver, bowel, spine
91
Cause of Hereditary Haemorrhagic Telangiectasia
- Autosomal dominant mutation (chromosome 9-- relates to TGFb signalling)
92
Features of Peutz-Jeghers Syndrome
- Mucucutaneous pigmented macules (lips, hands, feet)
- Benign hamartomas in GI tract
- Increased risk of malignancy (not related to hamartoma)
93
Surface marking of abdominal aorta
- Just left to midline
- Bifurcates at L4/5 (umbilicus)- less reliable if fat
94
Surface marking of gallbladder
- Right costal margin in mid-clavicular line
95
Surface markings of kidneys
- Lowest point of left and right costal margins (L1)
96
Surface anatomy of liver
- Left upper border = just medial to left nipple
- Right upper border = 5th rib at mid-clavicular line
- Lowest point of liver = 0.5inch below right costal margin in mid-axillary line
97
Gold-standard investigation for Primary Sclerosis Cholangitis
- MRCP (Magnetic Resonance Cholangiopancreatography)
98
Causes of palmar erythema
- Cirrhosis
- Hyperthyroidism
- Pregnancy
- Polycythaemia
- Rheumatoid arthritis
99
Indications for splenectomy
- Trauma (including intraoperative damage)
- Rupture
- ITP (platelets destroyed in spleen)
- So massive that destroys RBCs/platelets
100
Post-splenectomy management
- Vaccination against encapsulated bacteria 2 weeks BEFORE: pneumococcal, meningococcal, Hib
- Lifelong penicillin
- Medic alert bracelet
101
Patient with large kidneys and long-term catheter
- Hydronephrosis
102
3 commonest causes for liver transplant
- Cirrhosis
- Acute liver failure (paracetamol, Hepatitis A/B)
- Cancer
103
Differentiate caput medusae between portal HTN and IVC obstruction
Press vein below umbilicus
- Drains away from umbilicus = portal HTN
- Drains towards umbilicus = IVC obstruction
104
Areas to cover when presenting renal patient
- Cause for CKD
- Current RRT
- Previous RRT
- Immunosuppression evidence
- Volume status
105
Causes of dysphagia
Inflammatory
- Tonsillitis
- Oesophagitis
- Candidasis
Mechanical
- Luminal: foreign body, food
- Mural: cancer, benign stricture (Plummer Vinson)
- Extramural: goitre, mediastinal Lymph nodes, lung cancer
Motility:
- Achalasia
- Stroke
- MND
- Myasthenia gravis
106
Eradication therapy for H. Pylori
- Omeprazole 20mg BD
- Amoxicillin 1g BD
- Clarithromycin 500mg BD
107
Causes of jaundice
Pre-hepatic = excess bilirubin
- Haemolytic anaemia
- Ineffective erythropoiesis
Hepatic- Unconjugated
- Reduced bilirubin uptake: drugs (rifampicin), CCF
- Reduced bilirubin conjugation: Gilbert's (autosomal dominant), Crigler-Najjar (autosomal recessive
Hepatic - Conjugated
- Liver failure (congenital e.g. Wilson's, infectious, toxins, autoimmune)
Post-hepatic
- Gallstones
- Cancer head of pancreas
- PSC/PBC
108
Medication causes of liver injury/jaundice
Haemolytic
- Methyldopa
- Penicillin
- Anti-malarials
Hepatitis
- TB meds RIP
- Valproate
- Statins
Cholestatic
- Co-amoxiclav
- Flucloxacillin
- COCP
- Chlorpromazine
109
Deficiency in Gilbert's Syndrome
- UDP-glucuronyl transferase
110
Investigations for pre-hepatic jaundice
- Blood film
- Coomb's test (direct = antibodies attached to RBCs- shows haemolytic anaemia is immune-related; indirect = antibodies against foreign RBCs- do before transfusion)
- Hb electrophoresis (thalassaemia)
111
Diagnosis of spontaneous bacterial peritonitis
- Ascitic fluid polymorphonuclear cells >250mm3
112
Hepatitis B antibodies
- Surface antigen = acute infection
- Anti-HBc IgM = acute infection
- e Antigen = high infectivity
- Core antibody = previous infection
- Surface antibody = immunity
113
Features of carcinoid syndrome
FIVE HT
- Flushing
- Intestinal diarrhoea
- Valve fibrosis (TR, PS)
- whEEze
- Hepatic involvement
- Tryptophan deficiency = niacin precursor --> pellagra (diarrhoea, dermatitis, dementia)
114
Definition of pathological dilation on AXR
3-6-9
- 3cm small bowel
- 6cm large bowel
- 9cm caecum
115
Cancer screening in IBD
- Active disease for 10 years --> regular endoscopy to identify pre-malignant changes
116
Features of dermatitis herpetiformis rash
- Itchy
- Symmetrical
- Extensor surfaces
- Vesicular --> can erupt, leaving crusted lesions
117
Treatment for dermatitis herpetiformis if first-line management (gluten-free) does not work
- Dapsone (sulphonamide antibiotic which has anti-inflammatory properties)
118
Investigations for dermatitis herpetiformis
- Anti-TTG (also FBC, haematinics, LFTs etc)
- Skin biopsy: dermal papillae infiltrated with micro-abscesses containing eosinophils, neutrophils, fibrin
119
Investigations for coeliac disease
- Anti-TTG (also FBC, haematinics, LFTs etc)
- Duodenal biopsy: villous atrophy and high lymphocytes (should be on a gluten diet!)
120
Causes of renal transplant failure
SCARI
- Structural (transplant artery stenosis)
- Calcineurin toxicity
- Antibody
- Recurrence (focal segmental glomerulosclerosis)
- Infection
121
General management of chronic liver disease
MDT approach!
- Alcohol abstinence
- Nutrition (thiamine)
- Laxatives (3 soft poos a day)
- Avoid hepatotoxic meds
- Propranolol if varices
122
How does peritoneal dialysis work
- Dialysate fluid is infused via peritoneal catheter into abdo cavity
- Toxins diffuse across the peritoneum and into the dialysate fluid
- Dialysate fluid removed while patient sleeps (automatic peritoneal dialysis) or up to 6 times throughout the day (continuous ambulatory peritoneal dialysis)
123
Advantages for AV fistula over tunnelled line
- Faster flow rates = shorter dialysis sessions
- Less infection
- Longer lifespan
124
Complications of haemodialysis
- Dialysis washout (remove too much fluid --> hypotension)
- Infection
- Bleeding (heparin used in dialysis)
125
Complications of peritoneal dialysis
- Infection (peritonitis)
- Hernias
- Hyperglycaemia (sugar in dialysate fluid)
126
4 things must ask yourself if see a transplant
- Which organ
- Why done
- Is it working
- Complications
127
Important blood test in organ transplant rejection
- Immunosuppressant levels!
128
See ileostomy which has been reversed- what 2 surgeries has patient had
1. Pan-proctocolectomy with end-ileostomy
2. Reversal of ileostomy with J pouch formation (part of jejunum attaches to rectal stump)
129
Important panel of investigations in liver failure
- Non-invasive liver screen!
- Also AFP
130
Hepatomegaly with fluid overload
- Congestive hepatopathy! (right-sided heart failure --> hepatomegaly)
131
Management of Wilson's Disease
1. Copper-chelation (penicillamine or trientine hydrochloride)
2. Zinc once copper levels stable (stimulates protein in gut which binds to copper and prevents its reabsorption)
Also:
- Less copper in diet
- Liver transplant (nuts, shellfish, organ meats)
132
Alcohol effects on other systems
Cardio
- Alcoholic cardiomyopathy
- Arrythmias
Haem
- Macrocytic anaemia
- Coagulopathy
CNS
- Peripheral neuropathy
- Cerebellar
133
When to do SBP prophylaxis and which drug to use
- Ascitic protein content <15g/L or previous SBP
- Ciprofloxacin
134
Commonest cause of SBP
- E.coli (then staph and strep)
135
CKD stages in terms of eGFR
- 1: >90
- 2: 60-89
- 3: 30-59
- 4: 15-29
- 5: <15
136
Referral criteria for dialysis in CKD
- eGFR <30 (CKD stage 4 or 5)
- eGFR 30-60 but rapidly progressing (reducing by 15 in 1yr)
- Nephrotic syndrome and rapidly reducing eGFR <60
137
Risk of breast/ovarian cancer with BRCA1 and BRCA2
- BRCA1: 80% breast cancer, 40% ovarian cancer
- BRCA2: 40% breast cancer
138
1-year survival based on Child-Pugh grades
- A: 100%
- B: 80%
- C: 45%
139
Which IBD patients are eligible for screening colonoscopies (checking for cancer)?
- UC (not proctitis alone)
- Crohn's involving >1 segments of colon
140
Frequency of screening colonoscopies (checking for cancer) in IBD
- Low risk: 5 years.
- Intermediate risk: 3 years.
- High risk (severe inflammation, PSC, colonic stricture): 1 year.
141
Management of ascitic drain after insertion
- 100ml 20% HAS for every 2L drained
- Max 6hrs or 10L drained, whichever comes first
142
Management of Polycystic Kidney Disease
- Low salt, high fluid diet (suppresses vasopressin levels)
- HTN control
- Tolvaptan (vasopressor receptor antagonists) for rapidly progressive disease
- RRT
143
Indications for nephrectomy in Polycystic Kidney Disease
- To make room for transplanted kidney
- Renal cell carcinoma
- Chronic pain/haematuria
- Recurrent UTIs
144
Indications for liver transplant
- Acute (King's criteria)
- Cirrhosis with high UK End-Stage Liver Disease score >49
- Hepatocellular carcinoma (e.g. tumour <5cm)
- "Variant syndromes": PBC with intractable pruritus, hepatopulmonary syndrome
145
Absolute contraindications for liver transplant
- Ongoing alcohol/drug use
- Untreated HIV
- Previous/active extra-hepatic cancer
- Severe irreversible lung disease
146
When to refer for renal transplantation
- CKD stage 4+ (eGFR <30) who may need dialysis within next 6 months
147
Definition of end-stage renal failure
- eGFR <15ml/min
148
Absolute contraindications for renal transplantation
- Untreated malignancy
- Untreated HIV
- Deep-seated infection
149
Investigations in haemochromatosis
- Raised ferritin and transferrin saturations
- HFE gene mutation testing (but variable penetrance so not everyone with mutation will have the condition)
150
Meig's Syndrome components
- Ascites (transudative)
- Pleural effusion
- Benign ovarian tumour
151
Tests to send for ascitic fluid
- Albumin (calculate Serum: Ascites Albumin Gradient)
- Polymorphonuclear leukocyte count >250/mm3
- Amylase (raised in pancreatitis)
- MC&S inc Gram Stain
- Cytology (?malignant)
152
Indications for haemachromatosis screening
- 1st-degree relatives (check ferritin and transferrin saturations)
153
Mechanism of Hereditary Spherocytosis (inc mode of inheritance)
- Autosomal dominant on Chromosome 8 (can be recessive!)
- RBCs are spherical = more prone to rupture = haemolytic anaemia
154
Presenting symptoms of Hereditary Spherocytosis
- Splenomegaly
- Jaundice
- Lethargy
155
Complications of Hereditary Spherocytosis
- Aplastic crisis (triggered by infection)
- Gallstones
156
Investigations for Hereditary Spherocytosis
- Blood smear (check for haemolysis)
- Reticulocytes
- EMA-binding test = reduced fluorescence as reduced binding of eosin to the RBCs (do Osmotic Fragility Test if this is not available)
- Haemolysis screen (LDH, split bilirubin, Coomb's, haptoglobin)
157
Management of Hereditary Spherocytosis
- Folic acid
- Regular transfusions for anaemia
- Severe: splenectomy as stops haemolysis of RBCs in the spleen
- Cholecystectomy for gallstones
158
Foods which contain gluten
- Wheat
- Rye (flour, bread, beer)
- Barley (cereal, porridge)
159
Types of renal transplant
- Live
- Cadaveric (circulatory death or neurological death)
160
Types of renal transplant rejection and treatment for each
Hyperacute = within minutes/hours (pre-existing antibodies in recipient attack the transplant e.g. ABO)
- Plasmapheresis and IVIG
- May need to remove the transplanted kidney!
Acute = antibody or T-cell mediated
- Antibody: Plasma exchange --> IVIG. Rituximab (anti-CD20)
- T-cell: IV methylprednisolone
Chronic = usually antibody (may be non-compliance to immunosuppression) = irreversible usually
- Immunosuppressants
161
Complications of pancreatitis
Acute pancreatitis
- SIRS --> ARDS
Chronic pancreatitis
- Pseudocysts --> can obstruct pancreas/duodenum
- Portal vein thrombosis
162
Symptoms of chronic pancreatitis
- Chronic grumbling pain (usually epigastric, radiates to back, better sitting up)-- some patient experience attacks
- Steatorrhoea (fat malabsorption)
- Weight loss
163
Management of chronic pancreatitis
- Stop triggers (stop alcohol/smoking)
- Creon with PPI to improve absorption
- Endoscopic drainage of pseudocysts
- ERCP stenting of calcified ducts
164
Genetic causes of chronic pancreatitis
- CF!
- SPINK1 mutation
- PRSS1 mutation
165
Investigations for chronic pancreatitis
- Magnesium (low)
- Faecal elastase (low)
- IGG4 in autoimmune pancreatitis
- CT abdo-pelvis
- EUS with fine needle biopsy if suspect cancer (as may be difficult to differentiate cancer from pancreatitis on CT)
166
Mechanism of sickle cell disease (inc mode of inheritance)
- Autosomal recessive: sickle cell trait = 1 gene, disease = both genes
- Valine replaces glutamic acid at the sixth amino acid of the beta globin chain--> have sickled HbS instead of normal HbA
167
Complications of sickle cell disease
- Painful vaso-occlusive crises (bone, chest, priapism)
- Splenic sequestration (sickled RBCs build up --> splenomegaly and splenic failure = drop in RBCs)
- Aplastic crisis (triggered by parvovirus B19)
- Hyposplenism --> encapsulated infections
- Stroke/MI
- Gallstones
- Avascular necrosis
168
Investigations in sickle cell disease
- Blood film (Howell-Joly bodies = hyposplenism)
- Reticulocytes (high)
- Hb electrophoresis
169
Management of sickle cell disease
- Hydroxycarbamide reduces crises by increasing fetal Hb (HbF)
- Crizanlizumab (monoclonal against P-selectin) reduces vaso-occlusive crises
- Splenectomy (sequestration crises)
170
Types of glomerulonephritis
Non-proliferative
- Minimal change disease: nephrotic syndrome wibtoit changes on light microscopy. Steroid responsive
- Focal segmental glomerulosclerosis: steroids but half end in CKD
- Membranous glomerulonephritis: 1/3 stable, 1/3 remit, 1/3 end stage renal failure
Proliferative = increased cells in glomerulus
- IgA nephropathy: includes HSP
- Post-infectious: esp strep pyogenes (1 week after)
- Rapidly progressive
171
Nephritic syndrome symptoms
Triad of
- Haematuria
- Oligouria
- HTN
172
Definition of oligouria
<0.5ml/kg/hr
173
Definition of anuria
<100ml/day
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