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Hepatomegaly3Cs and 3Is

C C hronic liver disease/ C irrhosis 1

C C ancer (2º>>1º) 2

C C CF

I Infections: hepatitis A/B/C, IMN, hydatid diseaseI I

nammation: sarcoid/SLEI Inltration: amyloid, Gaucher’s and other sphingolipidoses

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PACES

Other rare conditions: Budd–Chiari syndrome

1 Especially early (liver later shrinks). Causes include: EtOH, primary biliarycirrhosis, haemochromatosis, Wilson’s,α 1 antitrypsin deciency,cryptogenic, hepatitis B or C, lupoid, drugs (eg methyldopa/amiodarone/

methotrexate)2 Also remember lymphomas, leukaemias and carcinoid

Remember to look hard for lymphadenopathy and comment on whether it isfound when presenting a case. Differential changes and most likely causesnow become lymphomas (especially CLL) and IMN

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Splenomegaly

NIHILIST

N N eoplasm: Myeloproliferatives 1

Lymphoproliferatives 2

I Infection: Viral: EBV/IMN/glandular fever, hepatitisBacterial (typhoid, brucella, TB)Protozoal: malaria*, kala-azar* 3

H H aemolytic anaemias: if chronic 4

I Inltration: amyloid, lipids (Gaucher’s/Niemann Pick)L L iver/ L iquor 5

I Inammatory: rheumatoid arthritis 6, SLE, sarcoidS S pherocytosis/ S BE/ S lender young femalesT T rauma/ T hyrotoxicosis

Hepatosplenomegaly

CML III

C C irrhosis (with portal HTN)/Budd–Chiari 1

M M yeloproliferative disorders 2

L Lymphoproliferative disorders

3

I Infections: hepatitis, Brucella , Weil’s, toxoplasmosis, CMV,EBV (IMN)

I Inammation: sarcoid, pernicious anaemiaI Inltration: amyloid, Gaucher’s and other sphingolipidoses

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PACES

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PACES

1 Myelobrosis*, CML*, PRV, essential thrombocythemia2 Most lymphomas, CLL, hairy cell leukaemia3 ’Black sickness’ = visceral infection withLeishmania donovani

4 For example, autoimmune haemolytic anaemia, cold haemagglutinin,spherocytosis and haemoglobinopathies

5 And other causes of portal hypertension: hepatic or portal vein thrombosis,CCF

6 If also leucopoenia = Felty’s!

*Causes of massive splenomegaly

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Ascites

5Ps and 5Hs

P P ortal hypertension (cirrhosis/Budd–Chiari)P P eritoneal metastasesP P eritoneal infection (especially TB)P P ericarditis (constrictive)P P ancreatitis

H H eart failure (right-sided or CCF)H H epatic failureH H ypoalbuminaemia (especially nephrotic syndrome)H H ypothyroid

H H epatic vein thrombosisNB Similar causes to pleural exudates (see pp. 17–18)

Primary biliary cirrhosis (Associations/features)

SCRATCHED

S S jögren’s/ S clerodermaC C oeliac diseaseR R heumatoid arthritisA A utoantibodies: ‘ MSN ’1

T T hyroiditis/ T ubular acidosis (renal)C C opper deposition 2

H H LA DR8 (or HLA C4B2)E E yes (Kayser–Fleischer rings 2)

D D ermatomyositis

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1 Causes: OCP, tumour, hypercoagulable states, myeloproliferative disorders,hydatid disease, PNH, trauma, radiotherapy

2 CML, myelobrosis, PRV, essential thrombocytopenia ±AML3 CLL, lymphoma, myelomatosis, Waldenstrom’s

If lymphadenopathy, lymphoma is most likely but also considerCHEST:

C CLLH Hepatitis A, B or CE EBV (ie infective mononucleosis = glandular fever)S SarcoidT Toxoplasmosis

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Scratch marks are one of the hallmarks of the disease. All causes of cholestasis can lead to pruritus, but in primary biliary cirrhosis it is often the most distressing symptom for patients

Hepatitis C

4Cs

C C hronicC C irrhosisC C ancerC C ryoglobulins (mixed essential type)

Pancreatitis: modified Glasgow criteria

GLASGOW Concerns Us

G G eriatric (age >55 years) 1L L DH >600 IU/lA A lbumin < 32 g/lS AS T >200 IU/l (NB not ALT!)G G lucose > 10 mmol/lO O xygen: P aO 2 <8 kPaW W hite cells >15·10 9 /l

Concerns

Ca <2 mmol/lU s U rea >16 mmol/l


1 MSN = Mitochondrial (95%),Smooth muscle (50%),Nuclear (20%)2 NBWilson’s is not the only cause of this (see p. 82)

Rx:

● Ursodeoxycholic acid, fat-soluble vitamins and liver transplant● Consider immunosuppressants: penicillamine (or steroids, azathioprine,

methotrexate, ciclosporin A)

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GLASGOW Concerns Us lists poor prognostic factors for acute pancreatitis

1 Is not strictly part of Glasgow criteria but is assoc with increased mortality

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Fat in liver

PODGE

P P regnancyO O besity 1

D D iabetes mellitusG G alactosaemia/ G lycogen storage disordersE E tOH

Malabsorption

TROPICAL ZOO

T T ropical sprueR R adiationO O perations (small bowel resection)P P ancreas: cancer or chronic pancreatitisI Intestinal lymphangiectasia

C C oeliac/ C rohn’sA A ntacids (other drugs: neomycin, cholestyramine)L L actose intolerance/ Lamblia intestinalis 1

Z Z ollinger–Ellison syndromeO O vergrowth of bacteria (folate often normal or increased!)O O veractive thyroid (Grave’s)


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1 And counter intuitively can also be caused by starvation/anorexia and

total parenteral nutritionOther causes: hyperlipidaemia (especially hypertriglyceridemia) and drugssuch as amiodarone, methotrexate, corticosteroids and oestrogens

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Other causes: Whipples (NBneuro and cardiac involvement –see p. 128) andhypogammaglobulinaemia

1 = Giardia lamblia

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Toxic megacolon

BACTERIAS

B B ehçet’s (and Chaga’s)A A nti-diarrhoea drugs*/ A ntidepressants*/ A nticholinergics*C C lostridium difcile / C MV/ C ampylobacter (Yersinia )T T rypanosoma cruzi E E ntamoeba histolytica (amoebic dysentery)R R adiation (or chemotherapy) colitisI Ischaemic colitisA A nalgesics*/ A nxiolytics*S S almonella (typhoid and non-typhoid)/ S higella

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Inammatory bowel disease (IBD) is considered too obvious tomention!

*Can all increase risk in those with IBD

Is associated with increased colonic wall thickness, multiple air levels andloss of haustral pattern, as seen on abdominal Xray

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Diagnosis

● Colon >6 cm radiographically● 3 of: (1) fever, (2) tachycardia, (3)↑ WCC, (4)↓ Hb● 1 of: (1) dehydration, (2) altered mental state, (3) electrolyte

abnormalities, (4)↓ BP

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