03.05 Jaundice in Adults Flashcards
Scleral icterus, presence of at least ____
3mg/dl serum bilirubin
Most visible manifestation of liver and biliary tract disease
Jaundice
D/dx for yellowing of skin
Jaundice
Carotenoderma/carotenemia
Quinacrine use
Excessive exposure to phenols
Becomes clinically evident when total serum bilirubin ____
> 3mg/dL
Helps in determining cause of jaundice or hyperbilirubinemia
Fractionation of bilirubin
Most commonly available technique of bilirubin measurement
Spectrophotometeric method (van der Bergh reaction)
Bilirubin reaction that directly reacts wth diazotized sulfanilic acid that is initially added (even in the absence of alcohol)
Direct bilirubin (conjugated)
Suspect liver disease or injury if conjugated bilirubin ____
> 0.3 mg/dL
The difference between the total and the direct bilirubin levels measured
Indirect bilirubin
Bilirubin formation occurs in ____
Reticuloendothelial system
Focus of history
Exposure to any chemicals or medications
Parenteral exposure
Risk-taking behaviour
Recent travel history
Exposure to people with jaundice and contaminated foods
Alcohol
Accompanying s/sx (antralgia, myalgia, rash, anorexia, weight loss, abdominal pain, fever, pruritus, urine or stool changes)
PE in assessing jaundice
Nutritional status
Muscle wasting (long-standing)
Stigmata of chronic liver disease: spider nevi, palmar erythema, gynecomastia, caput medusa, testicular atrophy
Abdominal examination: size and consistency of liver, palpation of the spleen for enlargement, presence or absence of ascites
Initial steps in evaluation
Liver-associated tests (total bilirubin, direct bilirubin, indirect bilirubin, alkaline phosphatase, ALT, AST, albumin, prothrombin time)
Determine if hyperbilirubinemia is direct or indirect
Other tests
Three main causes of jaundice
Isolated disorders of bilirubin metabolism Liver diseases (hepatic disorder with prominent cholestasis, hepatocellular dysfunction) Obstruction of the bile ducts
Both liver disease and obstruction of the bile ducts manifest with:
Elevated bilirubin
Abnormal liver test
Jaundice
Isolated elevation in bilirubin
Other liver tests are normal
Isolated disorder of bilirubin metabolism
Causes of IDBM
Hemolysis
Drugs (rifampicin)
Inherited disorders of metabolism
Unconjugated hyperbilirubinemia
Gilbert’s syndrome
Crigler-Najjar syndrome
Due to impairment in the conjugation of bilirubin
Gilbert’s syndrome
Not compatible with life
Crigler-Najjar syndrome
Conjugated hyperbilirubinemia
Dublin-Johnson syndrome
Rotor syndrome
Due to impairment in the export of bilirubin from the hepatocyte
Rotor syndrome
Decrease in bile flow due to impaired secretion by hepatocytes
Cholestasis
Clinical manifestations of cholestasis
Scleral icterus
Dark urine
Cutaenous jaundice (5 mg/dL)
Severe pruritus (inc. bile acids)
Lab tests of choletastic jaundice
Inc bilirubin
Abnormal ALT, AST, AlkPhos, albumin, PT)
ALP>ALT
In obstruction (extrahepatic cholestasis), the biliary tree is ____
Dilated
In hepatic disorder with prominent cholestasis (intrahepatic cholestasis), the biliary tree is ___
Not dilated
Causes of obstruction of bile duct
Choledocholithiasis
Diseases of the bile duct
Extrinsic compression of the bile ducts
Diseases of the bile duct
Primary sclerosing cholangitis
Neoplasm
Extrinsic compression of bile ducts
Neoplasm
Pancreatitis
Lymph nodes
Vascular engorgement
Most common cause of biliary obstruction
Choledocholithiasis
Dx of choledocholithiasis
Transabdominal UTZ CT scan Endoscopic retrograde pancreatography MR resonance cholangiopancreatography Endoscopic UTZ
Tx of choledocholithiasis
Urgent
ERCP
Percutaneous transhepatic procedure
Sugery: laparoscopic, open
Bacterial infection superimposed on an obstruction of the biilary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture
Acute cholangitis
Complications of choledocholithiasis
Charcot’s triad: RUQ pain, fever, jaundice
Raynold’s pentad: CT + hypotension + altered mental status
Choledocholithiasis may cause
Biliary obstruction
Stasis of bile
Infection
Tx of choledocholithiasis
Antibiotics and biliary drainage (ERCP with sphincterotomy)
Jaundice from bile duct obstruction (compression of a common hepatic duct by a stone impacted in cystic duct or neck of gallbladder)
Uncommon complication of gallstone disease
MIrizzi syndrome
Tx of Mirizzi syndrome
Surgery (not ERCP)
16% of all TB cases in a 6-year period in Western INdia
Hepatobiliary tuberculosis
Most common clinical manifestation of HBtb
Hepatomegaly
Classification of HBtb
Miliary TB
Granulomatous disease
Localized TB
Part of generalized TB
Minimal liver-relevant s/sx
Miliary TB
Unexplained fever, with or without jaundice, abnormal liver tests, hepatomegaly
Caseating granulomas
Granulomatous disease
Liver-relevant s/sx predominate
- solitary or multiple nodules
- tuberculomas
- tuberculous hepatic abscess
- bile duct dilation due to duct involvement or obstruction by lymph node
Localized TB
Important in those with obstructive jaundice for dx and therapy
ERCP
Findings of HBtb in ERCP
Bile duct stricture
Extraluminal narrowing
Dx of HBtb
Chronic RUQ pain
Chronic, recurrent obstructive jaundice
Tx of HBtb
No clear guidelines
Standard quadruple anti-TB therapy
Biliary decompression
Adjunct to those with obstructive jaundice whenever feasible
Biliary decompression
Hepatic disorder with prominent cholestasis are seen in patients with:
Infiltrative disease
Diseases of the intrahepatic ducts
Postoperative jaundice, sepsis, total intrahepatic cholestasis of pregnancy
Causes of intrahepatic cholestasis
Hepatitis Drugs Diseases of intrahepatic bile ducts Infiltrative disorders Sepsis Total parenteral nutrition Postoperative jaundice Cholestasis of pregnancy
Variant presentation: cholestatic instead of hepatocellular jaundice
Anti-HAV IgM+
Benign, no tx
Acute HepA
Fibrosing cholestatic hepatitis
Histology mimics obstruction of the extrahepatic ducts
Seen in recipients of solid organ transplantation
High mortality
Hepatic B and C
Syndrome of progressive inflammatory liver injury associated with long-term heavy intake of ethanol
Hepatocellular jaundice
Abdominal pain, leukocytosis, fever
Biopsy
Alcoholic hepatitis
Usually develops between 5 and 50 days after drug ingestion
Resolves when the drug is withdrawn
Exclusion of other causes
Drug-induced cholestasis
Extrahepatic sepsis
Pneumonia, intraabdominal sepsis
Usually severe infection, often with multi-organ failure (renal or respiratory)
Elevated serum bilirubin (80% conjugated)
Cholestasis of sepsis
Causing mainly hepatocellular dysfunction lead to hyperbilirubinemia by disrupting bilirubin metabolism at the level of hepatocyte
Liver diseases (hepatocellular dysfxn)
Causes of hepatocellular dysfxn
Viral hepatitis Alcoholic liver diseas Drug-induced liver injury Shock liver/ischemic hepatitis AI hepatitis Metabolic disorders (hemochromatosis, Wilson's disease, NAFLD, alpha-1 antitrypsin deficiency) Cirrhosis
Jaundice is due to cholestasis or impairment of bile flow
Bilirubin/ALP»_space; ALT/AST
Nondilated ducts
Cholestatic jaundice
Jaundice is due to global hepatocellular dysfunction
ALT/AST»_space;»>/= Bilirubin/ALP
Nondialted ducts
Hepatocellular jaundice
Prevention of viral hepatitis
Vaccine HepA and B
Post-exposure prophylaxis with Ig for Hep A B
Liver injury following inhalation, ingestion or parenteral administration of pharmacologic or chemical agents
ALT/AST > 1000u/L
Toxin/drug induced liver injury
Direct toxin examples
Paracetamol
Isoniazid
Idiosyncratic toxin examples
Isoniazid
Phenytoin
May result from hypotension or severe hypoxia
ALT/AST > 1000u/L
Ischemic hepatitis
Abdominal pain, tender, hepatomegaly, jaundice, fever
Alcohol drinker
AST/ALT < 300
AST/ALT ratio >2 u/L
Alcoholic hepatitis
Prognosis of alcoholic hepatitis
Discriminant function = [PT time - control] + serum bilirubin
Tx of alcoholic hepatitis
DF > 32: steroids, pentoxyphilline
More common in women
Two types can only be distinguished serologically
Gamma globulins are elevated
AI hepatitis
Type 1 AI hepatitis
ANA, ASMA
Type 2 AI hepatitis
Anti-LKM1
End stage of any chronic liver disease
Regenerative nodules surrounded by fibrous tissue
Cirrhosis
2 types of cirrhosis
Compensated
Decompensated
Liver is cirrhotic but somehow can still function
Compensated
With jaundice or complications of cirrhosis
Less than 30% of the liver is fxning
Decompenstaed
Dx of cirrhosis
Histological
PE findings of cirrhosis
Stigmata of CLD Palpable left lobe of the liver Small liver span Splenomegaly Signs of decompensation (jaundice, ascites, asterixis)
Lab findings of cirrhosis
Low albumin < 3.8
Prolonged albumin INR > 1.3
High bilirubin > 1.5
Low platelet count < 175
To score cirrhosis
Child-turcotte-pugh score
CTP 5-6
30% decompensated
CTP 10-15
Very much decompensated
