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Gastrointestinal > 03.05 Jaundice in Adults > Flashcards

03.05 Jaundice in Adults Flashcards

1
Q

Scleral icterus, presence of at least ____

A

3mg/dl serum bilirubin

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2
Q

Most visible manifestation of liver and biliary tract disease

A

Jaundice

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3
Q

D/dx for yellowing of skin

A

Jaundice
Carotenoderma/carotenemia
Quinacrine use
Excessive exposure to phenols

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4
Q

Becomes clinically evident when total serum bilirubin ____

A

> 3mg/dL

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5
Q

Helps in determining cause of jaundice or hyperbilirubinemia

A

Fractionation of bilirubin

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6
Q

Most commonly available technique of bilirubin measurement

A

Spectrophotometeric method (van der Bergh reaction)

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7
Q

Bilirubin reaction that directly reacts wth diazotized sulfanilic acid that is initially added (even in the absence of alcohol)

A

Direct bilirubin (conjugated)

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8
Q

Suspect liver disease or injury if conjugated bilirubin ____

A

> 0.3 mg/dL

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9
Q

The difference between the total and the direct bilirubin levels measured

A

Indirect bilirubin

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10
Q

Bilirubin formation occurs in ____

A

Reticuloendothelial system

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11
Q

Focus of history

A

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)

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12
Q

PE in assessing jaundice

A

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

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13
Q

Initial steps in evaluation

A

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

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14
Q

Three main causes of jaundice

A 
Isolated disorders of bilirubin metabolism
Liver diseases (hepatic disorder with prominent cholestasis, hepatocellular dysfunction)
Obstruction of the bile ducts
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15
Q

Both liver disease and obstruction of the bile ducts manifest with:

A

Elevated bilirubin
Abnormal liver test
Jaundice

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16
Q

Isolated elevation in bilirubin

Other liver tests are normal

A

Isolated disorder of bilirubin metabolism

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17
Q

Causes of IDBM

A

Hemolysis
Drugs (rifampicin)
Inherited disorders of metabolism

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18
Q

Unconjugated hyperbilirubinemia

A

Gilbert’s syndrome

Crigler-Najjar syndrome

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19
Q

Due to impairment in the conjugation of bilirubin

A

Gilbert’s syndrome

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20
Q

Not compatible with life

A

Crigler-Najjar syndrome

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21
Q

Conjugated hyperbilirubinemia

A

Dublin-Johnson syndrome

Rotor syndrome

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22
Q

Due to impairment in the export of bilirubin from the hepatocyte

A

Rotor syndrome

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23
Q

Decrease in bile flow due to impaired secretion by hepatocytes

A

Cholestasis

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24
Q

Clinical manifestations of cholestasis

A

Scleral icterus
Dark urine
Cutaenous jaundice (5 mg/dL)
Severe pruritus (inc. bile acids)

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25
Q

Lab tests of choletastic jaundice

A

Inc bilirubin
Abnormal ALT, AST, AlkPhos, albumin, PT)
ALP>ALT

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26
Q

In obstruction (extrahepatic cholestasis), the biliary tree is ____

A

Dilated

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27
Q

In hepatic disorder with prominent cholestasis (intrahepatic cholestasis), the biliary tree is ___

A

Not dilated

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28
Q

Causes of obstruction of bile duct

A

Choledocholithiasis
Diseases of the bile duct
Extrinsic compression of the bile ducts

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29
Q

Diseases of the bile duct

A

Primary sclerosing cholangitis

Neoplasm

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30
Q

Extrinsic compression of bile ducts

A

Neoplasm
Pancreatitis
Lymph nodes
Vascular engorgement

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31
Q

Most common cause of biliary obstruction

A

Choledocholithiasis

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32
Q

Dx of choledocholithiasis

A 
Transabdominal UTZ
CT scan
Endoscopic retrograde pancreatography
MR resonance cholangiopancreatography
Endoscopic UTZ
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33
Q

Tx of choledocholithiasis

A

Urgent
ERCP
Percutaneous transhepatic procedure
Sugery: laparoscopic, open

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34
Q

Bacterial infection superimposed on an obstruction of the biilary tree most commonly from a gallstone, but it may be associated with neoplasm or stricture

A

Acute cholangitis

35
Q

Complications of choledocholithiasis

A

Charcot’s triad: RUQ pain, fever, jaundice

Raynold’s pentad: CT + hypotension + altered mental status

36
Q

Choledocholithiasis may cause

A

Biliary obstruction
Stasis of bile
Infection

37
Q

Tx of choledocholithiasis

A

Antibiotics and biliary drainage (ERCP with sphincterotomy)

38
Q

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

A

MIrizzi syndrome

39
Q

Tx of Mirizzi syndrome

A

Surgery (not ERCP)

40
Q

16% of all TB cases in a 6-year period in Western INdia

A

Hepatobiliary tuberculosis

41
Q

Most common clinical manifestation of HBtb

A

Hepatomegaly

42
Q

Classification of HBtb

A

Miliary TB
Granulomatous disease
Localized TB

43
Q

Part of generalized TB

Minimal liver-relevant s/sx

A

Miliary TB

44
Q

Unexplained fever, with or without jaundice, abnormal liver tests, hepatomegaly
Caseating granulomas

A

Granulomatous disease

45
Q

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
A

Localized TB

46
Q

Important in those with obstructive jaundice for dx and therapy

A

ERCP

47
Q

Findings of HBtb in ERCP

A

Bile duct stricture

Extraluminal narrowing

48
Q

Dx of HBtb

A

Chronic RUQ pain

Chronic, recurrent obstructive jaundice

49
Q

Tx of HBtb

A

No clear guidelines
Standard quadruple anti-TB therapy
Biliary decompression

50
Q

Adjunct to those with obstructive jaundice whenever feasible

A

Biliary decompression

51
Q

Hepatic disorder with prominent cholestasis are seen in patients with:

A

Infiltrative disease
Diseases of the intrahepatic ducts
Postoperative jaundice, sepsis, total intrahepatic cholestasis of pregnancy

52
Q

Causes of intrahepatic cholestasis

A 
Hepatitis
Drugs
Diseases of intrahepatic bile ducts
Infiltrative disorders
Sepsis
Total parenteral nutrition
Postoperative jaundice
Cholestasis of pregnancy
53
Q

Variant presentation: cholestatic instead of hepatocellular jaundice
Anti-HAV IgM+
Benign, no tx

A

Acute HepA

54
Q

Fibrosing cholestatic hepatitis
Histology mimics obstruction of the extrahepatic ducts
Seen in recipients of solid organ transplantation
High mortality

A

Hepatic B and C

55
Q

Syndrome of progressive inflammatory liver injury associated with long-term heavy intake of ethanol
Hepatocellular jaundice
Abdominal pain, leukocytosis, fever
Biopsy

A

Alcoholic hepatitis

56
Q

Usually develops between 5 and 50 days after drug ingestion
Resolves when the drug is withdrawn
Exclusion of other causes

A

Drug-induced cholestasis

57
Q

Extrahepatic sepsis

A

Pneumonia, intraabdominal sepsis

58
Q

Usually severe infection, often with multi-organ failure (renal or respiratory)
Elevated serum bilirubin (80% conjugated)

A

Cholestasis of sepsis

59
Q

Causing mainly hepatocellular dysfunction lead to hyperbilirubinemia by disrupting bilirubin metabolism at the level of hepatocyte

A

Liver diseases (hepatocellular dysfxn)

60
Q

Causes of hepatocellular dysfxn

A 
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
61
Q

Jaundice is due to cholestasis or impairment of bile flow
Bilirubin/ALP&raquo_space; ALT/AST
Nondilated ducts

A

Cholestatic jaundice

62
Q

Jaundice is due to global hepatocellular dysfunction
ALT/AST&raquo_space;»>/= Bilirubin/ALP
Nondialted ducts

A

Hepatocellular jaundice

63
Q

Prevention of viral hepatitis

A

Vaccine HepA and B

Post-exposure prophylaxis with Ig for Hep A B

64
Q

Liver injury following inhalation, ingestion or parenteral administration of pharmacologic or chemical agents
ALT/AST > 1000u/L

A

Toxin/drug induced liver injury

65
Q

Direct toxin examples

A

Paracetamol

Isoniazid

66
Q

Idiosyncratic toxin examples

A

Isoniazid

Phenytoin

67
Q

May result from hypotension or severe hypoxia

ALT/AST > 1000u/L

A

Ischemic hepatitis

68
Q

Abdominal pain, tender, hepatomegaly, jaundice, fever
Alcohol drinker
AST/ALT < 300
AST/ALT ratio >2 u/L

A

Alcoholic hepatitis

69
Q

Prognosis of alcoholic hepatitis

A

Discriminant function = [PT time - control] + serum bilirubin

70
Q

Tx of alcoholic hepatitis

A

DF > 32: steroids, pentoxyphilline

71
Q

More common in women
Two types can only be distinguished serologically
Gamma globulins are elevated

A

AI hepatitis

72
Q

Type 1 AI hepatitis

A

ANA, ASMA

73
Q

Type 2 AI hepatitis

A

Anti-LKM1

74
Q

End stage of any chronic liver disease

Regenerative nodules surrounded by fibrous tissue

A

Cirrhosis

75
Q

2 types of cirrhosis

A

Compensated

Decompensated

76
Q

Liver is cirrhotic but somehow can still function

A

Compensated

77
Q

With jaundice or complications of cirrhosis

Less than 30% of the liver is fxning

A

Decompenstaed

78
Q

Dx of cirrhosis

A

Histological

79
Q

PE findings of cirrhosis

A 
Stigmata of CLD
Palpable left lobe of the liver
Small liver span
Splenomegaly
Signs of decompensation (jaundice, ascites, asterixis)
80
Q

Lab findings of cirrhosis

A

Low albumin < 3.8
Prolonged albumin INR > 1.3
High bilirubin > 1.5
Low platelet count < 175

81
Q

To score cirrhosis

A

Child-turcotte-pugh score

82
Q

CTP 5-6

A

30% decompensated

83
Q

CTP 10-15

A

Very much decompensated

Gastrointestinal (9 decks)

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