03.05 Jaundice in Adults Flashcards by Karla Guntayon

Scleral icterus, presence of at least ____

3mg/dl serum bilirubin

How well did you know this?

Not at all

Perfectly

Most visible manifestation of liver and biliary tract disease

Jaundice

How well did you know this?

Not at all

Perfectly

D/dx for yellowing of skin

Jaundice
Carotenoderma/carotenemia
Quinacrine use
Excessive exposure to phenols

How well did you know this?

Not at all

Perfectly

Becomes clinically evident when total serum bilirubin ____

> 3mg/dL

How well did you know this?

Not at all

Perfectly

Helps in determining cause of jaundice or hyperbilirubinemia

Fractionation of bilirubin

How well did you know this?

Not at all

Perfectly

Most commonly available technique of bilirubin measurement

Spectrophotometeric method (van der Bergh reaction)

How well did you know this?

Not at all

Perfectly

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

Direct bilirubin (conjugated)

How well did you know this?

Not at all

Perfectly

Suspect liver disease or injury if conjugated bilirubin ____

> 0.3 mg/dL

How well did you know this?

Not at all

Perfectly

The difference between the total and the direct bilirubin levels measured

Indirect bilirubin

How well did you know this?

Not at all

Perfectly

Bilirubin formation occurs in ____

Reticuloendothelial system

How well did you know this?

Not at all

Perfectly

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)

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Three main causes of jaundice

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

How well did you know this?

Not at all

Perfectly

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

Elevated bilirubin
Abnormal liver test
Jaundice

How well did you know this?

Not at all

Perfectly

Isolated elevation in bilirubin

Other liver tests are normal

Isolated disorder of bilirubin metabolism

How well did you know this?

Not at all

Perfectly

Causes of IDBM

Hemolysis
Drugs (rifampicin)
Inherited disorders of metabolism

How well did you know this?

Not at all

Perfectly

Unconjugated hyperbilirubinemia

Gilbert’s syndrome

Crigler-Najjar syndrome

How well did you know this?

Not at all

Perfectly

Due to impairment in the conjugation of bilirubin

Gilbert’s syndrome

How well did you know this?

Not at all

Perfectly

Not compatible with life

Crigler-Najjar syndrome

How well did you know this?

Not at all

Perfectly

Conjugated hyperbilirubinemia

Dublin-Johnson syndrome

Rotor syndrome

How well did you know this?

Not at all

Perfectly

Due to impairment in the export of bilirubin from the hepatocyte

Rotor syndrome

How well did you know this?

Not at all

Perfectly

Decrease in bile flow due to impaired secretion by hepatocytes

Cholestasis

How well did you know this?

Not at all

Perfectly

Clinical manifestations of cholestasis

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

How well did you know this?

Not at all

Perfectly

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 >> ALT/AST Nondilated ducts

Cholestatic jaundice

Jaundice is due to global hepatocellular dysfunction ALT/AST >>>>>/= 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