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YR3: MM FC Ed. > 14. Jaundice > Flashcards

14. Jaundice Flashcards

1
Q

What 3 steps can bilirubin metabolism be summarised into?

A

Production of unconjugated bilirubin
Conjugation of bilirubin
Excretion of bilirubin

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2
Q

What is prehepatic jaundice?

A

Jaundice caused by excessive production of BR

Extravascular + intravascular

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3
Q

What is hepatic jaundice?

A

Jaundice due to pathology in the liver (hepatocytes + bile canaliculi)

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4
Q

What is posthepatic jaundice?

A

Jaundice caused by problems with biliary flow

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5
Q

What is obstructive jaundice?

A

Jaundice caused by lack of bile flow into the gut

Results in pale faeces (lack of urobilin/stercobilin) + dark urine (conjugated BR)

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6
Q

What is cholestatic jaundice?

A

Jaundice caused by BR not flowing out the common bile duct

Can be due to gallstones, ileus or CBD peristalsis (drug induced)

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7
Q

What is unconjugated jaundice?

A

Jaundice caused by accumulation of unconjugated BR

Due to excessive production of unconjugated BR or decreased capacity to conjugate BR

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8
Q

What causes increased production of bilirubin?

A

Intravascular haemolysis
Congenital: G6PD, PKD, SCD + thalassemia
Acquired: artificial heart valves, DIC, malaria

Extravascular haemolysis
Congenital: hereditary spherocytosis
Acquired: AI haemolysis

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9
Q

What causes decreased conjugation of bilirubin?

A

Decreased hepatocyte uptake: contrast agents + portosystemic shunts to bypass a cirrhotic liver

Congential enzymatic problems: Gilbert’s

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10
Q

What causes decreased excretion of bilirubin?

A

INVITED MD
Infection: hepatitis, ascending cholangitis, liver abscess
Neoplastic: mets, HCC, cholangiocarcinoma + pancreatic
Vascular: Budd chiari syndrome
Inflammation: PBC, PSC, AI hepatitis, pancreatitis
Trauma: gallstones, stricture after ERCP
Endo: intraheptic cholestasis of pregnancy
Degenerative: none
Metabolic: Wilson’s, haemachromatosis
Drugs: some affect ability of hepatocytes to excrete BR- alcohol, paracetamol, valproate + rifampicin. Some cause biliary ileus: nitrofurantoin, OCP

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11
Q

What questions should you ask in the presenting complaint in someone with jaundice?

A

Acute/ chronic?
Pregnant?
Associated symptoms:
RUQ pain, N+V, pruritus (hepatitis)
Fever or diarrhoea (viral hepatitis/ abscess)
Steatorrhoea, dark urine, pruritus (obstructive jaundice)
Weight loss, fever, night sweats (malignancy)
Bronzed skin + DM (haemochromatosis)
Exposure to outdoor water/ sewage (risk factor for leptospirosis)

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12
Q

What should you ask in the PMHx in someone with jaundice?

A 
Gallstones
Liver disease
Haemophilia
Recent blood transfusion/ surgery
Ulcerative colitis
Diabetes
Emphysema (suggests alpa 1 antitrypsin deficiency)
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13
Q

What should you ask about in the social history in someone with jaundice?

A 
Excessive alcohol consumption
IV drug use
Unprotected sex/ multiple partners
Foreign travel
Tattoos
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14
Q

What physiological processes occur in production of unconjugated BR?

A

RBCs broken down by macrophages in spleen
Hb degraded into iron + insoluble BR
Insoluble BR travels to liver bound to albumin

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15
Q

What physiological processes occur in conjugation of BR?

A

Hepatocytes uptake unconjugated BR

Conjugate to glucuronate making it water soluble

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16
Q

What physiological processes occur in excretion of BR?

A

Conjugated BR secreted into bile canaliculi
Flows with bile into duodenum
Metabolised by bacteria into colourless urobilinogen + stercobilinogen
Some reabsorbed in gut + excreted via kidneys
Majority oxidised in gut to coloured pigments (urobilin + stercobilin) giving faeces its brown colour

17
Q

What is conjugated jaundice?

A

accumulation of conjugated BR

18
Q

By what 4 mechanisms can drugs cause haemolysis?

A

Intravascular: Sulphonamides
AI, extravascular: Methyldopa
Hepatitis: Paracetemol OD
Cholestasis: Co-amoxiclav

19
Q

What 7 familial conditions can cause jaundice?

A 
Gilbert's syndrome
Haemochromatosis
Wilson's disease
Sickle cel disease
Thalassaemia
Hereditary spherocytosis
G6PDH deficiency
20
Q

What is haemochromatosis?

A

Deficiency of iron regulatory hepcidin.
Allows increased intestinal absorption of iron causing accumulation in tissues, esp. the liver, which may lead to organ damage.

21
Q

What is Gilbert’s syndrome?

A

Defected gene for conjugating enzyme

Results in unconjugated hyperbilirubinaemia

22
Q

What is usually the cause of elevated AST > ALT?

A

Excessive alcohol intake

23
Q

What is usually the cause of elevated ALT > AST?

A

Viral hepatitis

24
Q

In which 3 situations may you see AST and ALT elevated into the 1000s?

A

Viral hepatitis
Paracetamol OD
Ischaemic hepatitis

25
Q

What is suggested by a raised ALP and GGT?

A

Bile duct pathology (obstruction)

26
Q

What is suggested by a raised ALP and normal GGT?

A

Increased bone turnover (malignant bone mets, primary hyperparathyroid)

27
Q

What is suggested by a raised GGT in isolation?

A

Recent alcohol consumption

28
Q

What does bilirubin in the urine signify?

A

Posthepatic jaundice

29
Q

Which antibodies should you include in an autoimmune screen for cause of jaundice with raised liver enzymes?

A 
Antinuclear antibodies (ANA)
Antismooth muscle antibodies (ASMA): Type 1 AI hepatitis 
Antimitochondrial antibodies (AMA): PBC + some AI hepatitis
30
Q

What pathophysiological process occurs in PBC?

A

AI destruction of the small interlobular bile ducts

Causes intrahepatic cholestasis which damages cells, leading to scarring, fibrosis + eventually cirrhosis.

31
Q

What is PSC? What condition is this strongly associated with)

A

Chronic cholestatic disorder characterised by inflammation + fibrosis of intra- + extrahepatic bile ducts, resulting in multifocal biliary strictures.
UC

32
Q

What is cholelithiasis?

A

Stones in gallbladder

33
Q

What is Cholecystitis?

A

Inflammation of gallbladder + cystic duct

34
Q

What is Choledocholithiasis?

A

Stones in the common bile duct

35
Q

What is Cholangitis?

A

Inflammation of bile ducts/ biliary system

YR3: MM FC Ed. (46 decks)

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