24. Jaundice

Question 1

Where is bilirubin conjugated?

Answer 1

liver

Question 2

Where does bilirubin come from?

Answer 2

heme products
lots from RBC
small portion myoglobin and maturing erythroid cells

Question 3

What is heme oxidized to prior to bilirbuin?

Answer 3

biliverdin

Question 4

Where does unconjugated bilirubin go?

Answer 4

passively taken into hepatocytes
udnergoes glucouronidation
becomes conjugated

then secreted into biliary system and emptied into gut –> urobilinogen (reabsorbed to urine) and stercobiligin (feces)

remaining conjug bili then deconjug and back to portal sys to be taken up by hepatocytes

Question 5

What level is clinical jaundice noted?

Answer 5

2.5mg/dL

Question 6

Why do eyes and skin show jaundice?

Answer 6

high albumin []

Question 7

What 3 ways can physiology of bile be altered?

Answer 7

1)over production of heme
2) failure of hepatocyte to take up conjugate and secrete bilirubin
3) obstruction of biliary secretion into intestine

Question 8

What increases the neurotoxcity of unconjugated hyperbili?

Answer 8

hemolysis
hypoalbuminemia
acidemia
drugs bind competitively to albumin

Question 9

3 major ddx categories for jaundice patients?

Answer 9

disorders of hemolysis
liver injury, dsyfunction or cholestasis
biliary obstruction

Question 10

Key hx questions in patients with jaundice

Answer 10

HEPATITIS-viral prodrome
IATRO- recent/remote bl products, occupational exposure, travel
ETOH- liver disease, etoh/ivdu, pregnancy, cv disease
TOX- toxic/therapeutic ingestion
DIRECT -biliary tract surgery, fever, abdo pain, changes to urine or stool, malignancy/w loss/night sweats,trauma

Question 11

PE specifics for pt with jaundice

Answer 11

mental status
abdo tender/liver size
hepatomegaly
skin: petechiae, purpura, caput medusae, spider angiomata, ascites, pulsatile mass

Question 12

Extra lab tests for specific situations in pt with jaundice

Answer 12

ammonia if AMS preesnt
LDH and haptoglobin if considering hemolysis
pregnancy
tox screen

Question 13

List ddx for 6 causes of hepatocellular/cholestatic processes causing jaundice

Answer 13

viral hepatitis
fulmainent hepatic failure
alcohol hepatitis (AST >ALT)
ischemia
toxins
autoimm disease
HELLP

Question 14

DDX of jaundice with normal transaminases, alk phos, pt/ptt, n or reduced hb/hematocrit
elevated ldh and low haptoglobin

Answer 14

hemolytic disorder
hematoma reabsorption
gilbert syndrome (inadq hepatic conjug of bilirubin)

Question 15

Name 6 causes of obstructive jaundice

Answer 15

choledocho
intrinsic bile duct dis: cholangitis, aids cholangiopathy, strictures, neoplasm
extrinsic biliary compression
neoplasm (pancr/liver)

Question 16

Dx of SBP

Answer 16

presence of more than 250 poly- morphonuclear (PMN) cells per cubic millimeter of ascitic fluid

Question 17

SAAG value >1.1g/dL - what does this mean clinically?

Answer 17

low albumin level in ascitic fluid and therefore transudative –> portal HTN

Question 18

SAAG value <1.1g/dL - what does this mean clinically?

Answer 18

higher albumin level in ascitis fluid and therefore exudative fluid
sle, pancreatitis

Question 19

Causes of portal htn causing jaundice?

Answer 19

cirrhosis
liver failure
HF

Question 20

What is best imaging for looking for obstruction in hepatic, portal or splenic veins

Answer 20

u/s with doppler

Question 21

MC 2 causes of biliary obstruction

Answer 21

biliary stones
benign/malignant stenoses

Question 22

Acute hepatic failure triad

Answer 22

jaundice
encephalopathy INR >1.5

Question 23

Charcot’s triad

Answer 23

fever
ruq pain
jaundice

cholangitis

Question 24

reynold’s pentad

Answer 24

fever
ruq pain
jaundice

hypotension
ams

asc cholangitis

Question 25

portal v thrombosis aka

Answer 25

budd chiari syndrome

Question 26

1000s club for transaminases - causes?

Answer 26

HELLP eclampsia budd chiari ischemia viral hepatitis autoimmune tylenol OD/overdose to liver

Question 27

SBP med choice

Answer 27

IV third- generation cephalosporin (e.g., cefotaxime 2 g IV, ceftriaxone 2 g IV). Patients with SBP should receive an albumin infusion (initial dose 25% 1.5g/kg IV), as it has been shown to reduce the risk for mortality and hepatorenal syndrome.

Question 28

Name 5 causes of fulminant hepatic failure that would be considered critical diagnosis of jaundice

Answer 28

toxin virus etoh ischemia reye syndrome

Question 29

name 5 emergent diagnoses of jaundice from hepatic in nature

Answer 29

Hepatitis of any cause with confusion, bleeding, or coagu- lopathy Wilson disease Primary biliary cirrhosis Autoimmune hepatitis Liver transplant rejection Infiltrative liver disease Drug induced (isoniazid, phenytoin, acetaminophen, ritona- vir, halothane, sulfonamides) Toxin ingestion or exposure

Question 30

Name one critical dx from biliary system and one emergent?

Answer 30

cholangitis bile duct obstr - stone/inflamm/stricture/neoplasm

Question 31

Name 2 critical dx of jaundice from systemic cause

Answer 31

sepsis heatstroke

Question 32

Name 3 emergent causes of jaundice due to systemic disease

Answer 32

sarcoid amyloid gvhd

Question 33

list 2 nonemergent systemic causes of jaundice

Answer 33

post traumatic hematoma reabsorp tpn

Question 34

cv critical causes of jaundice - list 3

Answer 34

obstructing aaa budd chiari synd severe HF

Question 35

cv emergent causes of jaundice - list 2

Answer 35

r sided HF veno occlusive disease

Question 36

hem-onc critical cause of jaundice - list 1

Answer 36

transfusion reaction

Question 37

hem-on emergent causes of jaundice - list 5

Answer 37

hemolytic anemia massive malign infiltation inborn error of metabolism pancreatitic head tumor metastatic disease

Question 38

name 2 reproductive causes of jaundice - critical dx

Answer 38

preeclampsia, hellp acute fatty liver of pregnancy

Question 39

Name an emergent cause of jaundice in pregnancy and nonemergent

Answer 39

hyperemesis gravardum cholestasis of pregnancy

Question 40

What signs/symptoms/labs to consider immediate transfer to a liver specialist

Answer 40

acute hepatitis with elevated INR or encephalopathy

Question 41

Which jaundice pt require hospitalization?

Answer 41

new-onset jaundice and transaminase levels approaching 1000 IU/L, bilirubin approaching 10 mg/dL, or any evidence of coag- ulopathy, as these laboratory abnormalities suggest significant hepatic dysfunction. biliary stone disease choledocho, gallstones in cbd cholangitis

Question 42

If >5L of ascitic fluid removed, how much IV albumin repletion?

Answer 42

for ea litre removed, 6-8g albumin

Question 43

Name the 3 categories and their parts of the Tokyo Guidelines for Dx of Acute cholangitis

Answer 43

a. sys: fever, wbc, elevated crp b. cholestasis: jaundice, abn LFT c. imaging: biliary dilatation, stricture, stone, stent