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Rosens > 24. Jaundice > Flashcards

24. Jaundice Flashcards

1
Q

Where is bilirubin conjugated?

A

liver

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2
Q

Where does bilirubin come from?

A

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

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3
Q

What is heme oxidized to prior to bilirbuin?

A

biliverdin

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4
Q

Where does unconjugated bilirubin go?

A

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

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5
Q

What level is clinical jaundice noted?

A

2.5mg/dL

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6
Q

Why do eyes and skin show jaundice?

A

high albumin []

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7
Q

What 3 ways can physiology of bile be altered?

A

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

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8
Q

What increases the neurotoxcity of unconjugated hyperbili?

A

hemolysis
hypoalbuminemia
acidemia
drugs bind competitively to albumin

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9
Q

3 major ddx categories for jaundice patients?

A

disorders of hemolysis
liver injury, dsyfunction or cholestasis
biliary obstruction

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10
Q

Key hx questions in patients with jaundice

A

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

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11
Q

PE specifics for pt with jaundice

A

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

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12
Q

Extra lab tests for specific situations in pt with jaundice

A

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

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13
Q

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

A

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

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14
Q

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

A

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

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15
Q

Name 6 causes of obstructive jaundice

A

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

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16
Q

Dx of SBP

A

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

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17
Q

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

A

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

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18
Q

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

A

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

19
Q

Causes of portal htn causing jaundice?

A

cirrhosis
liver failure
HF

20
Q

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

A

u/s with doppler

21
Q

MC 2 causes of biliary obstruction

A

biliary stones
benign/malignant stenoses

22
Q

Acute hepatic failure triad

A

jaundice
encephalopathy INR >1.5

23
Q

Charcot’s triad

A

fever
ruq pain
jaundice

cholangitis

24
Q

reynold’s pentad

A

fever
ruq pain
jaundice

hypotension
ams

asc cholangitis

25
Q

portal v thrombosis aka

A

budd chiari syndrome

26
Q

1000s club for transaminases - causes?

A

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

27
Q

SBP med choice

A

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.

28
Q

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

A

toxin
virus
etoh
ischemia
reye syndrome

29
Q

name 5 emergent diagnoses of jaundice from hepatic in nature

A

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

30
Q

Name one critical dx from biliary system and one emergent?

A

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

31
Q

Name 2 critical dx of jaundice from systemic cause

A

sepsis
heatstroke

32
Q

Name 3 emergent causes of jaundice due to systemic disease

A

sarcoid
amyloid
gvhd

33
Q

list 2 nonemergent systemic causes of jaundice

A

post traumatic hematoma reabsorp
tpn

34
Q

cv critical causes of jaundice - list 3

A

obstructing aaa
budd chiari synd
severe HF

35
Q

cv emergent causes of jaundice - list 2

A

r sided HF
veno occlusive disease

36
Q

hem-onc critical cause of jaundice - list 1

A

transfusion reaction

37
Q

hem-on emergent causes of jaundice - list 5

A

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

38
Q

name 2 reproductive causes of jaundice - critical dx

A

preeclampsia, hellp
acute fatty liver of pregnancy

39
Q

Name an emergent cause of jaundice in pregnancy and nonemergent

A

hyperemesis gravardum
cholestasis of pregnancy

40
Q

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

A

acute hepatitis with elevated INR or encephalopathy

41
Q

Which jaundice pt require hospitalization?

A

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

42
Q

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

A

for ea litre removed, 6-8g albumin

43
Q

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

A

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

Rosens (62 decks)

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