45 Jaundice

Question 1

What happens to unconjugated bilirubin in the gut

Answer 1

unconjugated bilirubin is reduced by gut bacteria into tetrapyrroles called urobilinogens

Question 2

True or false. Unconjucated bilirubin is always bound to albumin and not filtered in the urine

Answer 2

True. It is the conjugated bilirubin that is filtered and majority are reabsorbed in the proximal tubules

Question 3

Yellowish discoloration resulting from the deposition of bilirubin

Answer 3

jaundice

Question 4

Best site to examine slight increase in serum bilirubin

Answer 4

sclera for icterus

Question 5

Why is the sclera the best site

Answer 5

Sclera have high affinity for bilirubin due to the high elastin content

Question 6

What is the level of bilirubin for scleral icterus to manifest

Answer 6

Serum bilirubin of at least 3 mg/dl or 51 umol/L

Question 7

Second best site to examine icterus

Answer 7

underneath the tongue

Question 8

Other differential for yellowish discoloration of skin

Answer 8

carotenoderma, use of quinacrine, excessive exposure to phenol

Question 9

Differential jaundice from carotenoderma

Answer 9

In jaundice, yellowish discoloration is distributed evenly throughout the body. In carotenoderma, pigment is concentrated in the palms, soles, forehead and nasolabial folds and sparing of the sclera

Question 10

Breakdown product of heme

Answer 10

bilirubin

Question 11

Source of 80-84% of bilirubin produced each day

Answer 11

Senescent of RBC

Question 12

Where is the primary formation of bilirubin

Answer 12

Reticuloendothelial cells in the spleen and liver

Question 13

Two chemical reactions in the formation of bilirubin

Answer 13

First: hemo oxygenase; Second: biliverdin reductase

Question 14

What are the end products of the first reaction

Answer 14

biliverdin, carbon monoxide and iron

Question 15

Responsible for the conjugation of bilirubin

Answer 15

UDPGT

Question 16

What part of the GI tract hydrolyzes conjucated bilirubin to unconjucated bilirubin

Answer 16

At the distal ileum and colon, beta glucuronidases hydrolyze conjugated bilirubin to unconjugated bilirubin

Question 17

True or false. In hemolytic disorders, serum bilirubin rarely exceeds 86 umol/L or 5 mg/dl

Answer 17

True. Higher levels are seen with co existent renal or hepatocellular dysfunction

Question 18

Which Crigler- Najjar type is seen in neonates and which persists until adulthood

Answer 18

Crigler- Najjar Type I is rare as it is found in neonates with neurologic impairment due to kernicterus leading to death in infancy or childhood. Crigler- Najjar Type II live into adulthood

Question 19

Represent a deficiency of the major hepatic drug reuptake transporters OATP1B1 and OATP1B3

Answer 19

Rotor syndrome

Question 20

Causes of isolated indirect bilirubinemia

Answer 20

hemolytic disorders, ineffective erythropiesis, massive blood transfusion, resorption of hematoma, rifampicin, probenecid, ribavirin, protease inhibitors, Crigler-Najjar, Gilbert syndrome

Question 21

Causes of isolated direct bilirubinemia

Answer 21

Dubin Johnson syndrome, Rotor syndrome

Question 22

Periumbilical nodule that suggest abdominal malignancy

Answer 22

Sister Mary Joseph nodule

Question 23

Interpretation of jaundice and low albumin

Answer 23

Suggests chronic process such as cirrhosis or cancer

Question 24

Interpretation of jaundice and normal albumin

Answer 24

Suggests acute process such as viral hepatitis or choledocholithiasis

Question 25

True or false. Failure of the prothrombin time to correct with parenteral administration of vitamin K indicates sever hepatocellular injury

Answer 25

True.

Question 26

AST ALT ration in alcoholic hepatitis

Answer 26

AST ALT ratio of 2:1; AST rarely exceed 300 U/L

Question 27

AST ALT values associated with hepatocellular disease

Answer 27

AST ALT values 25 times normal

Question 28

Initial screening test for Wilsons disease

Answer 28

Ceruloplasmin

Question 29

The next appropriate test to determine whether it is intra- or extrahepatic cholestasis

Answer 29

Ultrasound

Question 30

Area difficult to visualize on ultrasound of hepatobiliary tree

Answer 30

distal common bile duct

Question 31

Gold standard in identifying choledocholithiasis

Answer 31

ERCP

Question 32

Drugs commonly associated with cholestatis

Answer 32

anabolic and contraceptive steroids

Question 33

Autoimmune disease characterized by progressive destruction of interlobular bile ducts

Answer 33

Primary biliary cholangitis

Question 34

How is primary biliary cholangitis diagnosed

Answer 34

Detection of antimitochondrial antibody

Question 35

When does cholestasis of pregnancy occur

Answer 35

Second and third trimester of pregnancy and resolves after delivery

Question 36

What trigger cholestasis in cholestasis in pregnancy

Answer 36

Triggered by estrogen administration

Question 37

Intrahepatic stasis associated with renal cell cancer

Answer 37

Stauffers syndrome

Question 38

Presents with highest surgical cure rates of all tumors that present as painless jaundice

Answer 38

Ampullary carcinoma

Question 39

Most common cause of extrahepatic cholestasis

Answer 39

Choledocholithiasis