69. Jaundice Flashcards
24 year old man with jaundice, fever, very raised ALT, raised bilirubin, mildly raised ALP
a) Describe the liver problem
b) Qs to ask
c) Tests to perform
a) Hepatitis
b) Travel history, occupational history, sexual history, IVDU, etc.
c) - Clotting test (for acute liver failure eg fulminant hepatitis, paracetamol overdose)
- Antibody test:
1. Look for core antibody for infection and surface antigen - IgM for acute; IgG for chronic
2. Look for surface ANTIBODY for immunity
(note: you cannot have surface antibody and surface antigen at the same time)
- Non-invasive liver screen (USS; as opposed to an invasive liver screen - biopsy)
Acute liver failure.
a) Define
b) Classification
c) Causes
d) Presentation
e) Social Hx - Qs to ask
f) Non-invasive liver screen + other tests to do
g) Score for mortality in cirrhosis
a) Acute encephalopathy, coagulopathy and jaundice without previous cirrhosis
b) < 7 days: hyperacute, 7-14: acute
c) Paracetamol OD, alcohol, viral hepatitis (ABCDE, CMV, EBV), NASH, autoimmune, ischaemic hepatitis
d) Jaundice, abdominal pain, bruising/bleeding, confusion, drowsiness, slurred speech (DDx - stroke), hepatomegaly, ascites
e) Alcohol, IVDU, foreign travel, tattoos, sexual activity
f) NILS: FBC, clotting, LFTs, HepBsAG, Anti-HCV, EBV/CMV serology, caeruloplasmin (Wilson), transferrin (Haemochromatosis), antibodies (AMA, ASMA, ANA - PBC, PSC, etc.), alpha-1-antitrypsin
- Other: UEs, CRP, amylase, Ca2+, glucose, paracetamol levels
g) Child Pugh score
Management of acute liver failure
a)
A-E Stop hepatotoxic drugs prophylactic abx IV fluids Monitor glucose/ PT
Decompensated chronic liver failure.
a) 4 key features
b) Causes (acute +….?)
c) Management
a) Cirrhosis: variceal bleeding, encephalopathy, coagulopathy, hypoalbuminaemia (ascites)
b) Wilson’s, haemochromatosis
c) - Pabrinex, chlordiazepoxide reducing regime
- SBP (>250 white cells/mm3): abdo pain in presence of ascites (+ sepsis signs) - IV ABx
- GI bleeding management + prophlaxis (propranolol, TIPS)
- Manage any AKI
Pre-hepatic jaundice.
a) Pathophysiology
b) Presentation
c) LFTs
d) Differentials
a) Increased haemolysis:
- Often causes ANAEMIA + JAUNDICE
b) - Anaemia signs and symptoms (pale and yellow)
?splenomegaly (from increased haemolysis)
c) - UNCONJUGATED hyperbilirubinaemia
- Normal LFTs
- Anaemia !
d) - Gilbert’s syndrome
- Sickle cell crises/ thalassaemia
- Sepsis
- Transfusion reactions: ABO/Rhesus incompatibility
- Haemolytic drug reaction
Hepatic jaundice.
a) Pathophysiology
b) Presentation
c) LFTs
d) Differentials
a) Hepatocellular dysfunction
b) - ?dark urine, pale stools (may be normal)
- ?RUQ pain
- ?hepatomegaly
c) - Conjugated/unconjugated hyperbilirubinaemia
- AST/ALT raised > GGT/Alk Phos
d) - Hepatitis: infective, alcoholic, drug-induced, autoimmune,
- Dysfunction: cirrhosis, ALD, CLD
- Malignancy: HCC, liver mets
Post-hepatic jaundice.
a) Pathophysiology
b) Presentation
c) LFTs
d) Differentials
a) Cholestasis - obstruction of the common bile duct
b) - Dark urine, pale stools
- Pruritis
- ?RUQ pain
c) - CONJUGATED hyperbilirubinaemia
- GGT/Alk Phos raised >ALT/AST
d) Gallstones (choleithiasis), acalculous cholecystitis, cholangitis (and biliary sepsis), pancreatic cancer, cholangiocarcinoma, biliary stricture, PSC/PBC
Courvoisier’s law.
a) Law
b) Why this happens?
c) Exceptions
a) The presence of a palpable non-tender gallbladder in a jaundiced patient is more likely to be due to malignancy than gallstones
b) Gallstones are a chronic inflammatory diseases, causing gallbladder fibrosis, meaning it is unable to distend (so won’t be palpable)
c) Double gallstones:
- One blocking the common bile duct (responsible for jaundice)
- One at the cystic duct (causing a palpable non-tender gallbladder)
Jaundice: history.
a) Onset
b) Associated symptoms to ask about
c) PMHx
d) FHx
e) DHx
f) SHx
a) - Sudden (and painful) - more likely gallstones
- Gradual (and painless, or vague abdominal discomfort, weight loss/anorexia) - more likely malignancy
b) - PAIN (especially RUQ/other abdominal)
- Obstructive: dark urine, pale faeces
- Systemic: fever, nausea, vomiting (?hepatitis), weight loss/ anorexia (?malignancy), pruritis
- Anaemia symptoms: pale, SOB, dizziness/LOC, fatigue
- Current pregnancy (?obstetric cholestasis)
c) - Gallstones
- IBD (can cause PSC)
- Surgery
- Malignancy
- Haematological disease
d) - Sickle cell, thalassaemia, etc.
- Hereditary jaundice (eg. Gilbert’s)
e) - Recent antibiotics (eg. erythromycin)
- Known hepatotoxics/ enzyme inducers
- Allergies
f) - Foreign travel (?hepatitis)
- Alcohol
- Smoking (?malignancy)
- IVDU
- Sexual history
Jaundice: examination.
a) Best way of examining
b) Chronic jaundice causes what appearance?
c) Inspection
d) Palpation
a) - Natural light
- Best seen in sclera, frenulum of tongue and abdomen
b) Greenish-yellow (biliverdin)
c) - Signs of chronic liver disease: clubbing, asterixis, palmar erythema (thenar and hypothenar eminences), spider naevi (chest), gynaecomastia, ascites, peripheral oedema
- Signs of malignancy: cachexia
d) - Tenderness
- Murphy’s sign (cholecystitis)
- Organomegaly: gallbladder (?malignancy), liver (tender = ?hepatitis), spleen (?haemolysis), pancreatic tumour
- Lymphadenopathy - ?malignancy
Jaundice and LFTs.
a) Mixed hyperbilirubinaemia, AST raise > ALT, GGT high, normal Alk Phos, macrocytosis
b) Mixed hyperbilirubinaemia, ALT raise > ALT, GGT and Alk Phos mildly raised, tender hepatomegaly
c) Unconjugated hyperbilirubinaemia, other LFTs normal, intermittent jaundice with intercurrent illness
a) Alcoholic liver disease
b) Acute hepatitis
c) Gilbert’s syndrome
Investigating jaundice.
a) Bedside
b) Bloods
c) Imaging
d) Special tests
a) - Urine dip
- Pregnancy test
b) - LFTs (C+UC bilirubin, liver enzymes, PT, albumin)
- FBC, haematinics, CRP, U+Es
- ?septic screen
- ?Hepatitis serology
- ?Antibodies (eg. ANA, AMA, ANCA) - PSC, PBC, etc.
c) - Abdominal USS (good at detecting gallstones, fluid, masses)
- MRCP (if high suspicion of gallstones not detected on USS)
- CT TAP - if malignancy suspected
d) - ERCP - diagnosis and intervention for gallstones
- Liver biopsy
- Ascitic tap (if present)
Liver cirrhosis: scoring
a) Non-invasive fibrosis / cirrhosis severity scores
b) Childs-Pugh (3 biochemical, 2 clinical)
c) Paracetamol OD - urgent liver transplant criteria (CHAI)
a) NAFLD score (used in NAFLD patients):
- Age, BMI, diabetes, AST, ALT, albumin, platelets
Fib-4 score (used in Hep B/ Hep C)
- Age, AST, ALT, platelets
b) Childs-Pugh (prognosis of patients with cirrhosis):
- Bilirubin level
- Albumin
- INR
- Ascites
- Encephalopathy
c) - Creatinine > 300
- Hepatic encephalopathy grade III or IV
- INR > 6.5
- Acidosis (pH < 7.3)
Abnormal LFTs: history and examination
a) Red flags in HPC
b) PMHx - things to consider
c) Drug history - possible causes of liver injury
d) Family history
e) Social history
a) - UGIB: haematemesis, melaena, shock!
- Decompensated LD - jaundice, encephalopathy, ascites, clotting abnormality/ bleeding
- Malignancy - weight loss, anorexia, fatigue, weakness, focal signs (eg. haemoptysis, neurology, bowel habit)
b) - Diabetes, hypertension, obesity (risks for NAFLD)
- Autoimmune disease (eg. IBD, RA)
- Infections - Hep B/C, HIV
- Psych conditions - substance misuse, etc.
c) - Antiepileptics (valproate)
- Oestrogens (COCP, HRT), tamoxifen
- Corticosteroids, anabolic steroids
- Antibiotics (tetracycline, macrolides)
- Cirrhotics (amiodarone, methotrexate)
- Paracetamol overuse
d) - Inherited - haemochromatosis, Wilson’s disease, alpha-1-antitrypsin
e) - Alcohol - overuse (consider alcoholic LD) or normal use (consider NAFLD)
- IVDU
- Social problems
Abnormal LFTs: investigations and management
a) NILS
b) Dominant ALP abnormality - ?
c) Dominant ALT abnormality - ?
d) Dominant bilirubin abnormality - ?
e) Confirming diagnosis of steatosis or cirrhosis
f) Management
a) USS liver and blood tests:
- Immunoglobulins
- Hep serology
- Autoimmune screen (Primary biliary cholangitis)
- Raised ferritin and high transferrin saturation
- Low caeruloplasmin
- Low alpha 1 anti-trypsin protein
b) - Raised GGT - ?biliary pathology, ?liver disease
- Normal GGT - ?bone disease, vit D deficiency, normal variant (third trimester pregnancy, growth spurts)
c) - Signs of decompensated LD - ?cirrhosis
- No signs of decompensated LD - ?steatosis
d) - Raised ALT or ALP - consider liver disease
- Normal ALT/ALP, raised CB - consider Gilbert’s
- Normal ALT/ALP, raised UCB or anaemia - consider haemolysis
e) - ELF blood test
- FIbroscan (transient elastography)
- If these suggest cirrhosis, do liver biopsy to assess extent of damage
f) - Weight loss
- Manage risk factors - HTN, diabetes, obesity
- Nutritional management
- Regular bowel opening if encephalopathic (laxatives may be required)
- Diuretics if ascites (spironolactone)
- Monitor renal function
- Pioglitazone useful in biopsy-proven NASH
