Abdominal

Question 1

Prehepatic causes of jaundice

Answer 1

Usually haemolysis
Massive transfusion
Haematoma resorption
Ineffective erythropoiesis
Inherited disorders of bilirubin metabolism

Question 2

Further assessment of prehepatic jaundice

Answer 2

Anaemia without overt bleeding and normal liver enzymes and synthetic function tests
Elevated reticulocyte count Haemolysis on blood film Haptoglobins
Unconjugated hyperbilirubinaemia

Question 3

Hepatic causes of jaundice

Answer 3

• Acute / fulminant liver failure
• Acute-on-chronic liver disease
• Chronic liver disease / cirrhosis and
  decompensation (e.g. hepatitis from alcohol, drugs, viral hepatitis, autoimmune liver disease, primary biliary cirrhosis, primary sclerosing cholangitis)
• Intrahepatic cholestasis (sepsis, drugs, total parenteral nutrition, viral)

Question 4

Posthepatic causes of jaundice

Answer 4

• Cholelithiasis (gallstones in CBD)
• Cholangitis
• Carcinoma of pancreas (head, ampulla)
• Cholangiocarcinoma
• Extrinsic compression (lymph nodes)
• Intrahepatic cholestasis (sepsis, drugs, TPN, viral)
• Systemic IgG4 disease/autoimmune pancreatitis

Question 5

Inherited disorders of bilirubin metabolism

Answer 5

• Gilbert’s syndrome (AD inheritance), isolated unconjugated hyperbilirubinaemia caused by defect in TATAA box leading to deficiency in bilirubin glucuronidation
• Dubin-Johnson syndrome (AR inheritance), conjugated hyperbilirubinaemia with no cholestasis. Green-black liver on biopsy

Question 6

Investigation of cholestatic jaundice

Answer 6

Begin with USS abdo - determine if bile ducts are dilated
- Dilation implies extrahepatic - therefore gallstones, strictures, malignant masses
- No dilation implies intrahepatic - therefore PBC, PSC, drugs, toxins

ERCP or MRCP if extrahepatic
Consider a liver biopsy for intrahepatic

Question 7

What types of gallstone are there?

Answer 7

• 80% white cholesterol
• 15% black calcium bilirubinate
• Brown pigment stones

E coli and Klebsiella produce glucuronidase, this converts water-soluble conjugated bilirubin back to lipid- soluble/water-insoluble unconjugated bilirubin, perpetuates crystals developing.

Question 8

Causes of ascites

Answer 8

Chronic liver disease and cirrhosis
Right or bilateral ventricular cardiac failure
Malignancy
Nephrotic syndrome
Rarer causes - e.g. hypothyroidism, pericarditis, Meig syndrome

Question 9

What are some of the factors which may contribute to ascites formation?

Answer 9

• Hypoalbuminaemia
• Portal hypertension
• Peripheral vasodilatation, leading to activation of the RAAS system causing sodium and water retention

Question 10

Tests to request for a diagnostic ascitic tap

Answer 10

• Cell count and differential
• Gram stain and culture
• Cytology
• Protein, albumin and amylase concentration
• Macroscopic appearance

Question 11

How does the appearance of ascitic fluid change depending on disease?

Answer 11

• Most causes: straw-coloured
• Turbid: pyogenic, TB
• Bloody: malignancy, TB
• Chylous: pancreatitis

Question 12

What is the value of the serum ascites albumin gradient?

Answer 12

• Most causes of ascites are transudates
• A high SAAG often reflects portal hypertension (heart failure, nephrotic syndrome, cirrhosis)
• A SAAG of <1.1g/dL usually represents no portal HTN, or an exudate

Question 13

Management of ascites

Answer 13

Salt restriction
Aldosterone antagonists (e.g. spironolactone)
Therapeutic paracentesis +/- HAS