Approach to Jaundice

Question 1

What are the synthetic functions of the liver?

Answer 1

Clotting factors
Bile acids
Carbohydrates
Proteins - albumin
Lipids
Hormones

Question 2

Explain detoxification in the liver

Answer 2

Urea production from ammonia
Detoxification of drugs
Bilirubin metabolism
Breakdown of insulin and hormones

Question 3

Explain the immune function of the liver

Answer 3

Combats infections
Clears the blood of particles and infections including bacteria
Neutralising and destroying all drugs and toxins

Question 4

Explain the storage function of the liver

Answer 4

Stores glycogen
Stores Vitamin A, D, B12 and K
Stores copper and iron

Question 5

What is bilirubin?

Answer 5

Is a by product of haem metabolism
Is generated by senescent RBC’s in the spleen

Question 6

What is bilirubin initially bound to before liver?

Answer 6

Bound to albumin which is unconjugated
Liver conjugates it

Question 7

What does conjugation of bilirubin in the liver do?

Answer 7

Solubilises it

Question 8

When can bilirubin be elevated?

Answer 8

Pre-hepatic - haemolysis
Hepatic - parenchymal damage
Post-hepatic - obstructive

Question 9

Describe aminotransferase

Answer 9

Enzymes which are present in hepatocytes
ALT more specific than AST

Question 10

What can AST/ALT ratio suggest?

Answer 10

Can point towards alcoholic liver disease
If both elevated then parenchymal involvement

Question 11

Describe alkaline phosphate

Answer 11

Enzymes present in bile ducts
Also present in bone, placenta and intestines

Question 12

What can elevated alkaline phosphate suggest?

Answer 12

Obstruction or liver infiltration

Question 13

Describe Gamma GT

Answer 13

Non specific liver enzyme
Useful to confirm liver source of ALP

Question 14

What does elevated Gamma GT suggest?

Answer 14

Can be elevated in alcohol use
Also NSAIDs can raise levels

Question 15

Describe albumin

Answer 15

Important test for synthetic function of liver

Question 16

What does low levels of albumin suggest?

Answer 16

Suggest chronic liver disease
Can be low in kidney disorders and malnutrition

Question 17

Describe prothrombin time

Answer 17

Extremely important test for liver function
Tells degree of liver dysfunction as liver produces clotting factors

Question 18

Describe creatine

Answer 18

Essentially kidney function
Determines survival from liver disease

Question 19

What is platelet count a marker of?

Answer 19

Indirect marker for Portal hypertension
Is low in cirrhotic subjects due to hypersplenism

Question 20

What are the symptoms of the liver stopping function?

Answer 20

Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy

Question 21

What is the definition of jaundice?

Answer 21

Yellowing of skin, sclerae and other tissue caused by excess circulating bilirubin

Question 22

When is jaundice detectable?

Answer 22

When plasma bilirubin levels exceed 34umol/L

Question 23

What causes jaundice in pre-hepatic cases?

Answer 23

Increased quantity of bilirubin - haemolysis
Impaired transport

Question 24

What causes jaundice in hepatic cases?

Answer 24

Defective uptake of bilirubin
Defective conjugation
Defective excretion

Question 25

What causes jaundice in post-hepatic cases?

Answer 25

Defective transport of bilirubin by the biliary ducts

Question 26

What are some clues on history for pre-hepatic cases?

Answer 26

History of anaemia Acholuric jaundice

Question 27

What are some clues on history for hepatic cases?

Answer 27

Risk factors for liver disease - IVDU Decompensation - ascites, variceal bleed and encephalopathy

Question 28

What are some clues on history of post-hepatitis cases?

Answer 28

Abdominal pain Cholestasis - pruritus, pale stools, high coloured urine

Question 29

What are clues on clinical exam for pre-hepatic cases?

Answer 29

Pallor and splenomegaly

Question 30

What are clues on clinical exam for hepatic cases?

Answer 30

Stigmata of CLD - spider naevi and gynaecomastia Ascites Asterixis - flapping tremor

Question 31

What are clues on clinical exam for post-hepatic?

Answer 31

Palpable gall bladder

Question 32

What would a liver screen look for?

Answer 32

Hepatitis B and C serology Autoantibody profile, serum immunoglobins Caeruloplasmin and copper Ferritin Alpha 1 anti trypsin Fasting glucose

Question 33

What is the most important investigation for jaundice?

Answer 33

Ultrasound of the abdomen

Question 34

What is an ERCP?

Answer 34

Use of endoscopy and fluoroscopy Diagnoses and treats biliary and pancreas ducts X ray monitored Has more complications and issues than MRCP but is therapeutic

Question 35

What is a MRCP?

Answer 35

Non invasive imaging to investigate intra and extra hepatic biliary tree Can also image out with ducts No complications

Question 36

What can ERCP treat?

Answer 36

Dilated biliary tree by removing tumour and visible stones Acute gallstone pancreatitis Stenting obstruction of ducts Post op biliary complications

Question 37

What are some complications of ERCP?

Answer 37

Sedation related - resp. and cardio Pancreatitis and cholangitis Sphincterotomy - bleeding and perforation

Question 38

When is percutaneous transhepatic cholangiogram (PTC) used?

Answer 38

ERCP not possible due to duodenal obstruction or previous surgery Hilar stenting Is more invasive then ERCP

Question 39

When is endoscopic ultrasounds (EUS) used?

Answer 39

Characterising pancreatic masses Staging of tumours FNA of tumours and cysts Excludes biliary microcalculi - biliary sludge

Question 40

What is liver biopsy important for?

Answer 40

Definitive diagnosis of certain conditions - autoimmune hepatitis Confirm diagnosis Staging of severity