Approach to Patient with Jaundice

Question 1

How is heme converted to bilirubin?

Answer 1

Heme is converted to biliverdin then bilirubin in phagocytic cells

Question 2

How is bilirubin transported to the hepatocytes?

Answer 2

Tightly bound to serum albumin

Question 3

What happens to bilirubin after it reaches the liver?

Answer 3

The bilirubin from the blood is in unconjugated (insoluble) from and must be conjugated before it is secreted into the bile canaliculus as part of bile and then delivered to the small intestine

Question 4

Hepatocyte function includes all of the following except:

1. Drug detoxification
2. Protein synthesis
3. Gluconeogenesis
4. Urea formation by deamination of amino acids
5. Breakdown of hemoglobin

Answer 4

5. Breakdown of hemoglobin

Question 5

Which statement about the enterohepatic circulation of bile salts is true?

1. The bile salt pool is re-circulated only at each meal
2. In the normal individual, 50% of the bile salt pool must
   be resynthesized and replaced daily
3. The rate of bile salt synthesis is subject to feedback inhibition, inversely proportionate to the amount of bile salts resorbed
4. Bile salts are stored and diluted in the gallbladder

Answer 5

3. The rate of bile salt synthesis is subject to feedback inhibition, inversely proportionate to the amount of bile salts resorbed

Question 6

Bilirubinuria

Answer 6

Conjugated bilirubin is detected in the urine

Question 7

What is the most common cause of bilirubinuria?

Answer 7

Most common cause is hepatocelular disease

Question 8

Dubin-Johnson and Rotor syndrome

Answer 8

Inability of hepatocytes to secrete conjugated bilirubin into bile

Question 9

Neonatal Jaundice

Answer 9

-􏰀 Yellowing of the skin in a newborn

􏰀- Bilirubin level > 5mg/dL

Question 10

What can lead to increased unconjugated bilirubin?

Answer 10

• 􏰀Overproduction (hemolysis)
  􏰀- Impaired uptake by the liver
  􏰀- Abnormalities of bilirubin conjugation

Question 11

What can lead to increased conjugated bilirubin?

Answer 11

-􏰀 Hepatocellular disease (viral hepatitis, cirrhosis) 􏰀
- Impaired canalicular excretion (drugs)
􏰀- Biliary obstruction (gallstones)

Question 12

An icteric patient with sickle cell disease might be expected to have:

1. Bilirubinuria
2. Absence of urinary urobilinogen
3. Cholesterol stones
4. Unconjugated hyperbilirubinemia

Answer 12

4. Unconjugated hyperbilirubinemia

Question 13

Primary Biliary Cirrhosis

Answer 13

Destruction of intrahepatic bile ducts that leads to progressive cholestatic liver disease that is of autoimmune etiology

Question 14

What Ab will be seen with Primary Biliary Cirrhosis?

Answer 14

Anti-mitochodrial Ab

Question 15

Who most commonly gets Primary Biliary Cirrhosis?

Answer 15

Middle aged women

Question 16

What lab value will be elevated in Primary Biliary Cirrhosis?

Answer 16

Alkaline Phosphatase

Question 17

Florrid Duct Lesion

Answer 17

Periductal inflammation with granuloma formation and duct destruction

Question 18

What is the treatment for Primary Biliary Cirrhosis?

Answer 18

Ursodeoxycholic Acid

Question 19

Primary Sclerosing Cholangitis

Answer 19

Obliterative fibrosis of intrahepatic and extrahepatic bile ducts with inflammation and dilation of preserved segments.

Question 20

What is Primary Sclerosing Cholangitis associated with?

Answer 20

Inflammatory Bowel Disease (Ulcerative Colitis and Crohn’s Disease)

Question 21

Who is affected by Primary Sclerosing Cholangitis?

Answer 21

Males are more affected

Question 22

What are the signs of Primary Biliary Cirrhosis?

Answer 22

Fatigue and pruritis

Question 23

What does ERCP of Primary Sclerosis Cholangitis show?

Answer 23

Beading with narrowing and swelling

Question 24

Jaundice

Answer 24

It describes the yellow pigmentation of skin/sclera/mucous membranes produced by increased serum bilirubin

Question 25

What are the 2 categories of jaundice?

Answer 25

• Unconjugated hyperbilirubinemia (water insoluble)

- 􏰀Conjugated hyperbilirubinemia (watersoluble)

Question 26

A 24 yo is referred for hyperbilirubinemia. He is asymptomatic, no drug or Etoh use. Liver tests have previously been normal and he has given blood several times this year without being refused. He is on no medications, no family history of liver disease. Physical examination is normal. T. bilirubin i2 2.1 mg/dL (0-1.5 mg/dL). Direct bilirubin is 0.2 mg/dL. Liver enzymes, albumin, and INR are normal. What should the next step in management be?

􏰀 1. Liver imaging (MRI, U/S)
􏰀2. Liver biopsy
􏰀 3. Genetic testing for a hepatic transport defect 􏰀
4. Genetic testing for a hepatic metabolic defect 􏰀
5. Reassurance, no further testing.

Answer 26

5. Reassurance, no further testing.

Question 27

Gilbert’s Syndrome

Answer 27

􏰀- Isolated elevation of total and indirect bilirubin
􏰀- Usually an incidental finding
􏰀- All other transaminases normal (ALT, AST)
􏰀- Genetic defect in the UDP-glucuronyl transferase

Question 28

What is the type of jaundice seen in Gilbert’s syndrome?

Answer 28

Unconjugated

Question 29

Courvoisier sign

Answer 29

Palpable gallbladder

Question 30

Gamma-glutamyl transpeptidase (GGT)

Answer 30

Goes up with alcohol use and is cholestasis marker

Question 31

A 20 asymptomatic male was found on a routine health exam to have the following lab results:
􏰀
Total bilirubin 4.5 mg/dL (0.2-1.2) 􏰀
Direct bilirubin 0.2 mg/dL (0-0.2) 􏰀AST normal
􏰀ALT normal
􏰀Alkaline Phosphatsase normal
Regarding this gentleman’s medical condition, which statement is correct?

1. Bilirubin is usually undetectable in the urine
2. Biliary dilation is commonly observed on ultrasound
3. It is caused by a molecular defect of transport protein at the canalicular membrane
4. Cirrhosis and hepatocellular carcinoma can develop after several decades of disease
5. Insulin resistance plays an important role in the pathogenesis

Answer 31

1.Bilirubin is usually undetectable in the urine

Question 32

What tests allow you to determine liver function?

Answer 32

Albumin and INR determines functioning of liver to

make the normal proteins that it needs to