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Semester 2 (3rd year) > Case 16: My skin is looking yellow > Flashcards

Case 16: My skin is looking yellow Flashcards

1
Q

another word for jaundice

A

icterus (comes from the past belief that jaundice could be cured by looking at a yellow bird)

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2
Q

what disorders cause and increase in unconjugated bilirubin

A

extravascular haemolytic anaemia (RBCs are broken down too young)

infective haematopoiesis (blood cells don’t from properly in the bone marrow, therefore macrophages break them down)

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3
Q

why is jaundice mainly seen in the eyes first

A

elastin in the eyes has a high affinity for bilirubin

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4
Q

what causes jaundice in newborns

A

the liver had lower levels of UGT enzyme (this is what converts unconjugated bilirubin to conjugated)

this causes an increase in unconjugated bilirubin

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5
Q

complications of an increase in unconjugated bilirubin (in newborns)

A

can collect in the basal ganglia (kernicterus)

this can cause brain damage and death

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6
Q

treatment for newborn jaundice

A

bilirubin lights (phototherapy)

light induces structural changes in the bilirubin molecule- makes it more soluble so it can be excreted in urine

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7
Q

those with Gilberts have low levels of what

A

UGT enzyme

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8
Q

what is crigler najjar syndrome

A

rare autosomal recessive disease characterized by significant unconjugated hyperbilirubinemia

there is no UGT enzyme

can lead on to kernicterus (is usually fatal)

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9
Q

management of crigler najjar syndrome

A

phototherapy or plasmapheresis helpful in short term

liver transplant only curative option

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10
Q

what is Dubin-Johnson syndrome

A

autosomal recessive defect in MRP2 meaning reduced movement of conjugated bilirubin from hepatocytes to bile ducts

this causes the up regulation of MRP3 meaning the conjugated bilirubin moves from hepatocytes to blood

this is transported to kidneys too making the urine dark also

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11
Q

obstructive jaundice is causes by an increase in which type of bilirubin

A

conjugated

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12
Q

what viral infection leads to an increase in both conjugated and unconjugated bilirubin

A

viral hepatitis

the death of hepatocytes mean less bilirubin is conjugated (unconjugated rises)

death of hepatocytes also causes bile to leak into the blood (increase in conjugated bilirubin)

will see darker urine

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13
Q

at low levels what is alcohol converted to

A

CO2 and water

this is excreted via urine, lungs and sweat

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14
Q

at high levels what is alcohol converted to

A

acetaldehyde via alcohol dehydrogenase

this happens in gastric mucosal cells and hepatocytes

then undergo lipogenesis to form fatty acids and glycerol

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15
Q

how can alcohol lead to hepatitis

A

the lipogenesis of acetaldehyde to fatty acids and glycerol can deposit in hepatocytes causes hepatitis and inflammation

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16
Q

mechanisms for how alcohol damages the liver

A

it is directly toxic

acetaldehyde is carcinogenic

induced fatty changes

inflammation and fibrosis

induces cp450

prevents absorption and storage of essential nutrients (particularly B vitamins)

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17
Q

the order of changes in alcoholic liver disease

A

fatty liver

hepatitis

fibrosis

cirrhosis

hepatocellular carcinoma

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18
Q

description of fibrosis

A

the reversible deposition of pericellular fibrous glands

19
Q

description of cirrhosis

A

irreversible nodules that comprise a hypo plastic hepatocyte surrounded by fibrous tissue

20
Q

how does alcohol affect CNS

A

is lipophilic so can cross BBB and act on neurones

chronic consumption interferes with absorption and utilisation of B1 (thiamine) with is essential for CNS glucose metabolism

at high levels acts on respiratory centres in brainstem

is a CNS depressant in high levels via activating GABA receptors

21
Q

prehepatic causes of jaundice

A

gilberts
drugs
haemolytic anaemia
crigler-najjar syndrome

22
Q

hepatic causes of jaundice

A

hepatitis
metabolic (haemachromatosis, Wilsons)
alcohol
NAFLD
autoimmune (primary biliary cholangitis, primary sclerosis cholangitis)
malignancy of biliary system (HCC, cholangiocarcinoma, gallbladder cancer)
drugs (cirprofloxacin, co-amoxiclav, phenytoin, erythromycin, nirtofurantoin)

23
Q

post hepatic cases of jaundice

A

gallstones
surgical strictures
extrahepatic malignancy (pancreatic cancer)
pancreatitis

24
Q

what may cause stigmata of alcoholic liver disease on examination

A

high oestrogen
low albumin
portal hypertension
signs of hepatic encephalopathy (asterixis/liver flap)
muscle loss (sarcopenia)

25
Q

examination findings of high oestrogen

A

palmar erythema
spider naevi
gynacomastia
loss of secondary body hair in males
male genital atrophy (testicles shrink)

26
Q

examination findings of low albumin

A

leukonychia (white nails)

27
Q

examination findings of portal hypertension

A

caput medusae (painless swollen veins around umbilicus)
ascites

28
Q

complete vs incomplete biliary obstruction

A

complete when there is development of pale stools

29
Q

what suggests obstructive jaundice

A

darkened stools
itching

30
Q

what would suggest pancreatic cancer

A

weight loss
epigastric pain radiating to back

31
Q

what causes benign biliary strictures

A

develop due to damage to the bile ducts during surgery/trauma to the abdomen, a recurring condition (pancreatitis or bile duct stones) or a chronic disease (PSC)

32
Q

prehepatic metabolism of bilirubin

A

RBCs are phagocytosed by macrophages when they reach the end of their life (120 days)

haemoglobin is broken down into haem and globin

haem is broken down into iron and portporphyrin

portporphyrin broken down into unconjugated bilirubin (in spleen)

albumin in blood binds to unconjugated bilirubin and transports it to liver

33
Q

hepatic metabolism of bilirubin

A

unconjugated bilirubin is taken up by hepatocytes in liver

here it is conjugated via UGT enzyme

conjugated bilirubin is water soluble, unconjugated is not

conjugated bilirubin is secreted into bile duct and stored in gall bladder as bile

34
Q

posthepatic metabolism of bilirubin

A

when you eat fatty food bile is excreted into duodenum from gallbladder

conjugated bilirubin in the bile is converted into urobilinogen by microbes in small intestine

some urobiliogen is converted to stercobilin which is excreted in stool giving them brown colour

reset of urobilinogen is reabsorbed into blood converted to urobilin and either sent to liver or excreted by kidneys giving urine yellow colour

35
Q

what is whipples procedure

A

operation to treat tumours and other conditions in the pancreas, small intestine and bile ducts

removal of head of pancreas, first part of small intestine, gall bladder and bile ducts

36
Q

negatives of benzodiazepines

A

can mask signs of underlying condition

can cause respiratory depression (more dangerous if have cardio-respiratory disorder)

may cause CNS depression

may limit their ability to give accurate history

may worsen delirium

may increase fall risk

37
Q

symptoms of alcohol withdrawal

A

anxiety
nausea/vomiting
insomnia
alcohol craving
tremor
sweating
palpitations
diarrhoea
confusion
hallucinations
seizures

38
Q

excessive alcohol may increase risk of GI bleed as it is a risk factor for

A

oesophagitis

mallory weiss tear

gastritis and peptic ulceration

oesophageal varices

oesophogastric malignancy

39
Q

alcohol withdrawal mechanism

A

chronic excessive alcohol up regulates GABA and inhibits NMDA

abrupt cessation unmasks this response leading to an overall over excitation of the CNS

40
Q

what ions increase due to excitatory neurones

A

glutamate causes Na+ and Ca2+ to increase

41
Q

what ion increases due to inhibitory neurones

A

GABA causes Cl- to increase

42
Q

clinical presentation of alcohol withdrawal

A

autonomic hyperreactivity (insomnia, tremulousness, mild anxiety, GI upset, anorexia, headache, diaphoresis, palpitations)

withdrawal seizures- generalised tonic-clonic seizures, singular/brief slurry of seizures over short period, usually happens in 4th-5th decade of life

alcoholic hallucinosis- usually visual but may be auditory/tactile, they are aware they’re hallucinating

delerium tremens- associated with abnormal vital sings, fluid status and electrolyte levels, not alert

43
Q

mortality of delirium tremens

A

5%
death usually due to dsyrrythmia, pneumonia

44
Q

tools to identify the severity of alcohol withdrawal

A

clinical institute withdrawal assessment
glasgow alchol score

Semester 2 (3rd year) (12 decks)

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