Case 16: My skin is looking yellow

Question 1

another word for jaundice

Answer 1

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

Question 2

what disorders cause and increase in unconjugated bilirubin

Answer 2

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)

Question 3

why is jaundice mainly seen in the eyes first

Answer 3

elastin in the eyes has a high affinity for bilirubin

Question 4

what causes jaundice in newborns

Answer 4

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

this causes an increase in unconjugated bilirubin

Question 5

complications of an increase in unconjugated bilirubin (in newborns)

Answer 5

can collect in the basal ganglia (kernicterus)

this can cause brain damage and death

Question 6

treatment for newborn jaundice

Answer 6

bilirubin lights (phototherapy)

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

Question 7

those with Gilberts have low levels of what

Answer 7

UGT enzyme

Question 8

what is crigler najjar syndrome

Answer 8

rare autosomal recessive disease characterized by significant unconjugated hyperbilirubinemia

there is no UGT enzyme

can lead on to kernicterus (is usually fatal)

Question 9

management of crigler najjar syndrome

Answer 9

phototherapy or plasmapheresis helpful in short term

liver transplant only curative option

Question 10

what is Dubin-Johnson syndrome

Answer 10

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

Question 11

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

Answer 11

conjugated

Question 12

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

Answer 12

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

Question 13

at low levels what is alcohol converted to

Answer 13

CO2 and water

this is excreted via urine, lungs and sweat

Question 14

at high levels what is alcohol converted to

Answer 14

acetaldehyde via alcohol dehydrogenase

this happens in gastric mucosal cells and hepatocytes

then undergo lipogenesis to form fatty acids and glycerol

Question 15

how can alcohol lead to hepatitis

Answer 15

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

Question 16

mechanisms for how alcohol damages the liver

Answer 16

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)

Question 17

the order of changes in alcoholic liver disease

Answer 17

fatty liver

hepatitis

fibrosis

cirrhosis

hepatocellular carcinoma

Question 18

description of fibrosis

Answer 18

the reversible deposition of pericellular fibrous glands

Question 19

description of cirrhosis

Answer 19

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

Question 20

how does alcohol affect CNS

Answer 20

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

Question 21

prehepatic causes of jaundice

Answer 21

gilberts
drugs
haemolytic anaemia
crigler-najjar syndrome

Question 22

hepatic causes of jaundice

Answer 22

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)

Question 23

post hepatic cases of jaundice

Answer 23

gallstones
surgical strictures
extrahepatic malignancy (pancreatic cancer)
pancreatitis

Question 24

what may cause stigmata of alcoholic liver disease on examination

Answer 24

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

Question 25

examination findings of high oestrogen

Answer 25

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

Question 26

examination findings of low albumin

Answer 26

leukonychia (white nails)

Question 27

examination findings of portal hypertension

Answer 27

caput medusae (painless swollen veins around umbilicus) ascites

Question 28

complete vs incomplete biliary obstruction

Answer 28

complete when there is development of pale stools

Question 29

what suggests obstructive jaundice

Answer 29

darkened stools itching

Question 30

what would suggest pancreatic cancer

Answer 30

weight loss epigastric pain radiating to back

Question 31

what causes benign biliary strictures

Answer 31

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)

Question 32

prehepatic metabolism of bilirubin

Answer 32

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

Question 33

hepatic metabolism of bilirubin

Answer 33

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

Question 34

posthepatic metabolism of bilirubin

Answer 34

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

Question 35

what is whipples procedure

Answer 35

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

Question 36

negatives of benzodiazepines

Answer 36

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

Question 37

symptoms of alcohol withdrawal

Answer 37

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

Question 38

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

Answer 38

oesophagitis mallory weiss tear gastritis and peptic ulceration oesophageal varices oesophogastric malignancy

Question 39

alcohol withdrawal mechanism

Answer 39

chronic excessive alcohol up regulates GABA and inhibits NMDA abrupt cessation unmasks this response leading to an overall over excitation of the CNS

Question 40

what ions increase due to excitatory neurones

Answer 40

glutamate causes Na+ and Ca2+ to increase

Question 41

what ion increases due to inhibitory neurones

Answer 41

GABA causes Cl- to increase

Question 42

clinical presentation of alcohol withdrawal

Answer 42

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

Question 43

mortality of delirium tremens

Answer 43

5% death usually due to dsyrrythmia, pneumonia

Question 44

tools to identify the severity of alcohol withdrawal

Answer 44

clinical institute withdrawal assessment glasgow alchol score