DSA 4 - Hepatobiliary Patient Jaundice (McGowan)

Question 1

This is the term for yellow pigmentation of the skin caused by elevation in serum bilirubin (hyperbilirubinemia). Often more easily discernible in sclera.

Answer 1

Jaundice (Icterus)

Question 2

What are the 3 general ways hyperbilirubinemia can occur?

Answer 2

1) Overproduction
2) Impaired uptake, conjugation, or excretion
3) Regurgitation of UCB or CB from damaged hepatocytes or bile ducts

Question 3

Clinical jaundice is seen at a bilirubin level of…

Answer 3

> 3 mg/dL (normal is 0.2-1.2)

Question 4

The ddx for jaundice is huge, but the main ones we should think of for UCB (indirect) are…

Answer 4

1) Hemolytic syndrome (anemia or reaction)
2) Gilbert syndrome
3) Crigler-Najjar syndrome
4) Viral hepatitis (can be both UCB and CB)

Question 5

The ddx for jaundice is huge, but the main ones we should think of for CB (direct) are…

Answer 5

1) Hepatitis (acute/chronic, infection/noninfectious)
2) Cirrhosis
3) Obstruction
4) Dubin-Johnson Syndrome
5) Rotor syndrome
6) Drug reaction
7) Pregnancy

Question 6

What are the initial steps in evaluating a patient with jaundice?

Answer 6

To determine if:

1) Hyperbilirubinemia is conjugated or unconjugated
2) Other biochemical liver tests are abnormal

Question 7

For jaundice, what labs should be ordered?

Answer 7

AST/ALT
Total bilirubin 
Fractionated bilirubin (indirect vs. direct) 
ALP 
GGT

Question 8

With jaundice, if the ALP is elevated it’s important to also get GGT. If the GGT is elevated then it is most likely from a _______ source, but if the GGT is normal then we need to consider _______, _______, or another source.

Answer 8

Liver
Bone
Placenta

***If ALP is increased in a pediatric patient, think of growing bones!

Question 9

From the following list of disorders, tell me if the type of jaundice would be prehepatic, hepatic, or posthepatic.

• • Transfusion reactions
• • Sickle cell anemia
• • Thalassemia
• • Autoimmune disease

Answer 9

Prehepatic

Question 10

From the following list of disorders, tell me if the type of jaundice would be prehepatic, hepatic, or posthepatic.

• • Hepatitis
• • Cancer
• • Cirrhosis
• • Congenital disorders
• • Drugs

Answer 10

Hepatic

Question 11

From the following list of disorders, tell me if the type of jaundice would be prehepatic, hepatic, or posthepatic.

• • Gallstones
• • Inflammation
• • Scar tissue
• • Tumors block the flow of bile into intestines

Answer 11

Posthepatic

Question 12

Draw out the jaundice map on slide 6!

Answer 12

:)

Question 13

Hemolysis will cause unconjugated hyperbilirubinemia (prehepatic). To look for this, what tests need to be done?

Answer 13

– CBC - looks for anemia and thrombocytopenia, haptoglobin, reticulocyte count, and LDH to look for hemolysis

– Peripheral smear - can show schistocytes or sickled cells

Question 14

This disease is due to the reduced activity of UGT1A1. It will cause unconjugated hyperbilirubinemia. It is a benign, asymptomatic hereditary jaundice that is usually brought about by fasting (stress in general). No treatment required.

Answer 14

Gilbert Syndrome

Question 15

This disease is a benign, asymptomatic hereditary jaundice. It occurs due to reduced bilirubin excretory function of hepatocytes because of deficiency of transport proteins. Causes conjugated hyperbilirubinemia, the gallbladder does not visualize on oral cholecystography and the liver is darkly pigmented on gross examination.

Answer 15

Dubin-Johnson Syndrome

Question 16

This disease is very similar to Dubin-Johnson, except the liver is NOT pigmented and you CAN see the gallbladder on oral cholecystography.

Answer 16

Rotor Syndrome

Question 17

T/F. Drug reactions can cause direct or indirect jaundice, there are TONS of meds. Always review the medication list.

Answer 17

True

Question 18

Intrahepatic cholestasis of pregnancy can cause jaundice due to predominantly conjugated (direct) hyperbilirubinemia. This is a benign cholestatic jaundice, usually occurring in the ________ trimester of pregnancy. There is itching, GI symptoms, and abnormal liver excretory function tests. Can recur with subsequent pregnancies or use of _______ _______.

Answer 18

Third

Oral contraceptives