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Medicine II > Gastro: Jaundice > Flashcards

Gastro: Jaundice Flashcards

1
Q

definition of jaundice

A

yellow discolouration of the skin, sclerae and other tissues due to excess circulating bilirubin

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2
Q

what is the clinical definition of jaundice?

A

conjugated/unconjugated concentration higher than 34umol/L

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3
Q

where is bilirubin metabolised?

A
  • red cell
  • plasma
  • hepatocyte
  • bile canaliculi
  • colonic bacterial gluronidases
  • intestine
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4
Q

what happens at the red cell?

A

haemoglobin is catabolised

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5
Q

what happens at the plasma?

A

unconjugated bilirubin bound to albumin, since this is lipid-soluble

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6
Q

what happens at the hepatocyte?

A

bilirubin conjugation - defective in Gilbert’s and Criggler Najjer

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7
Q

what happens at the bile canaliculi?

A

ATP-dependent biliary excretion of conjugated bilirubin; defective in Dubin-Johnson syndrome

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8
Q

what happens at colonic bacterial glucuronidases?

A

hydrolyse the conjugated bilirubin to form urobilinogen and urobilin which are excreted

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9
Q

what happens at the intestine?

A

absorption of urobilinogen which is re-excreted by liver and kidneys. renal component important in liver disease

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10
Q

how can you classify jaundice?

A
  • unconjugated

- conjugated

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11
Q

examples of conditions that cause unconjugated jaundice

A
  • haemolysis
  • gilbert’s
  • criggler najjar
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12
Q

what can cause conjugated jaundice?

A
  • hepatocyte failure

- cholestasis

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13
Q

things that can cause cholestasis

A
  • small duct disease
  • large duct obstruction
  • reduced canalicular excretion in hepatocytes
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14
Q

how can jaundice be classified by cause?

A
  • hepatic (prehepatic, hepatic, posthepatic)

- cholestatic

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15
Q

what is the problem in jaundice where the problem is cholestasis?

A

the conjugated bilirubin cannot be excreted

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16
Q

what can cause hepatocyte failure?

A
  • acute or chronic liver failure
  • viral
  • alcohol
  • drugs
  • autoimmune
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17
Q

clinical picture in haemolysis

A
  • increase bilirubin load
  • unconjugated hyperbilirubinaemia
  • normal liver enzymes
  • no bilirubinuria
  • check CBC and reticulocyte count
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18
Q

clinical picture in Gilbert’s syndrome

A
  • hereditary failure of bilirubin conjugation
  • isolated unconjugated hyperbilirubinaemia
  • normal liver enzymes
  • no bilirubinuria
  • bilirubin levels increase on fasting
  • no treatment required
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19
Q

clinical picture of Crigler-Najjer syndrome

A
  • hereditary failure of bilirubin conjugation
  • normal liver enzymes
  • phenobarbitone improve jaundice
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20
Q

2 types of Crigler-Najjer syndrome

A

Type 1: neonates die of kernicterus

Type 2: unconjugated hyperbilirubinaemia between Type 1 and Gilbert’s

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21
Q

what is kernicterus

A

brain damage found in newborns caused by jaundice

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22
Q

what is the cutoff between acute and chronic hepatic conditions?

23
Q

clinical picture in hepatic causes of jaundice?

A
  • prolonged INR
  • low albumin
  • conjugated hyperbilirubinaemia
  • maintained levels of uridine diphosphate glucuronosyl transferase
24
Q

causes of acute hepatitis causing liver failure

A
  • alcohol excess
  • drugs: NSAIDs, TB drugs, antiepileptics, paracetamol OD
  • infections: Hep viruses, EBV, toxoplasma, rickettsaie
  • autoimmune chronic active hepatitis
  • autoimmune diseases like SLE and RA
  • haemochromatosis
  • Wilson’s disease
  • liver infarction
25
what do the criteria consider for the diagnosis of AICAH?
- ANA - SMA - LKMA - SLA - IgG - liver histology score 6=probable AICAH score 7 or higher=definite
26
treatment regiments for AICAH
- prednisolone | - azathioprine
27
what is cholestasis?
interference of bile flow or formation
28
symptoms of cholestasis
- jaundice - fatigue - pruritis - pale stools - dark urine
29
how can you classify different types of cholestasis?
- intrahepatic (hepatocyte/cholangiocyte or small duct disease) - extrahepatic (dilatation of the bile ducts)
30
causes of bile duct dilatation
- obstruction | - no obstruction
31
obstructive causes of bile duct dilatation
- strictures | - stones
32
causes of strictures within the bile duct system
- neoplasms (cholangiocarcinoma, gallbladder adenocarcinoma, pancreatic adenocarcinoma) - postinflammatory (pancreatitis, post-radio/chemotherapy) - inflammatory (AIDS cholangiopathy, biliary parasites, primary sclerosing cholangitis)
33
non-obstructive causes of bile duct dilatation
- caroli disease - choledochal cyst - recurrent pyogenic cholangitis - primary sclerosing cholangitis
34
investigations in large duct obstruction
- trans-thoracic US - cross sectional imaging (CT/MRCP) - endoscopic US - ERCP and brush cytology (this is more therapeutic rather than diagnostic)
35
management of a patient with biliary dilatation, obstruction and is septic?
emergency ERCP and stenting
36
management of a patient with no obstruction
CS imaging and follow up
37
classify according to the liver biopsy
- disorder of the bile ducts - disorders with spare the bile ducts - no disorders
38
conditions that can cause bile duct involvement
- AMA negative PBC - primart/secondary sclerosing cholangitis - congenital disorders - sarcoidosis - idiopathic ductopenia - prolonged drug induced cholestasis - developmental abnormalities - cholangitis associated with malignancies - IgG4 associated cholangitis (autoimmune disease) - cystic fibrosis - graft vs host disease
39
histological features of PBC
- granulomatous changes - dense lymphocytic infiltrate - ruptured interlobular bile duct - epitheloid granuloma - FLORID DUCT LESION (focal duct obliteration with granuloma formation)
40
treatment of PBC
- ursodeoxycholic acid
41
how does ursodeoxycholic acid work in PBC?
protects injured cholangiocytes from toxic bile acids in the early stages; stimulates secretion from impaired hepatocytes in advanced cholestasis
42
things to note about ursodeoxycholic acid
- does not have an effect on pruritis or fatigue | - improves bilirubin levels, enzyme levels and IgM levels
43
histological features of PSC
- moderately dense inflammatory infiltrate | - onion skin fibrosis
44
which dose of UDCA has been shown to have benefits?
15-20mg/kg/day
45
what kind of benefits does UDCA have
- improves LFTs | - improves histological findings
46
interventional treatment for PSC
- ERCP (balloon dilatation, stenting) | - liver tranplantation
47
surgical interventions for PSC
- resection of the extrahepatic biliary tree | - Roux-en-Y choledochojejunostomy (indicated in advanced cirrhosis, failed ERCP stricture management)
48
which are abnormalities causing jaundice which do not involve the bile ducts?
- malignant infiltration - benign infiltration (amyloidosis/sarcoidosis) - peliosis hepatis - cirrhosis - congenital hepatic fibrosis - sinusoidal dilatation: Budd Chiari, veno-occlusive disease, congestive heart failure
49
what is peliosis hepatis?
- large blood filled spaces which may not be lined with sinusoidal cells - associated with drugs such as tamoxifen, OCP, androgenic steroids, danazol - seen in renal transplant recipients
50
what is sinusoidal dilatation associated with?
acute right heart failure
51
what is benign recurrent intrahepatic cholestasis
- inherited condition - presents in adolescents/adults - acute episodes of cholestasis with jaundice and pruritis - can resolve in weeks/months but they may recur after - BRIC 1 - pancreatitis - BRIC-2 - gall stones - may have liver fibrosis
52
drug treatment for pruritis
- UDCA - cholestryramine - rifampicin - naltrexone - sertraline
53
which drugs are not recommended for treating pruritis
- anti-histamines - ondansetron - phenobarbitone
54
supportive care
- pruritis - fatigue - fat-soluble vitamins - osteoporosis

Medicine II (16 decks)

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