Gastrointestinal: Jaundice and hepatopancreatobiliary Flashcards
Describe pre-, intra-, and post-hepatic jaundice
Pre-hepatic: Excessive UNCONJUGATED bilirubin due to increased red cell/haem breakdown
Intra-hepatic: MIXED bilirubin due to impaired conjugation by liver. Cirrhosis will additionally compress the intra-hepatic portions of the liver
Post-hepatic: Excessive CONJUGATED bilirubin. Blocked biliary drainage will prevent conjugated excretion
How can urine point towards which type of jaundice you are dealing with?
Dark urine: intra or post-hepatic
Excessive unconjugated bilirubin will be excreted through urine
What are the bilirubin, ALT/AST and ALP in the three types of jaundice
Pre-hepatic: normal/high bilirubin, others normal
Hepatic: ALT/AST very high, others raised
Post-hepatic: raised ALT/AST others very high
What are three causes of pre-hepatic jaundice?
Pre-hepatic: Increased haem breakdown
Haemolytic anaemia
Gilbert’s syndrome
Criggler-Najjar
List the 3 groups of causes for post-hepatic jaundice
Post-hepatic: blocked drainage
Intra-luminal: Gallstones
Mural: Cholangiocarcinoma, structures
Extramural: Cancers pressing on the duct (pancreatic, lymphomas)
What tests should be ordered in a patient with jaundice
Liver function tests: Assess nature of injury
Coag screen: Assess synthetic function
FBCs: Low Hb and platelets with high MCV in liver disease
Liver screen: Determine acute or chronic cause
What do the following LFTs inform you about:
Bilirubin
Albumin
AST/ALT
ALP
yGT
Bilirubin: Degree of jaundice
Albumin: synthetic function (along with coag PT)
AST/ALT: Hepatocellular injury (ratio >2 = ALD, ~1 viral hepatitis)
ALP: Raised in biliary obstruction (non-specific: bone disease, pregnancy, malignancy)
gGT: Biliary obstruction (more specific)
What viral (2) and non-infective markers (6) make up an acute liver screen?
Viral:
Hep A, B, C, E serology
CMV, EBV
Non-infective Markers:
Paracetamol (overdose)
Caeruloplasmin (copper levels)
ANA and IgGs (AIH, PBC, PSC)
Amylase (pancreatitis)
a-FP and CA 19-9 (hepatic and pancreatic cancer)
a1-antitrypsin (AATD)
What liver screen tests are used to suspect chronic liver injury?
viral
Hepatitis B and C
Non-infective markers
Caeruloplasmin (Wilson’s)
Ferritin and transferritin (Haemochromatosis)
t-TG (coeliac disease)
Autoantibodies: AMA, ASMA (PSC)
What imaging options can help diagnosis of jaundice?
1st line: Abdo US (gross liver or obstructive pathology)
Magnetic resonance cholanigopancreatography (MRCP): Visualise biliary tree for obstructive where US was inconclusive
Liver biospy: Where diagnosis is still unclear
What is considered a raised bilirubin?
>40mg/ml
What investigations should you perform in someone with acute hepatic failure?
LFTs: Assess liver injury and synthetic function
Coag screen: Synthetic function
U+Es: Check renal function
Liver screen
How do you manage acute hepatic failure?
Vitamin K: Increase PT
Lactulose 10-20ml/8hrs: Remove ammonia to improve encephalopathy
Antibiotics: Cefotaxime as prophylaxis
Review drugs and monitor biometrics
Dont give sodium to CLD/ascites patient!
Patient presents with jaundice. On examination they have red palms, distended veins on their abdomen and state they believe they have developed man-boobs. What is the diagnosis?
Chronic liver failure
What are the 6 complications of chronic liver failiure?
1. Malnutrition: damaged liver means reduced glycogenolysis/increased gluconeogenesis. This impairs glucose tolerance
2. Encephalopathy: Increased ammonia production
3. Varices: Cirrhosis presses on portal vein creating a back pressure
4. Ascites/oedema: Back pressure pushes fluid into bodily space
5. Spontaneous bacterial peritonitis: Infection of the ascitic fluid
6. Renal failure: failure of renal vasoconstriction to balance splanchnic vasodilation
How do you manage chronic liver failure?
Malnutrition: high calorie, high protein, low sodium meals every 2-3 hours
Bacterial peritonitis: Ascitic culture then cephalosporin
Encephalopathy: Lactulose
Ascites: Low salt diet +/- furosemide
Varices:
Bleeding: Terlipressin, vit K + FFP, broad spec antibiotics, endoscopic scleroscing
Stable: propanolol, band ligation/sclerotherapy, TIPS
Renal failure: renal failure management
What screening tools can be used for harmful alcohol use?
AUDIT: >= 8 harmful use
CAGE: >=2
Do you ever feel you should Cut down?
Do you ever feel Annoyed when people criticise your drinking?
Do you feel Guilty?
Do you ever drink as an Eye opener (in morning)
How do you manage acute alcoholic hepatitis?
Cease use
acute liver failure measures +/- steroids and pentoxifylline
How can viral hepatitis present?
Nausea, vomiting and anorexia
Fatigue
Jaundice + dark urine (intrahepatic)
RUQ pain
How are each subtype of hepatitis spread?
A+E: Faeco-oral
Blood: B,C,D
What are characterstic features of hepatitis A?
Faeco-oral spread
Flu-like prodrome
What antibodies are present in hepatitis A?
HAV-IgM (1 month after exposure)
HAV-IgG for life
How is HAV managed?
Immunisation (1st: 1 yr, 2nd: 20)
Supportive and alcohol avoidance
What are the defining features of hepatitis B?
Fever
Juandice
Bodily fluids (sex, blood, mother to child)
What do each of the following positive Hep B serologies mean?
HbsAg
HbsAb
HbcAb
Hbe
HbeAg
HBsAg: Active infection
HBsAb: Implies vaccination/previous infection
HBcAb: Implies past infection
HBe: high infectivity (viral replication marker)
HBeAg: Low infectivity (antibody to marker)
How do you manage hepatitis B?
Peg-interferon alpha/other antivirals: reduces viral load
avoid alcohol
immunise all sexual partners
What does hepatitis B infection increse risk of?
Hepatocellular carcinoma
What are the defining features of hepatitis C?
Most show no symptoms acutely
some show trainsient jaundice as well as fatigue and joint pain
What is the investigation of choice in HCV?
HCV RNA via PCR
What is the treatment for HCV?
Antivirals: peginterferon a and ribavarin
What are the complications of HCV infection?
Chronic infection
Cirrhosis
Hepatocellular carcinoma
What are the distinguishing features of HDV infection? What is worrying about HDV?
Requires HBV (completes its infection cycle)
Superinfection (Hep B then D) causes fulminant hepatitis
How is hepatitis D diagnosed?
reverse PCR of HDV RNA
Interferon
What are the defining features of HEV?
common around a ‘central belt (Mexico, North Africa, Central and South East Asia)
How does autoimmune hepatitis present? what antibodies does it show?
Young female
Presents with fatgue, RUQ pain and jaundice
Type I (all): ANA +/- ASMA
Type II (children only): LMK1
How is AIH confirmed?
Liver biopsy
Shows ‘piecemeal necrosis’
How do you manage AIH?
Steroids + azathioprine
Liver transplant
What condition are patients stereotypically ‘Fat/female/fertile/forties’?
Biliary Colic
What clinical features distinguish biliary colic, acute cholecystitis and ascending cholangitis?
Colic: Intermittent RUQ pain
Acute cholecystitis: Persistent RUQ pain + jaundice
Ascending cholangitis: Persistent RUQ pain + jaundice + fever
Aside from RUQ pain, jaundice and fever; what two features point towards ascending cholangitis?
Hypotension
Confusion
(Reynold’s pentad)
In suspected biliary colic, what is the
a) investigations
b) management
a) Ultrasound: Shows acoustic shadowing
b) Elective cholecystectomy
What is the pathogenesis of bilairy colic?
Stone formation in bile duct
Causes TRANSIENT irritation
What part of the abdo exam is indicative of acute cholecystitis
Pain when pressing over RUQ during inspiration
(Murphy’s sign)
In suspected cholecystitis what are the:
a) Investigations
b) Management
a) RUQ US +/- HIDA scan
b) IV antibiotics + cholecystecomy within a week
In suspected ascending cholangitis, what is the typical infective agent?
E. Coli
(Other coliforms eg Klebsiella and enterobacter also pathogens)
In suspected ascending cholangitis, what investigations and management should be performed?
IV antibiotics
ERCP 24-48 hours after
How can the ‘primary’ biliary conditions (PBC, PSC) be distinguished from other pathology?
No fever
Itching
What condition is primary sclerosing cholangitis associated with?
Ulcerative colitis
What group of conditions is primary biliary cirrhosis linked to?
Rheumatoid/HLA B27 conditions
Also get pigmentation over joints
How does primary sclerosing cholangitis and primary biliary cirrhosis differ in terms of markers?
PSC // PBC
p-ANCA // AMA-M2, raised IgM
What biliary condition shows a ‘beaded’ bile duct? what modality is does this appear on?
PSC
ERCP/MRCP
How is primary sclerosing cholangitis treated?
Liver transplant as incurable
Give cholestyramine for itch
What is the first line and adjunct management in PBC?
1st line: Ursodeoxycholic acid
+ Cholestyramine for itch
+ Fat soluble vitamins
+ Transplantation
How do you discern cholangiocarcinoma from other HPB conditions?
RUQ pain and jaundice
No fever
Palpable masses in RUQ +/- nodes in periumbilical/left supraclavicular
How can pancreatic cancer be discerned from other similar presenting conditions?
Pain: Classically none but can have epigastric +/- radiation to back
Jaundice
NO fever
Systemic features
What four mutations does pancreatic cancer have links to?
HNPCC
MEN
BRCA2
KRAS
How do you a) investigate and b) manage pancreatic cancer?
a) 1st line: US, GS: High res CT
b) Pancreaticoduodenectomy +/- adjuvant chemotherapy, stenting via ERCP
Severe epigastric pain that radiates to back with vomiting and fever is indicative of?
Acute pancreatitis
What investigations support a clinical diagosis of acute pancreatitis?
1st line: >3 x normal amylase
+ lipase if >24 horus
+ Ultrasound
Prior to surgery, what are the 3 points of management of acute pancreatitis?
Analgesia
Aggressive crystalloids
Alternative feeding
What are the 3 features of chronic pancreatitis?
epigastric pain, worse after eating
Fatty stool (exocrine)
Diabetes mellitus (endocrine)
What is the main imaging investigation for chronic pancreatitis? What lab test can help diagnosis?
CT for calcifications
Faecal elastase
What is the treatment for chronic pancreatitis?
Analgesia
Pancreatic enzyme supplements
