GI Problems Two: Jaundice

Question 1

What are the broad causes of jaundice?

Answer 1

Pre vs post hepatic causes.

Heamoylsis related jaundice is rare.

Question 2

What can the liver causes of jaundice be divided into?

Answer 2

Hepatocellular
Billiary obstruction

Question 3

What is murpheys sign?

Answer 3

Pain becomes prominent when asked to take a deep breathe with an examining hand just below the right costal margin

Question 4

Murpheys sign + fever indicates what pathophysiology?

Answer 4

Cholecystitis. (gall bladder inflammation)

Question 5

What is involuntary guarding?

Answer 5

Indicates peritonitis, rebound or percussion tenderness. Localised (visceral inflam) or generalised inflammation (peritonitis)

Question 6

Describe the pathophysiology of pain in viscera?

Answer 6

Intra-abdominal pain, organs dont have pain receptors within, they are on external surface therefore distension or fluid -> Stretching / swelling of organ = pain

Question 7

What stimulates gall bladder contraction?

Answer 7

Stimualted by food and cholecystokinin

Question 8

What is biliary colic?

Answer 8

Biliary colic -> Obstruction and pain on contraction (unlike inflam)

Question 9

Describe biliary colic pain:

Answer 9

Post prandial

Radiates to back and upper shoulder

Question 10

What is cholelithiasis?

Answer 10

Cholelithiasis -> Gallstones (symp or asymp)

Question 11

What is cholecystitis?

Answer 11

Inflammation of the gallbladder. any cause.

Question 12

What is choledocholithiasis?

Answer 12

Presence of stones in bile duct not gall bladder.

Question 13

What is cholangitis?

Answer 13

Clinical syndrome. Stones + Infection

Question 14

What are the types of gallstones?

Answer 14

Cholesterol stones: B/c conc. effect of gall bladder // bile.

Pigment stones

Question 15

What are GGT and alkaline phosphotase (ALP) indicative of?

Answer 15

Cholestatic enzymes

Elevated in cholestitis

Question 16

When is bilirubin elevated?

Answer 16

When the bile duct is obstructed

Question 17

What are the potential consequences of bile duct obstruction?

Answer 17

Pancreatitis because they come together in the ampulla thus if this is blocked can be bad

Infection can cause actue pancreatitis

Question 18

What can cause cholestasis?

Answer 18

• Stones
• Biliary disease (cholangeopathy)
  -> Primary biliary cirrhosis
  -> Primary sclerosing cholangitis
• Drugs
• Tumours

Question 19

Whats the different types of pain from the gall bladder?

Answer 19

• Biliary colic = Restlessness
• Inflam pain = Stillness

Pain and jaundice -> Thinking gall stones. No pain thinking hepatocellular disease

Question 20

What are the liver enzymes?

Answer 20

ASP and ALT

Go up when theres liver inflam

Question 21

Whats the presentation of acute cholangitis?

Answer 21

Charcots triad
- Fever
- Jaundice
- RUQ pain

Question 22

How can the gall bladder be imaged?

Answer 22

• US
• MR cholangiopancreatography
• Endoscopic retrograde cholangiopancreatography

Question 23

Is removing the gallstone the final step?

Answer 23

No probably need to remove the gall bladder as well as this is the source

Question 24

If a patient has elevated GGT and ALP but normal bilirubin and no pain where are your throughts direct?

Answer 24

Cholageopathy

Common ones:
- Primary biliary cirrhosis/cholangitis
- Primary biliary sclerosis

Question 25

What is found in primary biliary cirrhosis?

Answer 25

• Localised inflammation of very small ducts
• +ive mitochondrial antibodies
• Slowly progressive
• Commonly presents with itching not jaundice

++ Cant image

Question 26

What is found in primary biliary sclerosis?

Answer 26

• Wide spread inflammation of medium to large ducts
• Stricturing
• Diagnosed on imaging

Question 27

Whats required for a diagnosis of PBC?

Answer 27

• High ALP (&GGT -> second to ride, ALP by self might be bone)
• Positive AMA
• Liver biopsy. (rare)

Question 28

What are the early symptoms of PBC?

Answer 28

• Fatigue
• Pruritis
• Steatorrhoea (Vitamin deficiencies)

Question 29

Describe the progressive nature of PBC:

Answer 29

• Jaundice
• Liver cirrhosis and related complications (including hepatocellular carcinoma)

Question 30

What are the associated conditions of PBC?

Answer 30

• Striking dyslipidaemia (HDL elevated)
• Associated with osteopenia/osteoporosis (not because vit D malabsorption, but not known mechanisms)
• Other autoimmune conditions i.e hypothyroidism

Question 31

Whats the treatment for PBC?

Answer 31

Ursodeoxycholic acid (slows disease)

• non curative
• Slows progression

Question 32

Describe the pathophysiology of PSC:

Answer 32

Immune mediated (Antigen not identified)

• Often associated with IBD

Diagnosed by radiology

Question 33

Whats the presentation of PSC?

Answer 33

• Often assocaited with UC
• ~50% asymp. (LFTs noticed when something else done)

Symptomatic
- Pruritis
- Fatigue
- Steatorrhoea

Beading on imaging

Rapidly progressive, much more prone to infections

Question 34

What can PSC progress to?

Answer 34

Jaundice
Liver cirrhosis
Cholangitis

Question 35

What is PSC associated with?

Answer 35

• Osteopenia / osteoporosis (not due to vit D malabsortion, unknown mechanism)

Question 36

Whats the treatment of PSC?

Answer 36

• No meds to slow progression
• If it develops jaundice/cholangitis could dilate or stent

Question 37

What tumours cause obstructive jaundice?

Answer 37

• Pancreatic cancer in the head
• Cholangiocarcinoma

both painless because chronic and gradia;

Question 38

What are some characteristics of cancers causing jaundice?

Answer 38

• Painless jaundice
• Palpabale epigastric mass
• Palpable gall bladder (very rare and very slowly)