GI Problems Two: Jaundice Flashcards
What are the broad causes of jaundice?
Pre vs post hepatic causes.
Heamoylsis related jaundice is rare.
What can the liver causes of jaundice be divided into?
Hepatocellular
Billiary obstruction
What is murpheys sign?
Pain becomes prominent when asked to take a deep breathe with an examining hand just below the right costal margin
Murpheys sign + fever indicates what pathophysiology?
Cholecystitis. (gall bladder inflammation)
What is involuntary guarding?
Indicates peritonitis, rebound or percussion tenderness. Localised (visceral inflam) or generalised inflammation (peritonitis)
Describe the pathophysiology of pain in viscera?
Intra-abdominal pain, organs dont have pain receptors within, they are on external surface therefore distension or fluid -> Stretching / swelling of organ = pain
What stimulates gall bladder contraction?
Stimualted by food and cholecystokinin
What is biliary colic?
Biliary colic -> Obstruction and pain on contraction (unlike inflam)
Describe biliary colic pain:
Post prandial
Radiates to back and upper shoulder
What is cholelithiasis?
Cholelithiasis -> Gallstones (symp or asymp)
What is cholecystitis?
Inflammation of the gallbladder. any cause.
What is choledocholithiasis?
Presence of stones in bile duct not gall bladder.
What is cholangitis?
Clinical syndrome. Stones + Infection
What are the types of gallstones?
Cholesterol stones: B/c conc. effect of gall bladder // bile.
Pigment stones
What are GGT and alkaline phosphotase (ALP) indicative of?
Cholestatic enzymes
Elevated in cholestitis
When is bilirubin elevated?
When the bile duct is obstructed
What are the potential consequences of bile duct obstruction?
Pancreatitis because they come together in the ampulla thus if this is blocked can be bad
Infection can cause actue pancreatitis
What can cause cholestasis?
- Stones
- Biliary disease (cholangeopathy)
-> Primary biliary cirrhosis
-> Primary sclerosing cholangitis - Drugs
- Tumours
Whats the different types of pain from the gall bladder?
- Biliary colic = Restlessness
- Inflam pain = Stillness
Pain and jaundice -> Thinking gall stones. No pain thinking hepatocellular disease
What are the liver enzymes?
ASP and ALT
Go up when theres liver inflam
Whats the presentation of acute cholangitis?
Charcots triad
- Fever
- Jaundice
- RUQ pain
How can the gall bladder be imaged?
- US
- MR cholangiopancreatography
- Endoscopic retrograde cholangiopancreatography
Is removing the gallstone the final step?
No probably need to remove the gall bladder as well as this is the source
If a patient has elevated GGT and ALP but normal bilirubin and no pain where are your throughts direct?
Cholageopathy
Common ones:
- Primary biliary cirrhosis/cholangitis
- Primary biliary sclerosis
What is found in primary biliary cirrhosis?
- Localised inflammation of very small ducts
- +ive mitochondrial antibodies
- Slowly progressive
- Commonly presents with itching not jaundice
++ Cant image
What is found in primary biliary sclerosis?
- Wide spread inflammation of medium to large ducts
- Stricturing
- Diagnosed on imaging
Whats required for a diagnosis of PBC?
- High ALP (&GGT -> second to ride, ALP by self might be bone)
- Positive AMA
- Liver biopsy. (rare)
What are the early symptoms of PBC?
- Fatigue
- Pruritis
- Steatorrhoea (Vitamin deficiencies)
Describe the progressive nature of PBC:
- Jaundice
- Liver cirrhosis and related complications (including hepatocellular carcinoma)
What are the associated conditions of PBC?
- Striking dyslipidaemia (HDL elevated)
- Associated with osteopenia/osteoporosis (not because vit D malabsorption, but not known mechanisms)
- Other autoimmune conditions i.e hypothyroidism
Whats the treatment for PBC?
Ursodeoxycholic acid (slows disease)
- non curative
- Slows progression
Describe the pathophysiology of PSC:
Immune mediated (Antigen not identified)
- Often associated with IBD
Diagnosed by radiology
Whats the presentation of PSC?
- 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
What can PSC progress to?
Jaundice
Liver cirrhosis
Cholangitis
What is PSC associated with?
- Osteopenia / osteoporosis (not due to vit D malabsortion, unknown mechanism)
Whats the treatment of PSC?
- No meds to slow progression
- If it develops jaundice/cholangitis could dilate or stent
What tumours cause obstructive jaundice?
- Pancreatic cancer in the head
- Cholangiocarcinoma
both painless because chronic and gradia;
What are some characteristics of cancers causing jaundice?
- Painless jaundice
- Palpabale epigastric mass
- Palpable gall bladder (very rare and very slowly)
