Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gwen - GI and General surgery > Hepato-biliary: Jaundice and Liver function assessment > Flashcards

Hepato-biliary: Jaundice and Liver function assessment Flashcards

1
Q

What is the definintion of jaundice?

A

Yellowing of the skin, sclerae, and other tissues caused by excess circulating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

At what bilirubin level does jaundice become clinically evident?

A

Serum levels exceed 51 micromol/L (3 mg/dL).

First shows in sclera because of high affinity for bilirubin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

How are red blood cells broken down?

A

Macrophages breakdown haem into bilirubin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is bilirubin conjugated with?

A

Glucouronic acid (water soluble)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What transports unconjugated bilirubin in the blood?

A

Albumin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Where is bilirubin secreted into after it has been conjugated with glucuronic acid?

A

Into bile and then the intestine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What happens to conjugated bilirubin when it enters the bowel?

A

Glucuronic acid is removed by intestinal bacteria

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What happens to bilirubin once the glucuronic acid has been removed by bacteria?

A

Converted to urobilinogen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What happens to urobilinogen in the intestine?

A
  • Absorbed from the gut -> to kidney
  • Oxidised to stercobilinogen -> faeces
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is urobilinogen converted to in the kidneys?

A

Urobilin - characteristic colour of urine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Bilirubin is excreted as:

A

Urobilinogen (from kidney - 13%)

Urobin (from stool - 99%)

That which is not excreted is put back into the enterohepatic circulation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Describe the pathway of billirubin (the whole sha-bang)

A

Pre-hepatic

Spleen:

  • Haemoglobin breaks down into haem + globin
  • Haem converted into bilirubin
  • Bilirubin bound to albumin to make Bilirubin-Albumin Complex (+ travels in blood to liver)
  • Unconjugated bilirubin (water insoluble so can’t appear in urine due to HMW plasma protein)

Hepatic

Liver:

  • Uptake of bilirubin by hepatocytes
  • Conjugation of bilirubin in hepatocytes (becomes water soluble) so can appear in urine/stool
  • Excretion of conjugated bilirubin into biliary system

Post-hepatic

3 routes for bilirubin:

  • Transport of conjugated bilirubin in biliary system- excreted as
    • Uroblinogen
    • Uroblin
  • Breakdown of conjugated bilirubin in intestine
    • Further metabolised into stercoblin (gives stool brown colour)
  • Reabsorption of bilirubin into entero-hepatic circulation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are causes of unconjugated hyperbilirubinaemia?

A
  • Overproduction - Haemolysis, ineffective erythropoesis
  • Impaired hepatic uptake - Drugs, ischaemic hepatitis
  • Impaired conjugation - Gilbert’s syndrome, Crigler-Najjar
  • Physiological neontala jaundice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What sort of hyperbilirubinaemia occurs in pre-hepatic jaundice?

A

Unconjugated hyperbilirubinaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What type of hyperbilirubinaemia occurs in gilbert’s syndrome?

A

Unconjugated hyperbilirubinaemia

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What types of jaundice cause conjugated hyper bilirubinaemia?

A
  • Hepatocellular dysfunction
  • Post-hepatic/Cholestatic jaundice
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are causes of hepatocellular jaundice?

A
  • Viral hepatitis
  • CMV
  • EBV
  • Drugs
  • Alcohol/Cirrhosis
  • Liver mets
  • Liver abscess
  • Haemochromatosis
  • Autoimmune hepatitis
  • Septicaemia
  • Leptospirosis
  • Syphilis
  • Alpha1-antitrypsin
  • Budd chiari
  • Wilson’s Disease
  • Right heart failure
  • Toxins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are causes of post-hepatic jaundice?

A
  • PBC, PSC
  • Drugs
  • CBD gallstones
  • Pancreatic cancer
  • Compression of the bile duct
  • Cholangiocarcinoma
  • Choledochal cyst
  • Mirrizi’s syndrome
  • Caroli’s syndrome
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Presentation of pre-hepatic jaundice

A

Normal urine

Normal stool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Presentation of hepatic jaundice

A

Dark urine

Normal/pale stool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Presentation of post hepatic jaundice

A

Dark urine

Pale stool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

Causes of pre-hepatic jaundice

A
  • Haemolysis
    • Haemolytic anaemia eg spherocytosis
    • Post transfusion
  • Gilbert’s syndrome (harmless, no treamtent needed)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Causes of hepatic jaundice

A
  • Increase in unconjugated (liver function)
    • Hepatitis
    • Liver failure
    • Drugs
  • Increase in conjugated (swelling of hepatocytes)
    • PBC - granumomatous inflammation inolving bile ducts (progression to hepatic cirrhosis)
    • PBS - chronic inflammation involving bild ducts (progression to hepatic cirrhosis, increased risk cholangiocarcinoma)
    • Cirrhosis - liver failure, PHT, HCC. Alcohol, hepB and C, immune mediated liver disease, metabolic disorders
    • Liver/hepatocellular carcinoma - malignant tumour of hepatocytes
    • Metastases
    • Pregnancy
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Causes of post hepatic jaundice

A
  • Common bile duct obstruction
    • ​CBD stones
    • Strictures (benign/malignt)
    • External compression tumours - head of pancreas
    • Pancreatitis
  • Cholelithiasis/gall stones
    • ​Acute
    • Chronic
    • Miritzzi syndrome - gallstones that compress CBD
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Features of pre-hepatic jaundice in history

A

Anaemia: fatigue, SOB, pallor, chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

Features of hepatic jaundice in history

A

Risk factors for liver disease:

IVDU

Alcohol

Drug history

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

Features of post-hepatic jaundice in history

A
  • Calcular
    • ​Biliary colic
    • Fluctuating jaundice
    • No weight loss
  • Malignant
    • ​Constant abdo pain
    • Progressive jaundice
    • Weight loss
  • Cholesostasis
    • ​Pruritis
    • Dark urin
    • Pale stool
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

Features of pre-hepatic jaundice on examination

A

Anaemia: pallor

Splenomegaly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Features of hepatic jaundice on examination

A

Signs of chronic liver disease

General - asterixis, fetor hepaticus

Abdo inspectiono - spider naevia, gynaecomastia

Abdo palp - Ascites, hepatomegaly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

Features of post-hepatic jaundice on examination

A

General: jaundice, fever, weight loss

Abdo palpation: hepatomegaly

Courvosier’s sign

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

Blood tests pre-hepatic jaundice

A

Bilirubin - increased unconjugated

AST/ALT normal

ALP normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

Blood tests hepatic jaundice

A

Billirubin - increased both

AST/ALT: marked increase (++++)

ALP: increase/normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Blood tests post hepatic jaundice

A

Billirubin - increased conjugated

AST/ALT - mild increase/normal

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What blood tests are used to assess liver function?

A
  • Alanine transaminase (ALT)
  • Aspartate aminotransferase (AST)
  • Alkaline phosphatase (ALP)
  • Gamma-Glutamyltransferase (GGT)
  • Bilirubin
  • Albumin
  • Prothrombin time (PT)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

What tests are used to distinguish between hepatic and post-hepatic jaundice?

A
  • ALT
  • AST
  • ALP
  • GGT
36
Q

What tests are used to assess livers synthetic function?

A
  • Bilirubin
  • Albumin
  • PT
37
Q

What is ALT a useful marker of?

A

Hepatocellular injury - found in high concentrations in hepatocytes and enters blood following hepatocellular injury

ALT more specific to the liver - normal levels 5-40u/l

AST also present in heart and skeletal muscle - normal level 10-40u/l

38
Q

What is ALP a useful marker of?

A

Cholestasis (Indirect marker ) - particularly concentrated in the liver, bile duct and bone tissues. It is raised in liver pathology due to increased synthesis in response to cholestasis

39
Q

What can also cause a raised AlkP

A

Pregnancy

Paget’s

Osteomalacia

Growting children and bone mets

40
Q

What LFT results would indicate predominantly hepatocellular injury?

A
  • ALT - > 10-fold increase
  • ALP - <3-fold increase
41
Q

What LFT results would indicate cholestasis?

A
  • ALT - <10-fold increase
  • ALP - >3-fold increase
  • Raised GGT
42
Q

What are causes of an isolated rise in ALP?

A
  • Bony metastases / primary bone tumours (e.g. sarcoma)
  • Vitamin D deficiency
  • Recent bone fractures
  • Renal osteodystrophy
  • Paget’s Disease
43
Q

How would you distinguish between hepatocellular jaundice and cholestatic jaundice?

A

Compare to what degree the ALT and ALP are raised. If ALT is raised markedly compared to the ALP, this is primarily a hepatocellular pattern of injury. If ALP is raised markedly compared to ALT, this is primarily a cholestatic pattern of injury.

44
Q

What is a raised GGT indicative of?

A

Can be suggestive of biliary epithelial damage and bile flow obstruction.

It can also be raised in response to alcohol and drugs such as phenytoin.

A markedly raised ALP with a raised GGT is highly suggestive of cholestasis.

45
Q

What would a raised ALP in the absence of raised GGT suggest?

A

Non-hepatobiliary cause - Alkaline phosphatase is also present in bone and therefore anything that leads to increased bone breakdown can elevate ALP.

46
Q

What would jaundice with normal ALT/ALP levels suggest?

A

Pre-hepatic cause - Gilbert’s syndrome, haemolysis

47
Q

What are the livers main synthetic functions?

A
  • Conjugation and elimination of bilirubin
  • Synthesis of albumin
  • Synthesis of clotting factors
  • Gluconeogenesis
48
Q

What investigations can be used to test liver synthetic function?

A
  • Serum bilirubin
  • Serum albumin
  • Prothrombin time (PT) - Absence of bile, failure of fat soluble vit K absorption (vit K needed for clotting factor synthesis
  • Serum blood glucose
49
Q

What happens to an individuals stool and urine if they have unconjugated hyperbilirubinaemia?

A

Normal urine and normal stool

50
Q

What would the colour of someones stool be if they had hepatic jaundice?

A

Dark urine, normal stool

51
Q

What colour is the stool and urine in someone with post-hepatic jaundice?

A

Pale stool, dark urine

52
Q

What can cause albumin to fall?

A
  • Liver disease resulting in a decreased production of albumin (e.g. cirrhosis)
  • Inflammation triggering an acute phase response which temporarily decreases the liver’s production of albumin
  • Excessive loss of albumin due to protein-losing enteropathies or nephrotic syndrome
53
Q

What is PT, and what can it indicate in terms of liver disease?

A

Prothrombin time (PT) is a measure of the blood’s coagulation tendency, specifically assessing the extrinsic pathway.

In the absence of other secondary causes such as anticoagulant drug use and vitamin K deficiency, an increased PT can indicate liver disease and dysfunction.

54
Q

What does an ALT > AST tend to indicate when looking as the ALT/AST ratio?

A

Chronic liver disease

55
Q

What does an AST>ALT tend to indicate when looking as the ALT/AST ratio?

A
  • Cirrhosis
  • Acute alcoholic hepatitis
56
Q

What LFT profile might be present in someone with acute hepatocellular damage?

A
  • Markedly increased ALT
  • Normal/increased ALP
  • Normal/increased GGT
  • Increased/Markedly increased Bilirubin
57
Q

What LFT profile might you see in someone with Chronic hepatoceullular damage?

A

Normal or increase ALT, ALP, GGT and Bilirubin

58
Q

What LFT profile might you see in someone with Cholestasis?

A
  • Normal/increased ALT
  • Mardkedly increased ALP
  • Markedly Increased GGT
  • Markedly increased Bilirubin
59
Q

What are common causes of acute hepatoceullular damage?

A
  • Poisoning (paracetamol overdose)
  • Infection (Hepatitis A and B)
  • Liver ischaemia
60
Q

What are common causes of chronic hepatocellular injury?

A
  • Alcoholic fatty liver disease
  • Non-alcoholic fatty liver disease
  • Chronic infection (Hepatitis B or C)
  • Primary biliary cirrhosis
61
Q

What are rare causes of chronic heptocellular injury?

A
  • alpha-1 antitrypsin deficiency
  • Wilson’s disease
  • Haemochromatosis
62
Q

What tests are included in a liver screen?

A
  • LFTs
  • Coagulation screen
  • Hepatitis serology (A/B/C)
  • Epstein-Barr Virus (EBV)
  • Cytomegalovirus (CMV)
  • Anti-mitochondrial antibody (AMA)
  • Anti-smooth muscle antibody (ASMA)
  • Anti-liver/kidney microsomal antibodies (Anti-LKM)
  • Anti-nuclear antibody (ANA)
  • p-ANCA
  • Immunoglobulins – IgM/IgG
  • Alpha-1 Antitrypsin – Alpha-1 Antitrypsin deficiency
  • Serum Copper – Wilson’s disease
  • Ceruloplasmin – Wilson’s disease
  • Ferritin – Haemochromatosis
63
Q

If someone presented with jaundice, what would you want to ask them in the histroy?

A

Ask about

  • Blood transfusions
  • IV drug use
  • Body piercings/Tattoos
  • Sexual activity
  • Travel abroad
  • Family history
  • Contact with others with jaundice
  • Alcohol use
  • Fever/rigors
  • Surgery/anaesthetic history
  • Medications
64
Q

What clinical signs may be present in someone with jaundice?

A
  • Signs of chronic liver disease
  • Hepatic encephalopathy
  • Lymphadenopathy
  • Hepatomegaly
  • Splenomegaly
  • Ascites
  • Palpable gallbladder
  • Pale stool, dark urine
65
Q

What investigations would you consider doing in someone who presents with jaundice?

A
  • Bloods - FBC; Clotting; Blood film; Haemolysis testing - retic count/coomb’s; U+E’s, LFTs, Total protein, Albumin, Paracetamol levels, gamma-GT, Liver screening tests
  • Ultrasound - stones, bile ducts etc
  • MRCP/ERCP - gallstones
  • Liver biopsy
  • CT/MRI - metastastatic disease
66
Q

What are common causes of jaundice in someone with cirrhosis?

A
  • Sepsis
  • Malignancy - HCC
  • Alcohol
  • Drugs
  • GI bleeding
67
Q

What drugs can cause hepatocellular injury?

A
  • Paracetamol overdose
  • Isoniazid, rifampicin, pyrazinamide
  • MOAI
  • Sodium valproate
  • Halothane
  • Statins
68
Q

What drugs can cause cholestatic jaundice?

A
  • Fusidic acid, Co-amoxiclav, nitrofurantoin
  • Steroids
  • Flucloxacillin
  • Sulphonylureas
  • Prochlorperazine
  • Chlorpromazine
69
Q

What drugs can cause haemolytic jaundice?

A

Antimalarials

70
Q

What might a AST/ALT ratio of >/=2.5:1 indicate as a cause of deranged LFTs?

A

Alcoholic hepatitis

71
Q

What might an AST/ALT ratio = 1 indicate as the cause of deranged LFTs?

A

Associated with ischaemia (CCF and ischaemic necrosis and hepatitis)

72
Q

Surgical jaundice is typically..

A

Calcular obstructive jaundice - females, biliary colic, no weight loss, fluctuating jaundice

OR

Malignant obstructive jaundice - males, painless (vague abdo pain, less in comparison to above), weight loss, progressive jaundice

73
Q

List the immunoglobulin tests in chronic liver disease

A

Raised IgA: alcohol

Raised IgG: autoimmune hepatitis or hep C

Raised IgM: PBC or hep A

74
Q

List the autoantibodies tests in chronic liver disease

A

Antimitochondrial (AMA) - PBC

Anti smooth muscle (ASMA) - autoimmunehepatitis

Antinucelar factor - autoimmune hepatitis

75
Q

Hepatitis serology tests

A

HepA - riased IgM

Hep B - raised sAg

Hep C - raised IgG

76
Q

What test is done in wilson’s disease?

A

Ceruloplasmin

77
Q

What test is done in haemachromatosis

A

Raised ferritin/reduced transferrin

78
Q

In terms of imaging, what is the first investigation you would do in jaundice?

A

US - is biliary tree dilated?

YES: surgical
NO: medical - do liver biopsy/blood tests (viral markers, autoantibodies)

79
Q

List the imaging used if dilated biliary tree found on ultrasound

A

Need to answer two questions:

Cause of obstruction?

Level of obstruction?

  • CT
    • detects solid massess (pancreas and liver)
  • ERCP
    • Used in documented CBD stones
    • Visualises anatomy distal to obstruction
    • Diagnostic - stricture, filling defect, cytology, biopsy
    • Therapeutic - stenting
  • PTC
    • visualises anatomy proximal to obstruction
    • when ERCP not possible, US die injected into biliary tree
    • Therapeutic - transhepatic placement of biliary stents
  • MRCP
    • CBD stones/strictures
    • non inavsive assessment CBD
80
Q

Complications of ERCP

A

Pancreatitis

Perforation

Bleeding (esp with sphincerotomy)

Cholangitis (prophylactic antibitoics)

81
Q

Indications for endoscopyic ultrasound

A

Small <3cm - pancreatic tumours and ampullary neoplasms

Small <4cm - bile duct stones

82
Q

Prior to surgical mamangement of jaundice what is given?

A

IV vit K - due to lack of bile in gut so body unable to absorb fat soluble vit K so vit K factor devicience (IV not IM)

Prophylactic antibiotics - risk of cholangitis

IV fluids - body sensitive to dehydration (hepatic renal syndrome)

83
Q

Cholecocholithiasis/CBD stone management

A

Option 1 - ERCP - endoscopic sphincterotomy and CBD stone extraction followed by laparoscopic cholecystectomy

Option 2 - if failed ERCP - cholecystectomy, CBD exploration, stone extraction and T tube insertion

84
Q

Management traumatic biliary sitructure (previous cholecsytectomy)

A

Presention is either post op jaundice or intermittent cholangitis and jaundice

Management 0 biliary stent, roux-en-Y hepatico-jejunostomy

85
Q

Management malignant biliary strictures

A

Eg cholangiocarcinoa

If operable - resction and biliary reconstruction

If inoperable - CBD stent

Gwen - GI and General surgery (44 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions