Jaundice (1)

Question 1

How does it generally present?

At what level of Bilirubin is it typically seen?

What are its 3 types?

Answer 1

➊ Yellowing of skin, sclera and mucous membranes

➋ > 35 µmol/L

➌ Pre-hepatic, Hepatic, Post-hepatic

Question 2

Pre-hepatic:
What occurs here?

What are its causes?

Answer 2

➊ Unconjugated Hyperbilirubinaemia, which is not water soluble so cannot enter the urine

➋ • Haemolysis
• Conjugation disorders e.g. Gilbert’s disease, Crigler-Naajjar
• Drugs e.g. contrast, rifampicin

Question 3

Hepatic:
What occurs here?

What are its causes?

Answer 3

➊ Hepatocellular dysfunction, leading to less conjugation. But, if liver is cirrhotic, there’ll be some obstruction. Overall, both lead to a mixed picture of both unconjugated and conjugated hyperbilirubinaemia

➋ • Alcohol
• Viral infection (Hepatitis, CMV, EBV)
• NAFLD
• Drugs e.g. paracetamol OD
• Autoimmune liver disorders
• Liver mass (abscess or malignancy)

Question 4

Post-hepatic:
What occurs here?

What are its causes?

Other than the jaundice, what else does this type present with?

Answer 4

➊ Obstruction of biliary drainage, leading to Conjugated Hyperbilirubinaemia, which is water soluble so does enter the urine, but doesn’t pass into the gut (no stercobilin or urobilinogen production).

➋ * Intra-mural - Gallstone, Drug-induced cholestasis (co-amoxiclav, flucloxacillin, steroids, sulfonylureas)
* Mural - Cholangiocarcinoma, Strictures, Biliary atresia
* Extra-mural - Pancreatic ca., Abdominal mass

➌ * Dark urine - more bilirubin in urine
* Pale stools - less bilirubin in stool
* Itchiness - suggests an obstruction

N.B. The deposition of Bile salts in the skin causes the pruritus/itchiness.

Question 5

How is it investigated?

LFT Interpretation:
What’s Albumin a marker of?

What are AST and ALT markers of?

What does a raised ALP indicate?
→ What should also be measured to confirm it’s due to a biliary pathology?

Answer 5

➊ • LFT - Conjugated and unconjugated bilirubin levels
• Amylase (pancreatitis)
• Haemolytic screen

➋ Liver function

➌ Hepatocellular injury (enzymes leak from damaged cells)

➍ Biliary obstruction (as well as bone disease, pregnancy, and certain cancers)
→ GGT, which is more specific for biliary obstruction than ALP