Jaundice

Question 1

What level of serum bilirubin is jaundice detectable at?

Answer 1

Over 50micromol/L

Question 2

What causes pre-hepatic jaundice? How a patient present and why?

Answer 2

Haemolysis i.e. haemolytic anaemia

-increased production of bilirubin due to increased breakdown of RBC leads to liver being overloaded and cannot process the excess = rise in unconjugated bilirubin

Px

• normal urine and stool due to excess bilirubin not being conjugated and is therefore not water soluble
• elevated unconjugated bilirubin= need to request split bilirubin on blood test
• normal ALPs, transferase + albumin
• signs of anaemia or splenomegaly

Question 3

Jaundice can occur due to congenital hyperbilirubaemia. Which are the most common causes and would the bilirubin be conjugate or unconjugated?

Answer 3

Gilberts syndrome

• raised unconjugated bilirubin with no othe LFT derrangement or signs of liver disease
• caused by defect in enzyme which conjugated bilirubin with glucoronic acid
• tends to present with fasting and mild illness

Dubin-Johnson and Rotor’s syndrome

• conjugated
• defects in hepatic bilirubin handling which leads to problems in excretion from liver causing build up

Question 4

What is the difference between extrahepatic and intrahepatic cholestasis? Give examples of causes for each. How does cholestatic jaundice present clinically?

Answer 4

Extra= obstruction of bile flow distal to bile canaliculi
Common duct stones
Carcinoma of bile ducts, head of pancreas or ampulla
Biliary stricture
Sclerosing cholangitis

Intra= failure of bile secretion due to defects in secretion or inflammation of intrahepatic ducts 
Viral hepatitis 
Drugs
Alcoholic hepatitis 
Cirrhosis 
AI cholangitis

PX
-pale stools and dark urine

Question 5

If patient presents with hyperbilirubaemia, how can you determine the location of the cause?

Answer 5

Clinical presentation
Normal urine and stools= pre-hepatic causes i.e. haemolysis, impaired hepatic uptake, impaired conjugation

Dark urine + normal stools= hepatic cause i.e. conjugated bilirubin formed and able to be absorbed AND pass into duodenum due to lack of obstruction

Dark urine + pale stools= post-hepatic

LFTS:

• derranged LFTs can give indication to whether cause is biliary or hepatic
• Biliary= ALP
• Liver= ALT

Question 6

What are the common investigations for patient presenting with jaundice?

Answer 6

Bed side:
Examination for signs of liver disease or biliary disease

Bloods:
Viral markers= Hep A, B, C (indicated in YOUNG PEOPLE>ELDERLY)
LFTs
-raised ALT= hepatitis/liver disease
-raised ALP (or GGT if requested)= extrahepatic obstruction
-low albumin= long standing liver disease
Raised bilirubin= haemolytic jaundice
Raised WCC= cholangitis
Leukopenia= viral hepatitis

Imaging:
USS= exclude extrahepatic obstruction