Jaundice Flashcards
What are the LFT levels in pre-hepatic jaundice?
Bilirubin - normal or high (unconjucated)
ALT/AST - normal
Alkaline phosphatase - normal
What are the LFT levels in hepatic jaundice?
Bilirubin - high (mixed)
ALT/AST - elevated
Alkaline phosphatase - elevated but rarely v high
What are the LFT levels in post-hepatic jaundice?
Bilirubin - very high (unconjucated)
ALT/AST - moderately elevated
Alkaline phosphatase - v high
Why do gallstones cause jaundice?
Gallstones pass through the cystic duct and obstrut
Mirizzi syndrome - stone compresses the bile duct.
Rare occasion when cholecystitis presents with jaundice.
What is the pathogenesis of cholangitis?
Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.
What are the symptoms of cholangitis?
Charcots triad of symptoms (pain, fever, jaundice)
What is TPN associated jaundice?
Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.
Painless with non-obstructive features
What is the pathogenesis of cholangiocarcinoma?
Gradual onset obstructive pattern jaundice
Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.
Why might a septic surgical patient be jaundiced?
Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.
What is the first line investigation for jaundice?
Ultrasound of the liver and biliary tree
To
- establish bile duct calibre
- ascertain presence of stones
- check for pancreatic lesions
What is the preferred scan for liver tumours and cholangiocarcinoma?
MRI or MRCP
What are the risks associated with leaving jaundice untreated?
Higher incidence of septic complications, bleeding and death
What is the management of jaundice associated with malignancy?
Stent insertion (metal or plastic)
What is the management for jaundice caused by gallstones?
Removal of stones via ERCP
Then cholecystectomy
What is the management for jaundiced patients with cholangitis?
High dose broad spec ABs IV
Biliary decompression straight after despite likelihood of provoking septic episode
What are the 4 inherited causes of jaundice?
Gilbert’s syndrome
Crigler-Najjar syndrome
Dubin-Johnson syndrome
Rotor’s syndrome
What causes jaundice?
Accumulation of bilirubin in the bloodstream
Deposition on the skin, sclera and mucous membranes
What causes pre-hepatic jaundice?
Increased bilirubin production
What causes hepatic jaundice?
Impaired hepatocyte function
What causes post-hepatic jaundice?
Obstruction of the biliary system
What are common differentials for jaundice?
Alcoholic liver disease Choledocholithiasis Hepatitis A Hepatitis B Hepatitis C Drug-induced liver injury Ascending cholangitis Pancreatic carcinoma Liver metastases Haemolytic anaemia Decompensated cirrhosis Acute liver failure Acute-on-chronic liver failure
What is concerning if seen with jaundice?
Pale stools
Dark urine
What signs and symptoms should you look for in a jaundiced patients?
Hepatomegaly RUQ tenderness Palpable mass Spider nevi Ascites Track marks Palmar erythema Lymphadenopathy
What are differentials for pre-hepatic causes of jaundice?
Haemolysis: Autoimmune, haemolytic anaemia, thalassemia, sickle cell, spherocytosis, G6PD deficiency
Gilbert syndrome - inherited metabolic disorder
Crigler-Najjar syndrome - inherited disorder causing hepatic bilirubin conjugation
What are differentials for hepatic causes of jaundice?
Viral infections: Hep A-E, EBV, HIV
Alcohol and toxins: Alcholic hep, fatty liver, drugs
Non-alcoholic fatty liver disease
What are differentials for post-hepatic causes of jaundice?
Biliary disease Surgical strictures - Chronic cholestasis, recurrent cholangitis Pancreatic cancer Parasitic infections e.g. malaria Drugs e.g. penicillins esp co-amxiclav
What bedside investigations?
ECG - jaundice can cause bradycardia
Bloods: FBC, LFTs, U+Es, Clotting, CRP
Depending on LFTs and history:
Toxin levels
Haemolytic screen
Infection screen e.g. Hepatitis, HIV, Malaria
Autoimmune screen: ANA, ANCA
Metabolic screen: Ferritin, Alpha-1-antitrypsin
What imaging for jaundice?
Liver Ultrasound
- is the common bilde duct dilated?
CT Abdo
What special test for jaundice?
MRCP - MRI of biliary tree
ERCP - endoscopic imaging of biliary tree and can be therapeutic
What do different raised bilirubin mean?
Raised unconjuctated - prehepatic
Raised un/conjucated - hepatic
Urinary bilirubin - Positive in obstructive
What LFTs levels indicate alcoholic vs. viral hep?
AST>ALT in alcoholic hep
ALT>AST in viral hep
What is included in the haemolytic screen?
Tests that look for increased red cell breakdown
- Anaemia
- High bilirubin
- High LDH (lactate dehydrogenase, found in RBCs released when they breakdown)
- Low haptoglobin
Blood film
- Spherocytes
Tests that look for increased red cell synthesis
- High reticulocytes
If post
- Coombs test to look for autoimmune haemolytic anaemia
What LFTs would show a intrahepatic picture?
ALT/AST»_space; ALP/GGT
What would viral serology show in acute hep b?
Hep B Ag (surface antigen) - positive vaccination or previous infection
Anti-HBcAG (core antigen) - is postitive current infection
IgM is acute
IgG is chronic
What is the management for Hep B acutely?
Majority will get better with supportive care
Need treatment of any complications e.g. fluids for AKI, ABs for infection
Prevent further damage - reduce EO
Prevent transmission - contact tracing, avoid sharing razors/toothbrushes, sexual health clinic referral
What is the management for Hep B chronically?
Consider starting anti-viral treatment
Very specialist
What are the presenting features for post-hepatic jaundice?
Dark urine
Pale stools
Pruritus
What causes pruritus in post-hepatic jaundice?
Bile salts
What would be raised in post-hepatic jaundice?
Raised ALP/GGT
