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Year 3 Gastro > Jaundice > Flashcards

Jaundice Flashcards

1
Q

What are the LFT levels in pre-hepatic jaundice?

A

Bilirubin - normal or high (unconjucated)
ALT/AST - normal
Alkaline phosphatase - normal

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2
Q

What are the LFT levels in hepatic jaundice?

A

Bilirubin - high (mixed)
ALT/AST - elevated
Alkaline phosphatase - elevated but rarely v high

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3
Q

What are the LFT levels in post-hepatic jaundice?

A

Bilirubin - very high (unconjucated)
ALT/AST - moderately elevated
Alkaline phosphatase - v high

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4
Q

Why do gallstones cause jaundice?

A

Gallstones pass through the cystic duct and obstrut

Mirizzi syndrome - stone compresses the bile duct.

Rare occasion when cholecystitis presents with jaundice.

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5
Q

What is the pathogenesis of cholangitis?

A

Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile.

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6
Q

What are the symptoms of cholangitis?

A

Charcots triad of symptoms (pain, fever, jaundice)

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7
Q

What is TPN associated jaundice?

A

Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage.

Painless with non-obstructive features

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8
Q

What is the pathogenesis of cholangiocarcinoma?

A

Gradual onset obstructive pattern jaundice

Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis.

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9
Q

Why might a septic surgical patient be jaundiced?

A

Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis.

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10
Q

What is the first line investigation for jaundice?

A

Ultrasound of the liver and biliary tree

To

  • establish bile duct calibre
  • ascertain presence of stones
  • check for pancreatic lesions
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11
Q

What is the preferred scan for liver tumours and cholangiocarcinoma?

A

MRI or MRCP

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12
Q

What are the risks associated with leaving jaundice untreated?

A

Higher incidence of septic complications, bleeding and death

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13
Q

What is the management of jaundice associated with malignancy?

A

Stent insertion (metal or plastic)

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14
Q

What is the management for jaundice caused by gallstones?

A

Removal of stones via ERCP

Then cholecystectomy

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15
Q

What is the management for jaundiced patients with cholangitis?

A

High dose broad spec ABs IV

Biliary decompression straight after despite likelihood of provoking septic episode

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16
Q

What are the 4 inherited causes of jaundice?

A

Gilbert’s syndrome
Crigler-Najjar syndrome
Dubin-Johnson syndrome
Rotor’s syndrome

17
Q

What causes jaundice?

A

Accumulation of bilirubin in the bloodstream

Deposition on the skin, sclera and mucous membranes

18
Q

What causes pre-hepatic jaundice?

A

Increased bilirubin production

19
Q

What causes hepatic jaundice?

A

Impaired hepatocyte function

20
Q

What causes post-hepatic jaundice?

A

Obstruction of the biliary system

21
Q

What are common differentials for jaundice?

A 
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
22
Q

What is concerning if seen with jaundice?

A

Pale stools

Dark urine

23
Q

What signs and symptoms should you look for in a jaundiced patients?

A 
Hepatomegaly
RUQ tenderness
Palpable mass 
Spider nevi
Ascites
Track marks
Palmar erythema
Lymphadenopathy
24
Q

What are differentials for pre-hepatic causes of jaundice?

A

Haemolysis: Autoimmune, haemolytic anaemia, thalassemia, sickle cell, spherocytosis, G6PD deficiency

Gilbert syndrome - inherited metabolic disorder

Crigler-Najjar syndrome - inherited disorder causing hepatic bilirubin conjugation

25
Q

What are differentials for hepatic causes of jaundice?

A

Viral infections: Hep A-E, EBV, HIV

Alcohol and toxins: Alcholic hep, fatty liver, drugs

Non-alcoholic fatty liver disease

26
Q

What are differentials for post-hepatic causes of jaundice?

A 
Biliary disease
Surgical strictures - Chronic cholestasis, recurrent cholangitis
Pancreatic cancer
Parasitic infections e.g. malaria
Drugs e.g. penicillins esp co-amxiclav
27
Q

What bedside investigations?

A

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

28
Q

What imaging for jaundice?

A

Liver Ultrasound
- is the common bilde duct dilated?

CT Abdo

29
Q

What special test for jaundice?

A

MRCP - MRI of biliary tree

ERCP - endoscopic imaging of biliary tree and can be therapeutic

30
Q

What do different raised bilirubin mean?

A

Raised unconjuctated - prehepatic

Raised un/conjucated - hepatic

Urinary bilirubin - Positive in obstructive

31
Q

What LFTs levels indicate alcoholic vs. viral hep?

A

AST>ALT in alcoholic hep

ALT>AST in viral hep

32
Q

What is included in the haemolytic screen?

A

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

33
Q

What LFTs would show a intrahepatic picture?

A

ALT/AST&raquo_space; ALP/GGT

34
Q

What would viral serology show in acute hep b?

A

Hep B Ag (surface antigen) - positive vaccination or previous infection

Anti-HBcAG (core antigen) - is postitive current infection
IgM is acute
IgG is chronic

35
Q

What is the management for Hep B acutely?

A

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

36
Q

What is the management for Hep B chronically?

A

Consider starting anti-viral treatment

Very specialist

37
Q

What are the presenting features for post-hepatic jaundice?

A

Dark urine
Pale stools
Pruritus

38
Q

What causes pruritus in post-hepatic jaundice?

A

Bile salts

39
Q

What would be raised in post-hepatic jaundice?

A

Raised ALP/GGT

Year 3 Gastro (39 decks)

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