Jaundice

Question 1

What is jaundice?

Answer 1

Yellow discolouration of the sclera and skin due to hyperbilirubinaemia. Bilirubin levels >50umol/L

Question 2

What is the pathway of bilirubin breakdown and excretion?

Answer 2

Catbolism of haem to bilirubin which is conjugated by the liver and excreted as bile into the small intestines. Here it is converted to urobilinogen and stercobilin. 10% of urobilinogen is reabsorbed and excreted through the kidneys. If this pathway is disrupted it can lead to jaundice.

Question 3

What are the types of jaundice?

Answer 3

Pre-hepatic
Hepatocellular
Post-hepatic

Question 4

What are some pre-hepatic causes of jaundice?

Answer 4

Haemolytic anaemia
Gilberts syndrome
Criggler-Najjar syndrome

Question 5

What are some hepatocellular causes of jaundice?

Answer 5

Alcoholic liver disease 
Viral hepatitis
Iatrogenic e.g. medication 
Hereditary haemochromatosis 
Autoimmune hepatitis 
Primary biliary cirrhosis or primary sclerosing cholangitis 
Hepatocelluar carcinoma

Question 6

What are some post hepatic causes of jaundice?

Answer 6

Intra-luminal - e.g. gallstones
Mural - e.g. cholangiocarcinoma, strictures or drug-induced cholestasis
Extra-mural - e.g. pancreatic cancer or abdominal masses(lymphomas)

Question 7

What is the significance of urine colour and stool colour in jaundice?

Answer 7

Dark (coca-cola) urine - conjugated or mixed hyperbiliruninaemias
Normal urine - unconjugated

Pale stools - obstructive picture as lack of sterocobilin

Question 8

What are some investigations that could be ordered in jaundice?

Answer 8

LFTS
Coagulation studies
FBC - aneamia, rasied MCV and thrombocytopenia all seen in liver disease
Specilaist blood tests - liver screen

Imaging:
Ultrasound abdomen
MRCP - magnetic resonance cholangiopancreatography
If inconclusive then liver biopsy

Question 9

What is the management of jaundice?

Answer 9

Treat underlying cause

Symptomatic treatment - itching - obstructive cause use cholestyramine (increase bilary drainage) or anti-histamines

Identify and manage complications - monitor coagulopathy, treat hypoglycamia orally

Decompensated chronic liver disease - laxatives +/- neomycin or rifaximin in and attempt to reduce number of ammonia-producing bacteria in the bowel.