Jaundice

Question 1

what is jaundice

Answer 1

yellow discolouration of the skin, sclera and mucous membranes
due to the deposition of bilirubin in the tissues

Question 2

when does jaundice occur

Answer 2

it develops when serum bilirubin levels are elevated about 34mmol/L

Question 3

normal level of serum bilirubin

Answer 3

5-17mmol/L

Question 4

where is jaundice seen on the body

Answer 4

bilirubin has a high affinity for elastin
jaundice is detected earliest in tissues with high elastin eg. sclera

Question 5

bilirubin is a waste product of

Answer 5

the breakdown of team from red blood cells

Question 6

how is bilirubin transported

Answer 6

transported by albumin because it is water insoluble (unconjugated bilirubin)

Question 7

how is bilirubin taken up by the liver

Answer 7

taken up passively into hepatic cytoplasm with some active uptake as well
inefficient process

Question 8

what happens to bilirubin in the liver cytoplasm

Answer 8

conjugated to bilirubin glucuronosides (conjugated bilirubin)
this is water soluble

Question 9

how does conjugated bilirubin leave the liver

Answer 9

excreted actively against the gradient by energy dependant transporters

Question 10

what happens to conjugated bilirubin after leaving the liver

Answer 10

may diffuse back into hepatic sinusoids passively
majority will be excreted into bile and then into small intestine

Question 11

how does bilirubin leave the body

Answer 11

in the terminal ileum and the colon, bacteria remove the glucuronic acid
bilirubin becomes unconjugated again and is called urobilinogen

Question 12

what happens to urobilinogen

Answer 12

further oxidation by bacteria to form stercobilin and is released in faeces

Question 13

bilirubinuria

Answer 13

conjugated bilirubin being excreted in urine

Question 14

why can’t unconjugated bilirubin be excreted in urine?

Answer 14

it is fat soluble and water insoluble therefore doesn’t dissolve in urine

Question 15

is the presence of bilirubin in urine normal?

Answer 15

no
it is a marker of conjugated hyperbilirubinaemia
can be an early sign of hepatic or biliary disease

Question 16

what may the urine of a patient with conjugated hyperbilirubinaemia look like

Answer 16

tea or cola coloured urine

Question 17

what may the urine of someone with unconjugated hyperbilirubinaemia look like

Answer 17

normal

Question 18

describe two reasons someone may be jaundiced

Answer 18

1. they are producing more bilirubin than the liver can process
2. they are unable to excrete bilirubin and it is accumulating

Question 19

why might you not be able to excrete bilirubin?

Answer 19

1. you can’t conjugate it due to enzyme dysfunction (either ineffective or lack or enzyme, or due to unhealthy hepatocytes)
2. you can’t excrete the bilirubin either due to ineffective transport out of hepatocytes or obstruction of biliary system

Question 20

what is the cause of being unable to conjugate bilirubin enzymatically?

Answer 20

caused by ineffective or lack of enzymes, which is usually a genetic issue
Crigler-Najjar syndrome type 1 is life threatening due to almost complete lack of activity
Crigler-Najjar syndrome type 2 causes significant reduction in activity

Question 21

what happens when you can’t conjugate bilirubin enzymatically

Answer 21

predominantly unconjugated jaundice

Question 22

why does hepatocyte damage cause jaundice?

Answer 22

come conjugation occurs but bilirubin leaks out of cytoplasm due to cell damage
usually inflammatory issue or related to infection
progressive damage will deplete functioning enzymes and ultimately no conjugation will occur

Question 23

what kind of jaundice does hepatocelular damage cause?

Answer 23

both conjugated and unconjugated

Question 24

what kind of jaundice does ineffective or lack of enzymes cause?

Answer 24

predominantly unconjugated

Question 25

why might you not be able to transport bilirubin out of hepatocytes

Answer 25

a problem with transporters which is genetic eg. Dublin-johnson syndrome rotor syndrome

Question 26

what happens when you can't transport bilirubin out of hepatocytes

Answer 26

conjugated bilirubin accumulates causing jaundice with conjugated bilirubin

Question 27

why might you be unable to excrete bilirubin into the intestine

Answer 27

obstruction of biliary system must affect a large portion of liver drainage to be a problem

Question 28

what type of jaundice to you get when the biliary system is obstructed

Answer 28

predominantly unconjugated

Question 29

jaundice in neonate

Answer 29

can accumulate and cause brain damage kernicterus

Question 30

what is the type of brain damage caused to neonates due to accumulation of bilirubin in blood

Answer 30

kernicterus

Question 31

jaundice with abdominal pain

Answer 31

stone

Question 32

jaundice with high temp

Answer 32

infection

Question 33

jaundice with weight loss

Answer 33

cancer

Question 34

jaundice with bleeding

Answer 34

coagulopathy

Question 35

jaundice with ascites

Answer 35

liver failure

Question 36

jaundice and low blood pressure

Answer 36

sepsis

Question 37

jaundice and portal hypertension

Answer 37

cirrhosis

Question 38

jaundice and itching

Answer 38

obstructive jaundice

Question 39

jaundice with fatigue

Answer 39

haemolytic anaemia

Question 40

4 most common causes of jaundice

Answer 40

gallstone infectious hepatitis carcinoma head of pancreas haemolytic anaemia

Question 41

additional symptoms in gallstones

Answer 41

episodic indigestion flatulent dyspepsia pruritus

Question 42

additional symptoms in infectious hepatitis

Answer 42

anorexia, nausea, malaise

Question 43

additional symptoms in cancer in head of pancreas

Answer 43

anorexia, weight loss, pruritus

Question 44

additional symptoms in haemolytic jaundice

Answer 44

general malaise, dyspnoea, weight loss

Question 45

Charcot's triad

Answer 45

RUQ pain jaundice fever

Question 46

raynold's pentad

Answer 46

RUQ pain jaundice fever hypotension altered mental status

Question 47

Courvoisier's sign/law

Answer 47

enlarged, non tender, and palpable gallbladder in patients with obstructive jaundice due to tumours of the biliary tree or pancreatic head

Question 48

Murphy's sign

Answer 48

positive if patient experiences RUQ tenderness and stops breathing upon inspiration as the gallbladder moves down in contact with the examiner's hand suggestive of acute cholecystitis

Question 49

pre hepatic cause of jaundice

Answer 49

excessive haemolysis leading to increased bilirubin delivered to the liver

Question 50

intrahpetic cause of jaundice

Answer 50

defective conjugation impaired cellular uptake abnormal secretion

Question 51

post hepatic causes of jaundice

Answer 51

mechanical obstruction of bile flow causing impaired secretion

Question 52

nature of pre hepatic jaundice

Answer 52

unconjugated normal urine and stool colour no pruritus

Question 53

nature of intrahepatic jaundice

Answer 53

unconjugated and conjugated dark urine normal stool no pruritus

Question 54

nature of post hepatic jaundice

Answer 54

conjugated dark urine acholic faeces pruritus

Question 55

what to look for on FBC

Answer 55

anaemia (haemolysis and chronic disease) infection (high WCC) platelet function (low in cirrhosis)

Question 56

what to look for on U&Es

Answer 56

assess renal and electrolyte status severe sepsis can damage kidney

Question 57

what to check for with lipase

Answer 57

assess associated pancreas obstruction

Question 58

what to look for with CRP

Answer 58

indicated inflammation and complication of inflammation (but has delayed response)

Question 59

extra hepatic cholestasis

Answer 59

in the duct: stones/ foreign bodies / parasites in the wall: atresia/ traumatic stricture/ tumour/ PSC outside the duct: 1° or 2° tumour/pancreatitis

Question 60

benign causes of extra hepatic cholestasis

Answer 60

choledocholithiasis mitizzi syndrome bile duct stricture chronic pancreatitis primary sclerosing cholangitis choledochal cyst ischaemic strictures

Question 61

malignant causes of extra hepatic cholestasis

Answer 61

pancreatic cancer or ampullarf cancer bile duct cancer (cholangiocarcinoma)

Question 62

using ultrasound to image cholestasis

Answer 62

assess for signs of obstruction (dilatation of biliary tree and at what level) assess for gall stones in gall bladder or bile duct assess liver parenchyma for massess, oedema, contour measure fibroids (sign of cirrhosis)

Question 63

endoscopic ultrasound for imaging cholestasis

Answer 63

allows for a closer view of the ampulla, bile duct and pancreas can contain biopsies via core needle

Question 64

abdo CT scan to investigate cholestasis

Answer 64

good resolution helps assess anatomy and level of obstruction may not always seen stones as they are radiopaque (cholesterol) very good for staging cancer needs contrast and had radiation hazard to patient

Question 65

cholangiogram is used for

Answer 65

assessing anatomy of bile duct and look for obstruction and cause

Question 66

ERCP

Answer 66

side viewing endoscope passed into duodenum to view ampulla of Vater cannula is placed through ampulla of Vater contrast injected and x-rays taken to evaluate latency of the ducts a stone can be retrieved after incising the sphincter sometimes a stent can be placed to bypass the obstruction to allow bile drainage