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Surgery > Jaundice > Flashcards

Jaundice Flashcards

1
Q

what is jaundice

A

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

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2
Q

when does jaundice occur

A

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

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3
Q

normal level of serum bilirubin

A

5-17mmol/L

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4
Q

where is jaundice seen on the body

A

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

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5
Q

bilirubin is a waste product of

A

the breakdown of team from red blood cells

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6
Q

how is bilirubin transported

A

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

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7
Q

how is bilirubin taken up by the liver

A

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

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8
Q

what happens to bilirubin in the liver cytoplasm

A

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

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9
Q

how does conjugated bilirubin leave the liver

A

excreted actively against the gradient by energy dependant transporters

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10
Q

what happens to conjugated bilirubin after leaving the liver

A

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

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11
Q

how does bilirubin leave the body

A

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

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12
Q

what happens to urobilinogen

A

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

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13
Q

bilirubinuria

A

conjugated bilirubin being excreted in urine

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14
Q

why can’t unconjugated bilirubin be excreted in urine?

A

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

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15
Q

is the presence of bilirubin in urine normal?

A

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

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16
Q

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

A

tea or cola coloured urine

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17
Q

what may the urine of someone with unconjugated hyperbilirubinaemia look like

A

normal

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18
Q

describe two reasons someone may be jaundiced

A
  1. they are producing more bilirubin than the liver can process
  2. they are unable to excrete bilirubin and it is accumulating
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19
Q

why might you not be able to excrete bilirubin?

A
  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
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20
Q

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

A

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

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21
Q

what happens when you can’t conjugate bilirubin enzymatically

A

predominantly unconjugated jaundice

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22
Q

why does hepatocyte damage cause jaundice?

A

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

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23
Q

what kind of jaundice does hepatocelular damage cause?

A

both conjugated and unconjugated

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24
Q

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

A

predominantly unconjugated

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25
Q

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

A

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

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26
Q

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

A

conjugated bilirubin accumulates causing jaundice with conjugated bilirubin

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27
Q

why might you be unable to excrete bilirubin into the intestine

A

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

28
Q

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

A

predominantly unconjugated

29
Q

jaundice in neonate

A

can accumulate and cause brain damage
kernicterus

30
Q

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

A

kernicterus

31
Q

jaundice with abdominal pain

A

stone

32
Q

jaundice with high temp

A

infection

33
Q

jaundice with weight loss

A

cancer

34
Q

jaundice with bleeding

A

coagulopathy

35
Q

jaundice with ascites

A

liver failure

36
Q

jaundice and low blood pressure

A

sepsis

37
Q

jaundice and portal hypertension

A

cirrhosis

38
Q

jaundice and itching

A

obstructive jaundice

39
Q

jaundice with fatigue

A

haemolytic anaemia

40
Q

4 most common causes of jaundice

A

gallstone
infectious hepatitis
carcinoma head of pancreas
haemolytic anaemia

41
Q

additional symptoms in gallstones

A

episodic indigestion
flatulent dyspepsia
pruritus

42
Q

additional symptoms in infectious hepatitis

A

anorexia, nausea, malaise

43
Q

additional symptoms in cancer in head of pancreas

A

anorexia, weight loss, pruritus

44
Q

additional symptoms in haemolytic jaundice

A

general malaise, dyspnoea, weight loss

45
Q

Charcot’s triad

A

RUQ pain
jaundice
fever

46
Q

raynold’s pentad

A

RUQ pain
jaundice
fever
hypotension
altered mental status

47
Q

Courvoisier’s sign/law

A

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

48
Q

Murphy’s sign

A

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

49
Q

pre hepatic cause of jaundice

A

excessive haemolysis leading to increased bilirubin delivered to the liver

50
Q

intrahpetic cause of jaundice

A

defective conjugation
impaired cellular uptake
abnormal secretion

51
Q

post hepatic causes of jaundice

A

mechanical obstruction of bile flow causing impaired secretion

52
Q

nature of pre hepatic jaundice

A

unconjugated
normal urine and stool colour
no pruritus

53
Q

nature of intrahepatic jaundice

A

unconjugated and conjugated
dark urine
normal stool
no pruritus

54
Q

nature of post hepatic jaundice

A

conjugated
dark urine
acholic faeces
pruritus

55
Q

what to look for on FBC

A

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

56
Q

what to look for on U&Es

A

assess renal and electrolyte status
severe sepsis can damage kidney

57
Q

what to check for with lipase

A

assess associated pancreas obstruction

58
Q

what to look for with CRP

A

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

59
Q

extra hepatic cholestasis

A

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

60
Q

benign causes of extra hepatic cholestasis

A

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

61
Q

malignant causes of extra hepatic cholestasis

A

pancreatic cancer or ampullarf cancer
bile duct cancer (cholangiocarcinoma)

62
Q

using ultrasound to image cholestasis

A

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)

63
Q

endoscopic ultrasound for imaging cholestasis

A

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

64
Q

abdo CT scan to investigate cholestasis

A

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

65
Q

cholangiogram is used for

A

assessing anatomy of bile duct and look for obstruction and cause

66
Q

ERCP

A

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

Surgery (18 decks)

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