Jaundice Flashcards
yellow pigmentation of skin, sclerae and mucous membranes that results from accumulation of bilirubin within tissues
Jaundice
excessive red cell breakdown which overwhelms the liver’s ability to conjugate bilirubin
This causes an unconjugated hyperbilirubinemia
pre-hepatic (or hemolytic) jaundice
causes an unconjugated hyperbilirubinemia
pre-hepatic (or hemolytic) jaundice
dysfunction of the hepatic cells
liver loses the ability to conjugate bilirubin, but in cases where it also may become cirrhotic, it compresses the intra- hepatic portions of the biliary tree to cause a degree of obstruction
This leads to both unconjugated and conjugated bilirubin in the blood, termed a ‘mixed picture’
hepatocellular (or intrahepatic) jaundice
leads to both unconjugated and conjugated bilirubin in the blood, termed a ‘mixed picture’
hepatocellular (or intrahepatic) jaundice
both unconjugated and conjugated bilirubin in the blood, termed a …….
mixed picture
obstruction of biliary drainage
bilirubin that have been conjugated by the liver is not excretedwell,hence resulting conjugated hyperbilirubinemia
Post-hepatic (or obstructive) jaundice
resulting conjugated hyperbilirubinemia
Post-hepatic (or obstructive) jaundice
Ascites
evidence of complications of cirrhosis
Dilated periumbilical veins (‘caput medusae’)
evidence of complications of cirrhosis
Splenomegaly
evidence of complications of cirrhosis
Hepatic encephalopathy
evidence of complications of cirrhosis
Look for evidence of complications of cirrhosis, Especially ………
Portal HT
Risk for NAFLD are …. (2)
Obesity (Metabolic syndrome)
Abdominal USG
diagnostic for NAFLD and it can demonstrate morphologic features of cirrhosis
Abdominal USG
Abdominal USG demonstrate morphologic features of cirrhosis are …… (4)
▪ Coarse echotexture
▪ Increased nodularity
▪ Splenomegaly
▪ Reversed flow in the portal vein
Coarse echotexture
demonstrate morphologic feature of cirrhosis in Abdominal USG
Increased nodularity
demonstrate morphologic feature of cirrhosis in Abdominal USG
Splenomegaly
demonstrate morphologic feature of cirrhosis in Abdominal USG
Reversed flow in the portal vein
demonstrate morphologic feature of cirrhosis in Abdominal USG
To check for Risk for chronic viral hepatitis (B and C) do …….
hepatitis profile check
Screen for rare causes
(4) tests
Antinuclear antibody (ANA)
Antimitochondrial antibodies (AMA)
Anti-Smooth Muscle Antibody (ASM)
Copper
In difficult cases, …….. may be required to confirm the diagnosis and suggest an etiology
biopsy
hemolysis features (3)
↑Red cell breakdown (↓Hb, ↑LDH, ↓haptoglobin)
Blood film abnormalities e.g. red cell fragments
Evidence of ↑red cell production (↑reticulocytes, polychromasia)
No signs of CLD and Normal Liver enzymes with no features of hemolysis
the likely diagnosis is …….
Gilbert’s syndrome
No signs of CLD and Normal Liver enzymes consider
hemolysis
No signs of CLD
+ rise in ALP/GGT out of proportion to ALT/AST
Suggests ……..
cholestasis
especially with pale stools/dark urine
No signs of CLD with evidence of cholestasis on LFT
Perform USG to look for …..
bile duct dilatation
and an underlying cause e.g. gallstones
bile duct dilatation indicating …..
extrahepatic cholestasis
If USG shows dilated bile ducts but not the underlying cause do …..
MRCP
provides excellent definition of the biliary tree
MRCP
No signs of CLD with no evidence of cholestasis on LFT but ALT >500 U/L, ↑PT or features of encephalopathy
acute liver failure/encephalopathy
Identify patients with acute liver failure/encephalopathy use ……..
West Haven Grading
To Seek cause of acute liver injury ask about …. (5)
alcohol and paracetamol intake
all recent drugs (prescribed or not)
possible exposure to environmental or occupational toxins
To Seek cause of acute liver injury check ….. (5)
Check viral serology (IgM anti-HBc, anti-HAV, anti- HEV, anti- CMV, anti-EBV)
Serum ceruloplasmin
Autoantibodies (ANA, ASMA, LKM)
Full toxicology screen
Arrange abdominal USG
Arrange abdominal USG to exclude …… (2)
Budd–Chiari syndrome
extensive malignant infiltration
IgM anti-HBc
viral serology
anti-HAV
viral serology
anti-HEV
viral serology
anti- CMV
viral serology
anti-EBV
viral serology
ANA
Autoantibodies
ASMA
Autoantibodies
LKM
Autoantibodies
If all are normal then check for
Medications
Paracetamol (in overdose) can cause ……….
Acute hepatitis
Cocaine, ecstasy can cause ……….
Acute hepatitis
Aspirin, NSAIDs can cause ……….
Acute hepatitis
Halothane can cause ……….
Acute hepatitis
Anti-tuberculous therapy: pyeazinamide, isoniazid, rifampicin
can cause ……….
Acute hepatitis
Antifungals: ketoconazole can cause ……….
Acute hepatitis
Anti hypertension: methyldopa, hydralazine
can cause ……….
Acute hepatitis
Antibiotics: penicillins eg. flucloxacillin,
co-amoxiclav, ciproflocin,
macrolides eg. erthromycin
can cause ……
Cholestasis / cholestatic hepatitis
Chlorpromazine can cause ……….
Cholestasis / cholestatic hepatitis
Azathioprine can cause ……….
Cholestasis / cholestatic hepatitis
Oestrogens (including oral contraceptive pill) can cause ……….
Cholestasis / cholestatic hepatitis
Amitriptyline can cause ……….
Cholestasis / cholestatic hepatitis
Carbamazepine can cause ……….
Cholestasis / cholestatic hepatitis
ACE inhibitors can cause ……….
Cholestasis / cholestatic hepatitis
Cimetidine/ ranitidine can cause ……….
Cholestasis / cholestatic hepatitis
Sulphonamides can cause ……….
Cholestasis / cholestatic hepatitis
