Jaundice

Question 1

yellow pigmentation of skin, sclerae and mucous membranes that results from accumulation of bilirubin within tissues

Answer 1

Jaundice

Question 2

excessive red cell breakdown which overwhelms the liver’s ability to conjugate bilirubin

This causes an unconjugated hyperbilirubinemia

Answer 2

pre-hepatic (or hemolytic) jaundice

Question 3

causes an unconjugated hyperbilirubinemia

Answer 3

pre-hepatic (or hemolytic) jaundice

Question 4

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’

Answer 4

hepatocellular (or intrahepatic) jaundice

Question 5

leads to both unconjugated and conjugated bilirubin in the blood, termed a ‘mixed picture’

Answer 5

hepatocellular (or intrahepatic) jaundice

Question 6

both unconjugated and conjugated bilirubin in the blood, termed a …….

Answer 6

mixed picture

Question 7

obstruction of biliary drainage

bilirubin that have been conjugated by the liver is not excretedwell,hence resulting conjugated hyperbilirubinemia

Answer 7

Post-hepatic (or obstructive) jaundice

Question 8

resulting conjugated hyperbilirubinemia

Answer 8

Post-hepatic (or obstructive) jaundice

Question 9

Ascites

Answer 9

evidence of complications of cirrhosis

Question 10

Dilated periumbilical veins (‘caput medusae’)

Answer 10

evidence of complications of cirrhosis

Question 11

Splenomegaly

Answer 11

evidence of complications of cirrhosis

Question 12

Hepatic encephalopathy

Answer 12

evidence of complications of cirrhosis

Question 13

Look for evidence of complications of cirrhosis, Especially ………

Answer 13

Portal HT

Question 14

Risk for NAFLD are …. (2)

Answer 14

Obesity (Metabolic syndrome)

Abdominal USG

Question 15

diagnostic for NAFLD and it can demonstrate morphologic features of cirrhosis

Answer 15

Abdominal USG

Question 16

Abdominal USG demonstrate morphologic features of cirrhosis are …… (4)

Answer 16

▪ Coarse echotexture
▪ Increased nodularity
▪ Splenomegaly
▪ Reversed flow in the portal vein

Question 17

Coarse echotexture

Answer 17

demonstrate morphologic feature of cirrhosis in Abdominal USG

Question 18

Increased nodularity

Answer 18

demonstrate morphologic feature of cirrhosis in Abdominal USG

Question 19

Splenomegaly

Answer 19

demonstrate morphologic feature of cirrhosis in Abdominal USG

Question 20

Reversed flow in the portal vein

Answer 20

demonstrate morphologic feature of cirrhosis in Abdominal USG

Question 21

To check for Risk for chronic viral hepatitis (B and C) do …….

Answer 21

hepatitis profile check

Question 22

Screen for rare causes
(4) tests

Answer 22

Antinuclear antibody (ANA)

Antimitochondrial antibodies (AMA)

Anti-Smooth Muscle Antibody (ASM)

Copper

Question 23

In difficult cases, …….. may be required to confirm the diagnosis and suggest an etiology

Answer 23

biopsy

Question 24

hemolysis features (3)

Answer 24

↑Red cell breakdown (↓Hb, ↑LDH, ↓haptoglobin)

Blood film abnormalities e.g. red cell fragments

Evidence of ↑red cell production (↑reticulocytes, polychromasia)

Question 25

No signs of CLD and Normal Liver enzymes with no features of hemolysis the likely diagnosis is …….

Answer 25

Gilbert’s syndrome

Question 26

No signs of CLD and Normal Liver enzymes consider

Answer 26

hemolysis

Question 27

No signs of CLD + rise in ALP/GGT out of proportion to ALT/AST Suggests ……..

Answer 27

cholestasis especially with pale stools/dark urine

Question 28

No signs of CLD with evidence of cholestasis on LFT Perform USG to look for …..

Answer 28

bile duct dilatation and an underlying cause e.g. gallstones

Question 29

bile duct dilatation indicating …..

Answer 29

extrahepatic cholestasis

Question 30

If USG shows dilated bile ducts but not the underlying cause do …..

Answer 30

MRCP

Question 31

provides excellent definition of the biliary tree

Answer 31

MRCP

Question 32

No signs of CLD with no evidence of cholestasis on LFT but ALT >500 U/L, ↑PT or features of encephalopathy

Answer 32

acute liver failure/encephalopathy

Question 33

Identify patients with acute liver failure/encephalopathy use ……..

Answer 33

West Haven Grading

Question 34

To Seek cause of acute liver injury ask about …. (5)

Answer 34

alcohol and paracetamol intake all recent drugs (prescribed or not) possible exposure to environmental or occupational toxins

Question 35

To Seek cause of acute liver injury check ….. (5)

Answer 35

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

Question 36

Arrange abdominal USG to exclude …… (2)

Answer 36

Budd–Chiari syndrome extensive malignant infiltration

Question 37

IgM anti-HBc

Answer 37

viral serology

Question 38

anti-HAV

Answer 38

viral serology

Question 39

anti-HEV

Answer 39

viral serology

Question 40

anti- CMV

Answer 40

viral serology

Question 41

anti-EBV

Answer 41

viral serology

Question 42

ANA

Answer 42

Autoantibodies

Question 43

ASMA

Answer 43

Autoantibodies

Question 44

LKM

Answer 44

Autoantibodies

Question 45

If all are normal then check for

Answer 45

Medications

Question 46

Paracetamol (in overdose) can cause ……….

Answer 46

Acute hepatitis

Question 47

Cocaine, ecstasy can cause ……….

Answer 47

Acute hepatitis

Question 48

Aspirin, NSAIDs can cause ……….

Answer 48

Acute hepatitis

Question 49

Halothane can cause ……….

Answer 49

Acute hepatitis

Question 50

Anti-tuberculous therapy: pyeazinamide, isoniazid, rifampicin can cause ……….

Answer 50

Acute hepatitis

Question 51

Antifungals: ketoconazole can cause ……….

Answer 51

Acute hepatitis

Question 52

Anti hypertension: methyldopa, hydralazine can cause ……….

Answer 52

Acute hepatitis

Question 53

Antibiotics: penicillins eg. flucloxacillin, co-amoxiclav, ciproflocin, macrolides eg. erthromycin can cause ……

Answer 53

Cholestasis / cholestatic hepatitis

Question 54

Chlorpromazine can cause ……….

Answer 54

Cholestasis / cholestatic hepatitis

Question 55

Azathioprine can cause ……….

Answer 55

Cholestasis / cholestatic hepatitis

Question 56

Oestrogens (including oral contraceptive pill) can cause ……….

Answer 56

Cholestasis / cholestatic hepatitis

Question 57

Amitriptyline can cause ……….

Answer 57

Cholestasis / cholestatic hepatitis

Question 58

Carbamazepine can cause ……….

Answer 58

Cholestasis / cholestatic hepatitis

Question 59

ACE inhibitors can cause ……….

Answer 59

Cholestasis / cholestatic hepatitis

Question 60

Cimetidine/ ranitidine can cause ……….

Answer 60

Cholestasis / cholestatic hepatitis

Question 61

Sulphonamides can cause ……….

Answer 61

Cholestasis / cholestatic hepatitis