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Jaundice Flashcards

1
Q

What are the normal serum bilirubin levels, and at what level does jaundice become clinically evident?

A

Normal serum bilirubin: 0.3–1.0 mg/dL
Conjugated (direct): 0.1–0.3 mg/dL
Unconjugated (indirect): 0.2–0.7 mg/dL
Jaundice becomes clinically evident when serum bilirubin exceeds 3 mg/dL.

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2
Q

Where should you look to assess for jaundice in a patient?

A

Upper bulbar conjunctiva
Base of the tongue
Mucous membrane of the palate
Palms and soles
General skin surface

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3
Q

Describe the steps of bilirubin metabolism and excretion.

A

Formation of Unconjugated Bilirubin:
Produced from hemoglobin breakdown during hemolysis.
Binds to albumin for transport to the liver.

Liver Processing:
Unconjugated bilirubin is conjugated with glucuronic acid to become water-soluble.

Excretion:
Conjugated bilirubin is excreted into bile, enters the intestine, and is converted to urobilinogen by bacteria.
90% of urobilinogen becomes stercobilin (feces), and 10% is reabsorbed and excreted in urine as urobilin.

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4
Q

What are the causes of unconjugated hyperbilirubinemia?

A

Increased production: Hemolysis
Decreased hepatic uptake/conjugation: Gilbert’s syndrome, drugs

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5
Q

What are the causes of conjugated hyperbilirubinemia?

A

Hepatocellular disease: Viral hepatitis (A, B, C, D, E), alcohol, drugs (e.g., acetaminophen), toxins (e.g., vinyl chloride).
Cholestatic disease:
Intrahepatic: Primary biliary cirrhosis, sepsis.
Extrahepatic: Stones, tumors, primary sclerosing cholangitis.

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6
Q

What are the key radiological investigations for jaundice?

A

Ultrasound (US)
CT scan
Cholangiography
Biopsy

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7
Q

What is ERCP, and what are its indications?

A

Definition: Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is a procedure combining endoscopy and fluoroscopy to diagnose and treat biliary and pancreatic duct disorders.

Indications:
Bile duct stones (choledocholithiasis)
Pancreatitis due to duct obstruction
Biliary or pancreatic duct strictures
Biliary leakage after surgery
Suspected tumors (bile duct, pancreatic cancer)

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8
Q

What are the risks and complications of ERCP?

A

Pancreatitis (most common)
Infection (cholangitis, sepsis)
Bleeding (post-sphincterotomy)
Perforation of the intestine or ducts
Allergic reaction to contrast dye

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9
Q

What is the Triad of Charcot, and what does it indicate?

A

Triad of Charcot:
Ictericia (jaundice)
Dolor abdominal (abdominal pain)
Fiebre (fever)

Indication: Suggests cholangitis (biliary infection).

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10
Q

What is the Pentad of Reynolds, and why is it significant?

A

Pentad of Reynolds:
Confusión (confusion)
Hipotensión (hypotension)
Dolor abdominal (abdominal pain)
Ictericia (jaundice)
Fiebre o escalofríos (fever or chills)

Significance: Indicates severe cholangitis, which can progress rapidly to septic shock and requires urgent treatment.

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11
Q

What are the key laboratory findings in a patient with jaundice?

A

Bilirubin levels:
Total bilirubin: Elevated
Direct (conjugated): Elevated in hepatocellular or cholestatic disease
Indirect (unconjugated): Elevated in hemolysis or Gilbert’s syndrome

Liver function tests:
AST (TGP), ALT (TGO): Elevated in hepatocellular disease
GGT, ALP: Elevated in cholestatic disease
Albumin: May be decreased in chronic liver disease.

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12
Q

What is the significance of white stools (acolia) and dark urine (coluria) in jaundice?

A

White stools (acolia): Indicate a lack of bile excretion, often due to biliary obstruction.
Dark urine (coluria): Caused by excess bilirubin excretion in urine, seen in conjugated hyperbilirubinemia.

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13
Q

What is the gold standard for diagnosing bile duct stones?

A

ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is the gold standard for diagnosing and treating bile duct stones.

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14
Q

What is the normal thickness of the gallbladder wall and common bile duct (CBD) on ultrasound?

A

Gallbladder wall: Normal thickness ≤ 4 mm.
Common bile duct (CBD): Normal diameter 2–10 mm.

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15
Q

What is the Whipple procedure, and when is it performed?

A

Whipple procedure (Pancreaticoduodenectomy): Surgical removal of the head of the pancreas, duodenum, gallbladder, and part of the bile duct.

Indication: Performed for tumors of the pancreas, bile duct, or duodenum.

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16
Q

What is the significance of elevated GGT and ALP in jaundice?

A

Elevated GGT and ALP suggest cholestasis (biliary obstruction or intrahepatic cholestasis).

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17
Q

What is the first step in evaluating a jaundiced patient?

A

First step: Order a hepatic function panel (liver function tests) to assess bilirubin levels (total, direct, indirect), AST, ALT, ALP, GGT, and albumin.

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18
Q

What is the significance of colangioresonance (MRCP) in biliary disease?

A

MRCP (Magnetic Resonance Cholangiopancreatography): Non-invasive imaging to visualize biliary and pancreatic ducts, useful for detecting dilatation, stones, or strictures.

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19
Q

What is the treatment for bile duct stones if ERCP is unavailable?

A

Surgical exploration of the bile duct with placement of a T-tube to prevent stenosis.

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20
Q

What is the significance of elevated transaminases (AST, ALT) in alcoholic hepatitis?

A

Elevated AST and ALT (AST > ALT) with a ratio > 2:1 is characteristic of alcoholic hepatitis.

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21
Q

What is the significance of elevated total bilirubin with normal direct bilirubin?

A

Suggests unconjugated hyperbilirubinemia, caused by:

  • Increased hemolysis (e.g., hemolytic anemia).
  • Impaired hepatic uptake or conjugation (e.g., Gilbert’s syndrome).
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22
Q

What is the significance of elevated direct (conjugated) bilirubin?

A

Indicates conjugated hyperbilirubinemia, caused by:

  • Hepatocellular disease (e.g., hepatitis, cirrhosis).
  • Cholestatic disease (intrahepatic or extrahepatic obstruction).
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23
Q

What is the difference between intrahepatic and extrahepatic cholestasis?

A

Intrahepatic cholestasis: Obstruction within the liver (e.g., primary biliary cirrhosis, sepsis).

Extrahepatic cholestasis: Obstruction outside the liver (e.g., gallstones, tumors, primary sclerosing cholangitis).

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24
Q

What is the significance of elevated GGT and ALP in cholestasis?

A

GGT and ALP elevation indicates cholestasis:

  • GGT is specific to biliary disease.
  • ALP is elevated in both biliary and bone disease, but GGT confirms a biliary source.
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25
Q

What is the significance of white stools (acolia) in jaundice?

A

Acolia indicates complete biliary obstruction, as no bilirubin reaches the intestines to form stercobilin (brown pigment in feces).

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26
Q

What is the significance of dark urine (coluria) in jaundice?

A

Coluria indicates conjugated hyperbilirubinemia, as excess conjugated bilirubin is excreted in the urine, giving it a dark, Coca-Cola-like appearance.

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27
Q

What is the significance of elevated AST and ALT in liver disease?

A

AST and ALT elevation indicates hepatocellular injury:

  • AST > ALT (2:1 ratio) suggests alcoholic hepatitis.
  • ALT > AST suggests viral hepatitis or other causes of liver damage.
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28
Q

What is the significance of a dilated common bile duct (CBD) on ultrasound?

A

CBD dilation (>10 mm) suggests biliary obstruction, which may be caused by:

  • Stones (choledocholithiasis).
  • Tumors (e.g., pancreatic cancer).
  • Strictures (e.g., primary sclerosing cholangitis).
29
Q

What is the significance of a thickened gallbladder wall on ultrasound?

A

Gallbladder wall thickening (>4 mm) suggests:

  • Acute cholecystitis.
  • Chronic inflammation or other systemic conditions (e.g., heart failure, hypoalbuminemia).
30
Q

What is the significance of elevated urobilinogen in urine?

A

Elevated urobilinogen suggests:

  • Increased bilirubin production (e.g., hemolysis).
  • Impaired liver function (e.g., hepatitis, cirrhosis).
31
Q

What is the significance of absent urobilinogen in urine?

A

Absent urobilinogen suggests complete biliary obstruction, as no bilirubin reaches the intestines to form urobilinogen.

32
Q

What is the significance of elevated indirect bilirubin with normal direct bilirubin?

A

Suggests unconjugated hyperbilirubinemia, caused by:

  • Hemolysis (e.g., hemolytic anemia).
  • Impaired hepatic uptake or conjugation (e.g., Gilbert’s syndrome).
33
Q

What is the significance of elevated direct bilirubin with normal indirect bilirubin?

A

Suggests conjugated hyperbilirubinemia, caused by:

  • Hepatocellular disease (e.g., hepatitis, cirrhosis).
  • Cholestatic disease (intrahepatic or extrahepatic obstruction).
34
Q

What is the significance of elevated ALP with normal GGT?

A

Suggests a non-biliary source of ALP elevation, such as:

  • Bone disease (e.g., Paget’s disease).
  • Pregnancy (placental ALP).
35
Q

What is the significance of elevated ALP with elevated GGT?

A

Confirms biliary disease (e.g., cholestasis, biliary obstruction).

36
Q

What is the significance of elevated bilirubin with normal liver enzymes?

A

Suggests pre-hepatic jaundice (e.g., hemolysis) or Gilbert’s syndrome.

37
Q

What is the significance of elevated bilirubin with elevated liver enzymes?

A

Suggests hepatic jaundice (e.g., hepatitis, cirrhosis) or cholestasis.

38
Q

What is the significance of elevated bilirubin with elevated ALP and GGT?

A

Suggests cholestasis (intrahepatic or extrahepatic obstruction).

39
Q

What is the significance of elevated bilirubin with elevated AST and ALT?

A

Suggests hepatocellular injury (e.g., viral hepatitis, alcoholic hepatitis).

40
Q

What is the significance of elevated bilirubin with normal ALP and GGT?

A

Suggests pre-hepatic jaundice (e.g., hemolysis) or Gilbert’s syndrome.

41
Q

What is the significance of elevated bilirubin with elevated ALP and normal GGT?

A

Suggests a non-biliary source of ALP elevation (e.g., bone disease, pregnancy).

42
Q

What is the significance of elevated bilirubin with elevated GGT and normal ALP?

A

Suggests biliary disease (e.g., cholestasis, biliary obstruction).

43
Q

What is the significance of elevated bilirubin with elevated AST and normal ALT?

A

Suggests alcoholic hepatitis (AST:ALT ratio > 2:1).

44
Q

What is the significance of elevated bilirubin with elevated ALT and normal AST?

A

Suggests viral hepatitis or other causes of hepatocellular injury.

45
Q

What is the significance of elevated total bilirubin with normal direct bilirubin?

A

Suggests unconjugated hyperbilirubinemia, caused by:

  • Increased hemolysis (e.g., hemolytic anemia).
  • Impaired hepatic uptake or conjugation (e.g., Gilbert’s syndrome).
46
Q

What is the significance of elevated direct (conjugated) bilirubin?

A

Indicates conjugated hyperbilirubinemia, caused by:

  • Hepatocellular disease (e.g., hepatitis, cirrhosis).
  • Cholestatic disease (intrahepatic or extrahepatic obstruction).
47
Q

What is the difference between intrahepatic and extrahepatic cholestasis?

A

Intrahepatic cholestasis: Obstruction within the liver (e.g., primary biliary cirrhosis, sepsis).

Extrahepatic cholestasis: Obstruction outside the liver (e.g., gallstones, tumors, primary sclerosing cholangitis).

48
Q

What is the significance of elevated GGT and ALP in cholestasis?

A

GGT and ALP elevation indicates cholestasis:

  • GGT is specific to biliary disease.
  • ALP is elevated in both biliary and bone disease, but GGT confirms a biliary source.
49
Q

What is the significance of white stools (acolia) in jaundice?

A

Acolia indicates complete biliary obstruction, as no bilirubin reaches the intestines to form stercobilin (brown pigment in feces).

50
Q

What is the significance of dark urine (coluria) in jaundice?

A

Coluria indicates conjugated hyperbilirubinemia, as excess conjugated bilirubin is excreted in the urine, giving it a dark, Coca-Cola-like appearance.

51
Q

What is the significance of elevated AST and ALT in liver disease?

A

AST and ALT elevation indicates hepatocellular injury:

  • AST > ALT (2:1 ratio) suggests alcoholic hepatitis.
  • ALT > AST suggests viral hepatitis or other causes of liver damage.
52
Q

What is the significance of a dilated common bile duct (CBD) on ultrasound?

A

CBD dilation (>10 mm) suggests biliary obstruction, which may be caused by:

  • Stones (choledocholithiasis).
  • Tumors (e.g., pancreatic cancer).
  • Strictures (e.g., primary sclerosing cholangitis).
53
Q

What is the significance of a thickened gallbladder wall on ultrasound?

A

Gallbladder wall thickening (>4 mm) suggests:

  • Acute cholecystitis.
  • Chronic inflammation or other systemic conditions (e.g., heart failure, hypoalbuminemia).
54
Q

What is the significance of elevated urobilinogen in urine?

A

Elevated urobilinogen suggests:

  • Increased bilirubin production (e.g., hemolysis).
  • Impaired liver function (e.g., hepatitis, cirrhosis).
55
Q

What is the significance of absent urobilinogen in urine?

A

Absent urobilinogen suggests complete biliary obstruction, as no bilirubin reaches the intestines to form urobilinogen.

56
Q

What is the significance of elevated indirect bilirubin with normal direct bilirubin?

A

Suggests unconjugated hyperbilirubinemia, caused by:

  • Hemolysis (e.g., hemolytic anemia).
  • Impaired hepatic uptake or conjugation (e.g., Gilbert’s syndrome).
57
Q

What is the significance of elevated direct bilirubin with normal indirect bilirubin?

A

Suggests conjugated hyperbilirubinemia, caused by:

  • Hepatocellular disease (e.g., hepatitis, cirrhosis).
  • Cholestatic disease (intrahepatic or extrahepatic obstruction).
58
Q

What is the significance of elevated ALP with normal GGT?

A

Suggests a non-biliary source of ALP elevation, such as:

  • Bone disease (e.g., Paget’s disease).
  • Pregnancy (placental ALP).
59
Q

What is the significance of elevated ALP with elevated GGT?

A

Confirms biliary disease (e.g., cholestasis, biliary obstruction).

60
Q

What is the significance of elevated bilirubin with normal liver enzymes?

A

Suggests pre-hepatic jaundice (e.g., hemolysis) or Gilbert’s syndrome.

61
Q

What is the significance of elevated bilirubin with elevated liver enzymes?

A

Suggests hepatic jaundice (e.g., hepatitis, cirrhosis) or cholestasis.

62
Q

What is the significance of elevated bilirubin with elevated ALP and GGT?

A

Suggests cholestasis (intrahepatic or extrahepatic obstruction).

63
Q

What is the significance of elevated bilirubin with elevated AST and ALT?

A

Suggests hepatocellular injury (e.g., viral hepatitis, alcoholic hepatitis).

64
Q

What is the significance of elevated bilirubin with normal ALP and GGT?

A

Suggests pre-hepatic jaundice (e.g., hemolysis) or Gilbert’s syndrome.

65
Q

What is the significance of elevated bilirubin with elevated ALP and normal GGT?

A

Suggests a non-biliary source of ALP elevation (e.g., bone disease, pregnancy).

66
Q

What is the significance of elevated bilirubin with elevated GGT and normal ALP?

A

Suggests biliary disease (e.g., cholestasis, biliary obstruction).

67
Q

What is the significance of elevated bilirubin with elevated AST and normal ALT?

A

Suggests alcoholic hepatitis (AST:ALT ratio > 2:1).

68
Q

What is the significance of elevated bilirubin with elevated ALT and normal AST?

A

Suggests viral hepatitis or other causes of hepatocellular injury.

Oolong (6 decks)

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