Jaundice

Question 1

Important Hx points in Precenting complaint

Answer 1

How did you discover the change in colour? Was it you or someone else?

Could you tell me when and how it started?

ONSET AND DURATION

Has it been intermittent or constant?
	Has it been getting worse?
Fevers
Pains
Pruritus
Bruising

Any other symptoms?
Any recent illnesses?

Any previous episodes of jaundice?
Family members or contacts with similar symptoms?

Question 2

Acute onset jaundice (days) DDx

Answer 2

Gallstones
Acute hepatitis
Acute Budd-Chiari
Haemolysis

Question 3

Subacute onset of jaundice (weeks-months) DDx

Answer 3

Pancreatic / hepatobiliary malignancy
Intrahepatic cholestasis
Right sided heart failure

Question 4

Recurrent episodes of jaudice DDx

Answer 4

Gallstones

Disorder of bile transport (Gilbert’s)

Question 5

features if gallstones/biliary causes

Answer 5

Abdominal pain (RUQ)
	Pale stools
	Itching
	Change in bowel habit: diarrhoea
	Dark urine

Question 6

Features of liver causes

Answer 6

Abdominal swelling
Ankle swelling
Bleeding/ bruising

Question 7

Features of autoimmune causes

Answer 7

Joint pains

Rashes

Question 8

Hepatitis B and C risk factors

Answer 8

IVDU
	Blood transfusions
	Tattoos
	Piercings
	Needlestick injuries if healthcare professional

SIGNPOST Sexual history:
Number of sexual partners 
New sexual partners: do you have a regular sexual partner?
What type of contraception do you use?

Question 9

Hepatitis A risk factors

Answer 9

Recent travel
Shellfish eating
COntact with affected individuals

Question 10

Red flags

Answer 10

No abdo pain

Weight loss

Question 11

PMHx

Answer 11

Previous jaundice
	Previous surgery
	Autoimmune conditions (PBC, AIH)
	UC/ or IBD for(PSC)
	Haemolytic anaemia

Question 12

drugs

Answer 12

Haemolysis
• Antimalarials (eg dapsone)

Hepatitis
• Paracetamol overdose 
• Isoniazid, rifampicin, pyrazinamide
• Monoamine oxidase inhibitors
• Sodium valproate
• Halothane
• Statins

Cholestasis
• Flucloxacillin (may be weeks after 
•Fusidic acid, co-amoxiclav, nitrofurantoin
• Steroids (anabolic; the Pill)
• Sulfonylureas
• Prochlorperazine

• Chlorpromazine

Question 13

What are the causes of BUDD-CHIARI?

Answer 13

Hypercoagulabloe states: pregnancy, contraceptive pill, PRV, essential thrombocythaemia, antiphospholipid syndrome, Protein C, S or antithrombin III deficiency
HCC
Hepatic infections such as hydatid disease
Renal and adrenal tumours
Congenital venous webs

Question 14

What is BUDD-CHiari>

Answer 14

Characterised by thrombosis of the hepatic veins, resulting in: abdo pain, ascites, hepatomegaly
Jaundice usually absent
No cutaneus features of liver disease as the onset of liver failure is rapid
Liver is smoothly enlarged and tender

Question 15

When can liver be palpable without being enlarged?

Answer 15

Emphysema – overinflated lungs#
Reidel’s lobe
R-sided pleural effusion

Question 16

What are the causes of hepatomegaly?

Answer 16

Cirrhosis – look for signs of chronic liver disease/
Carcinoma – usually secondary tumours
cCF – liver is firm, smooth, may be pulsatile if tricuspid regurg
Infections – HAV, HBV, HCV, EBV, leptospirosis, pyogenic
Metabolic cuases: haemochromatosis, Wilson’s
PBC
Lymphoproliferative disorders
Sarcoidosis, amyloidosis
Budd-Chiari syndrome

Question 17

What is Hep C?

Answer 17

It is an RNA virus. Main routes of transmission: through needles in IVDU, blood transfusions, blood products. Sexual transmission is low. Complicaitons: liver cirrhosis, HCC. Tx: interferon-alpha and ribavarin.

Question 18

What is Hep B>

Answer 18

It is a DNA virus
Transmitted perenterally or by sexual contact. Complications include liver cirrhosis and HCC. Tx with interferon-alpha is successful in about 40% of cases. SEs include flu-like sx, depression, fatigue, haematological abnormalities. Other drugs: lamivudine, adefovir, entecavir.

Question 19

What is AIH?

Answer 19

More common in females. Associated with autoimmune conditions such as type 1 diabetes, thyroiditis, RA, scleroderma, IBD.
Presents with fatigue, RUQ pain, arthralgia, abnormal LFTs
Tx with immunosuppressive drugs (steroids, azathioprine)
80% are associated with HLA B8/DRw£, ANA, anti-smooth muscle antibodies and polyclonal hypergammaglobulinaemia.

Question 20

WHat is Gilbert’s syndorme?

Answer 20

Autosomal dominant condition resulting in reduced levels of the enzyme glucuronyltransferase. This results in reduced conjugation of bilirubin.→ lvls of unconjugated bilirubin ↑. Precipitated by stress, fasting, infection. Condition is benign and asymptomatic, no treatment necessary

Question 21

What causes jaundice?

Answer 21

The causes can be classified as Pre-hepatic , hepatic and post-hepatic causes.
Prehepatic: when bilirubin production is increased through exercise, haemoglobin breakdown (haemolysis) or myoglobin breakdown (rhabdomyolisis). Haemolysis can be intrinsic where the RBC is defective or extrinsic, where RBC is normal.
Hepatic: bilirubin increases in any process in which cell necrosis reduces liver’s ability to metabolize and excrete bilirubin such as:
Acute hepatitis and liver cirrhosis of any cause, enzymopathies such as Gilbert’s syndrome and Crigler-Najjar syndrome.

Posthepatic: when there is an obstruction of biliary drainage system causing their reflux to blood. Within the liver: PBC, PSC, drugs. Extrahepatically: gallstones, pancreatic Ca, parasites.