Jaundice 3 Flashcards
What bloods do you do for jaundiced patient in the initial screen?
- FBC and reticulocyte levels
- Serum bilirubin levels
- Liver enzymes
- ALP + GGT
- Serum amylase or lipase
What would a low RBC with high reticulocyte count suggest?
increased RBC turnover consistent with haemolysis or recent bleed
What would a low rbc volume (microcytosis) be consistent with?
thalasseamia
Why do you check serum bilirubin levels in jaundiced patient?
confirm if jaundice is due to hyperbilirubinaemia
What bilirubin levels are consistent with Gilberts disease?
total bilirubin not >100 muM
How can serum bilirubin levels indicate a problem with obstruction to bile flow?
proportion of conjugated bilirubin >20% of total bilirubin
When is ALP released?
damaged biliary epithelial cells, bones and placenta
What would a raised ALP and GGT suggest?
bile duct pathology (maybe hep)
What would raised ALP and normal GGT suggest?
increased bone turnover (malignancy?) or pregnancy
When is AST and ALT raised?
- damage to hepatocytes
- very high in acute viral hep
What would elevation of AST>ALT suggest?
excessive alcohol intake
What would elevation of ALT>AST suggest?
viral hepatitis
When are levels of AST/ALT in thousands?
- viral hep
- paracetemol overdose
- ischaemia hep
What would a raised serum amylase or lipase suggest?
pancreatic pathology
What urine tests do you do for a jaundiced patient?
- Urinanalysis
2. Pregnancy test
What does bilirubin present in urine mean?
post-hepatic obstruction (no uroglobin in urine)
What second line bloods do you do in a jaundiced patient?
- Haemolysis screen
- Viral Screen
- Autoimmune screen
- Congenital screen
What might suggest jaundice is due to heamolysis?
- anaemia
2. elevated unconjugated bilirubin
What do you check in the haemolysis screen?
- Haptoglobins (protein that binds to Hb released by haemolysed RBCs)
- Lactate dehydrogenase (LDH) released by haemolysed RBC
- Direct antiglobulin test (DAT or coombs) for autoimmune haemolysis
- Blood film: see if schistocytes, sickles cells, target cells, spherocytes or malaria
Why would you do a haemolysis screen?
if you suspect jaundice is due to haemolysis
What is checked in the viral screen?
- Check serology for Hep A, B, C
- Check for EBV, CMV
- Check for HIV
What do you check in the autoimmune screen?
- ANA
- AMA
- ASMA
When is it ASMA positive?
type 1 autoimmune hep
When is AMA elevated?
with PBC and some autoimmune hep
What do you check for in the congenital screen?
- Haematochromatosis (high ferrtin, high trasnferrin sat)
- Alpha 1 antitrypsin deficiency (low alpha one antitrypsin levels)
- Wilson’s disease (high Cu, low caeruloplasmin)
What imaging may be used for jaundice?
US
Why is US good?
- Safe, non invasive
- Shows liver cirrhosis or liver carcinoma
- Can also do US of CBD if suggested
What further investigations may you consider with a jaundiced patient?
- Clotting studies and albumin
2. Liver biopsy
Why are clotting studies are albumin useful?
- Measure of liver synthetic function - used in MELD and Charles-Pugh score
- Measured if liver pathology suspected
- Deranged PT earliest marker of bad liver function
Are albumin levels useful?
- takes 20 days to fall
- due to either reduced synthesis (e.g. liver damage, severe malnutrition)
- or increased albumin loss (e.g. nephrotic syndrome)
Why would you do a liver biopsy in a jaundiced patient?
establish diagnosis if blood tests and imaging inconclusive
What is the prognosis of acute Hep B?
- Full recovery: self-limiting
- Carier status: 10% become asymptomatic carrier
- Chronic hep B: 5-10% develop chronic symptomatic hep B
- Fulminant Hep: 0.5% of patients will develop this (mortality 80%)
How do you manage acute hep b LT?
referral to specialist hepatology
How do you manage acute hep b short term?
- Practice safe sex
- Minimise alcohol consumption during acute pahse
- Avoid sharing any toothbrushes or razors
- Contact tracing
- Vaccination of current sexual partners and children who are at risk of exposure via cuts and scratches
- Go to GUM clinic to check for other STIs if appropriate
