Jaundice 3

Question 1

What bloods do you do for jaundiced patient in the initial screen?

Answer 1

1. FBC and reticulocyte levels
2. Serum bilirubin levels
3. Liver enzymes
4. ALP + GGT
5. Serum amylase or lipase

Question 2

What would a low RBC with high reticulocyte count suggest?

Answer 2

increased RBC turnover consistent with haemolysis or recent bleed

Question 3

What would a low rbc volume (microcytosis) be consistent with?

Answer 3

thalasseamia

Question 4

Why do you check serum bilirubin levels in jaundiced patient?

Answer 4

confirm if jaundice is due to hyperbilirubinaemia

Question 5

What bilirubin levels are consistent with Gilberts disease?

Answer 5

total bilirubin not >100 muM

Question 6

How can serum bilirubin levels indicate a problem with obstruction to bile flow?

Answer 6

proportion of conjugated bilirubin >20% of total bilirubin

Question 7

When is ALP released?

Answer 7

damaged biliary epithelial cells, bones and placenta

Question 8

What would a raised ALP and GGT suggest?

Answer 8

bile duct pathology (maybe hep)

Question 9

What would raised ALP and normal GGT suggest?

Answer 9

increased bone turnover (malignancy?) or pregnancy

Question 10

When is AST and ALT raised?

Answer 10

• damage to hepatocytes

- very high in acute viral hep

Question 11

What would elevation of AST>ALT suggest?

Answer 11

excessive alcohol intake

Question 12

What would elevation of ALT>AST suggest?

Answer 12

viral hepatitis

Question 13

When are levels of AST/ALT in thousands?

Answer 13

• viral hep
• paracetemol overdose
• ischaemia hep

Question 14

What would a raised serum amylase or lipase suggest?

Answer 14

pancreatic pathology

Question 15

What urine tests do you do for a jaundiced patient?

Answer 15

1. Urinanalysis

2. Pregnancy test

Question 16

What does bilirubin present in urine mean?

Answer 16

post-hepatic obstruction (no uroglobin in urine)

Question 17

What second line bloods do you do in a jaundiced patient?

Answer 17

1. Haemolysis screen
2. Viral Screen
3. Autoimmune screen
4. Congenital screen

Question 18

What might suggest jaundice is due to heamolysis?

Answer 18

1. anaemia

2. elevated unconjugated bilirubin

Question 19

What do you check in the haemolysis screen?

Answer 19

1. Haptoglobins (protein that binds to Hb released by haemolysed RBCs)
2. Lactate dehydrogenase (LDH) released by haemolysed RBC
3. Direct antiglobulin test (DAT or coombs) for autoimmune haemolysis
4. Blood film: see if schistocytes, sickles cells, target cells, spherocytes or malaria

Question 20

Why would you do a haemolysis screen?

Answer 20

if you suspect jaundice is due to haemolysis

Question 21

What is checked in the viral screen?

Answer 21

1. Check serology for Hep A, B, C
2. Check for EBV, CMV
3. Check for HIV

Question 22

What do you check in the autoimmune screen?

Answer 22

• ANA
• AMA
• ASMA

Question 23

When is it ASMA positive?

Answer 23

type 1 autoimmune hep

Question 24

When is AMA elevated?

Answer 24

with PBC and some autoimmune hep

Question 25

What do you check for in the congenital screen?

Answer 25

1. Haematochromatosis (high ferrtin, high trasnferrin sat) 2. Alpha 1 antitrypsin deficiency (low alpha one antitrypsin levels) 3. Wilson's disease (high Cu, low caeruloplasmin)

Question 26

What imaging may be used for jaundice?

Answer 26

US

Question 27

Why is US good?

Answer 27

- Safe, non invasive - Shows liver cirrhosis or liver carcinoma - Can also do US of CBD if suggested

Question 28

What further investigations may you consider with a jaundiced patient?

Answer 28

1. Clotting studies and albumin | 2. Liver biopsy

Question 29

Why are clotting studies are albumin useful?

Answer 29

1. Measure of liver synthetic function - used in MELD and Charles-Pugh score 2. Measured if liver pathology suspected 3. Deranged PT earliest marker of bad liver function

Question 30

Are albumin levels useful?

Answer 30

- takes 20 days to fall - due to either reduced synthesis (e.g. liver damage, severe malnutrition) - or increased albumin loss (e.g. nephrotic syndrome)

Question 31

Why would you do a liver biopsy in a jaundiced patient?

Answer 31

establish diagnosis if blood tests and imaging inconclusive

Question 32

What is the prognosis of acute Hep B?

Answer 32

1. Full recovery: self-limiting 2. Carier status: 10% become asymptomatic carrier 3. Chronic hep B: 5-10% develop chronic symptomatic hep B 4. Fulminant Hep: 0.5% of patients will develop this (mortality 80%)

Question 33

How do you manage acute hep b LT?

Answer 33

referral to specialist hepatology

Question 34

How do you manage acute hep b short term?

Answer 34

1. Practice safe sex 2. Minimise alcohol consumption during acute pahse 3. Avoid sharing any toothbrushes or razors 4. Contact tracing 5. Vaccination of current sexual partners and children who are at risk of exposure via cuts and scratches 6. Go to GUM clinic to check for other STIs if appropriate