Jaundice Flashcards
____________- is a yellow discolouration of the skin and mucosal surfaces caused by the accumulation of excessive bilirubin.
Jaundice
Categories of jaundice
• obstructive: — extrahepatic — intrahepatic • hepatocellular • haemolytic
Jaundice is defined as a serum bilirubin level exceeding____________
19 μ mol/L.
Clinical jaundice manifests only when the bilirubin level exceeds_________
50 μ mol/L.
It can be distinguished from yellow skin due to___________ (due to dietary excess of carrots, pumpkin, mangoes or pawpaw) and ___________ by involving the sclera.
hypercarotenaemia
hypothyroidism
The most common causes of jaundice recorded in a general practice population are (in order) 1 2 3 4
viral hepatitis, gallstones, pancreatic cancer, cirrhosis, pancreatitis and drugs
A ______________ can occur not only with alcohol excess but also with obesity, diabetes and starvation. There is usually no liver damage and thus no jaundice.
fatty liver (steatosis)
In the middle-aged and elderly group, a common cause is ____________-
obstruction from gallstones or cancer
Malignancy must always be suspected, especially in the elderly patient and those with a history of____________-
chronic active hepatitis (e.g. post hepatitis B or C infection).
A patient who has the classic Charcot triad of upper abdominal pain, fever (and chills) and jaundice should be
regarded as having _________________
ascending cholangitis until proved
otherwise.
__________, although rare, must be
considered in all young patients with acute hepatitis.
A history of neurological symptoms, such as a tremor or a clumsy gait, and a family history is important
Wilson syndrome
If Wilson syndrome is suspected an ocular slit lamp examination, _____ and _____________should be performed
serum ceruloplasmin levels (low in 95%
of patients) and a liver biopsy
_________is the commonest form of unconjugated hyperbilirubinaemia. It affects at least 3% of the population.
Gilbert syndrome
Labs associated wtih CPC
Usually there is a moderate rise in
bilirubin and alkaline phosphatase and sometimes, in acute failure, a marked elevation of transaminase
may occur, suggesting some hepatocellular necrosis
patterns of drug-related jaundice
The patterns of drug-related liver damage
include cholestasis, necrosis (‘hepatitis’), granulomas,
chronic active hepatitis, cirrhosis, hepatocellular
tumours and veno-occlusive disease
Drugs causing drug-related jaudice
Antibiotics, especially flucloxacillin,
amoxycillin + clavulanate and erythromycin, are commonly implicated
The patient may present with the symptoms of underlying anaemia and jaundice with no noticeable
change in the appearance of the urine and stool
Haemolysis
severe haemolytic crisis can be precipitated by drugs or broad beans (favism) in a patient
with an inherited ___________
red cell deficiency of glucose-6- phosphate dehydrogenase (G6PD).
Red flag pointers for jaundice
- Unexplained weight loss
- Progressive jaundice including painless jaundice
- Oedema
- Cerebral dysfunction (e.g. confusion, somnolence)
A palpable gall bladder indicates ____________, and splenomegaly may ________________, portal hypertension or _____________
extrahepatic biliary obstruction
indicate haemolytic anaemia
viral hepatitis.
Skin excoriation may indicate pruritus, which is associated with __________
cholestatic jaundice
What to see in dipstick urine for pts with jaundice
bilirubin and urobilinogen
Diagnostic markers for hepatitis
1
2
3
- Hepatitis A: IgM antibody (HAV Ab)
- Hepatitis B: surface antigen (HBsAg)
- Hepatitis C: HCV antibody (HCV Ab)
_________________the most
useful investigation for detecting gallstones and dilatation of the common bile duct
Transabdominal ultrasound (US):
__________________: useful in diagnosis of acute cholecystitis
HIDA scintiscan
________________-:
shows imaging of biliary tree
PTC: percutaneous transhepatic cholangiography
__________determine the cause of the obstruction and relieves it by sphincterotomy and removal of CBD
stones
ERCP: endoscopic retrograde
cholangiopancreatography; PTC and ERCP (best)
__________
provides non-invasive planning for obstructive jaundice
MRCP: magnetic resonance cholangiography
___________: useful for liver cirrhosis,
especially of the left lobe
Liver isotopic scan
Some specific tests include:
•_______for autoimmune chronic active
hepatitis and primary biliary cirrhosis
• ________ to detect liver
secondaries, especially colorecta
autoantibodies
carcinoembryonic antigen
Some specific tests include:
serum iron studies, especially transferrin
saturation—elevated in _____________
______—elevated in hepatocellular carcinoma; mild elevation with acute or chronic liver disease (e.g. cirrhosis
serum ceruloplasmin level—low in _____
haemochromatosis
alpha-fetoprotein
Wilson
syndrome
Jaundice in the newborn is clinically apparent in ____ of term babies and more than ____of preterm
50%
80%
Which type of bilirubin is always pathological?
conjugated
(always pathological
Jaundice occurring in the first 24 hours after birth is not due to immature liver function but is pathological and usually due to ____________
In primigravidas it is
usually due to ___________
haemolysis consequent
on blood group incompatibility
ABO incompatibility.
With increasing serum levels of bilirubin, an encephalopathy (which may be transient) can develop, but if persistent
can lead to the irreversible brain damage known as _______–
kernicterus.
levels of bilirubin causing Rh Disease
unconjugated bilirubin of 340 μ mol/L (20 mg/dL).
Guidelines for treatment for hyperbilirubinaemia (at 24–36 hours)—
• >285 μ mol/L—____________
• >360 μ mol/L—____________
phototherapy
consider exchange transfusion
This mild form of jaundice, which is very common in infants, is really a diagnosis of exclusion
Physiological jaundice
In a term infant the serum bilirubin rises quickly after birth to reach a maximum by day_______ then declines
rapidly over the next ____________before fading more slowly for the next ______________
3–5,
2–3 days
1–2 weeks
This is antibody-mediated haemolysis (Coomb test positive):
• Mother is O
• Child is A or B
ABO blood group incompatibility
Mx of ABO blood group incompatibility
• Perform a direct Coomb test on infant.
• Phototherapy is required immediately.
• These children require follow-up developmental
assessment including audiometry.
If the secondary causes of prolonged jaundice are excluded, the baby is well and breastfeeding, the likely
cause of unconjugated elevated bilirubin is______
breast milk jaundice
Patterns of breast milk jaundice
It usually begins late in the first week and peaks at 2–3 weeks
How to confirm dx of breast milk jaundice
Diagnosis is confirmed by suspending
(not stopping) breastfeeding for 24–48 hours
Viral infection is the commonest cause of jaundice in the older child, especially _______
hepatitis A and hepatitis B
Obstructive jaundice is the commonest form of jaundice in the elderly and may be caused by _____and_____
gallstones blocking the common bile duct (may be painless)
carcinoma
of the head of the pancreas, the biliary tract itself, the stomach or multiple secondaries for other sites.
What law
painless obstructive jaundice is due to neoplasm—particularly
if the gall bladder is palpable
(Courvoisier’s law).
_____ and _____ are the most commonly reported types of viral hepatitis with an onset that is more insidious and with a longer incubation period
hepatitis B and C
hepatitis______ from faeco-oral transmission;
and hepatitis_______ from intravenous drugs and bodily fluids
A and E
B, C, D and G
______ virus has been claimed to be
transmitted enterically while the newly designated ______ is transmitted parenterally
Hepatitis F
hepatitis G virus (HGV)
In _____ liver damage is directly due to
the virus, but in _______it is due to an immunologic reaction to the virus
hepatitis A,
hepatitis B and C
Two phases of Hep A infection
- Pre-icteric (prodromal) phase
2. Icteric phase (many patients do not develop jaundice):
Recovery from hep A infection usually in _____
3–6 weeks.
_______ antibodies, which means past
infection and lifelong immunity and which is common in the general population.
IgG
Best way of prevention for Hep A infection
An active vaccine consisting of a two-dose primary course is the best means of prevention.
In Hep B infection
______ per cent of subjects go on to become chronic carriers of the virus
Five
The serology of hepatitis B involves antibody responses to the four main antigens of the virus 1 2 3 4
(core, DNA polymerase, protein X and surface antigens).
The main viral investigation for HBV is _______
(surface antigen), which is searched for routinely
HBsAg
_______ is defined as the presence of HBsAg for at least 6 months.
Chronic hepatitis B (carriage)
_______is a soluble protein from the pre-core and core
HBeAg
HBsAg + ve, anti-HBcIgM + anti-HBs -ve
Acute hepatitis
HBsAg + ve, anti-HBcIgG + anti-HBs -ve
Chronic hepatitis
How to monitor progress of disease
Monitor progress with 6–12 monthly LFTs,
HBeAg and HBV DNA
Negative HBsAg and HBV DNA (with anti-HBe)
resolving
Negative HBsAg and HBV DNA (with anti-HBe), with anti-HBs
full recovery
Positive HBsAg and HBV DNA =
replicating and
infective—refer
Treatment of chronic hepatitis B infection (abnormal LFTs) is with the immunomodulatory and antiviral agents—
pegylated interferon alpha and entecavir or tenofir
Remission rates for pts tx with pegylated interferon alpha and entecavir or tenofir
This is expensive but it achieves permanent remission in 25% of patients, and temporary remission in a further 25%.
Outcomes of pts with chronic hep b and undergo liver transplant
Liver transplantation has been
performed, but is often followed by recurrence
of hepatitis B in the grafted liv
If there is a negative antibody response
after 3 months of active immunization, what to do?
revaccinate with a double dose
If the response is positive after 3 months of active immunization, what to do?
consider a test in 5 years with a view to a booster injection.
Clinical symptoms of________are usually
minimal (often asymptomatic), and the diagnosis is often made after LFTs are found to be abnormal
hepatitis C
there are at least _______major genotypes of HCV and treatment decisions are based
on the genotype;
six
The severity of hepatic fibrosis from Hep C can be assessed by liver biopsy or, preferably, by a non-invasive device called a ______ that assesses ‘hardness or
stiffness’ of the liver via the technique of transient
elastography.
FibroScan
In HCV infection,
A ________level that is tested
three times over the next 6 months implies disease activity.
raised ALT
________(a PCR test) is present when the
ALT becomes abnormal while the anti-HCV rises more slowly and may not be detectable for several weeks.
If the PCR test is negative, the hepatitis C
infection has_______
HCV RNA
resolved.
The current standard treatment for chronic hepatitis C is _______orally daily and _________ by weekly SCI—genotypes 1, 4, 5, 6 for 48 weeks; genotypes 2, 3 for 24 weeks
ribavirin
pegylated alphainterferon
SE of combination Tx for HCV
The combination therapy, which can cure many cases of hepatitis C, has considerable side effects, ranging from flu-like
symptoms to depression to significant anaemia
Vaccine for HCV
There is no vaccine yet available
Those at increased risk of having
hepatitis B and C
Blood transfusion recipients (prior to HBV and HCV testing)
• Intravenous drug users (past or present)
• Male homosexuals who have practised unsafe sex
• Kidney dialysis patients
• Sex industry workers
• Those with abnormal LFTs with no obvious cause
• Tattooed people/body piercing
_____ is a small defective virus that lacks a
surface coat.
Hepatitis D
T or F
hepatitis D infection occurs only in patients with concomitant hepatitis B.
T
Antibodies being measured for Hep D infection
Antibodies to the delta virus, both
anti-HDV and anti-HDV IgM (indicating a recent infection) as well as HDV Ag can be measured
HEV behaves like________
with well-documented water-borne epidemics in areas of poor sanitation
HAV,
HEV has high mortality in?
There is a high case fatality
rate (up to 20%) in pregnant females
Researchers claim to have identified HGF virus, which is spread _______
enterically
_______ has been identified as a transfusion-spread virus. It has subsequently been found to be prevalent
among Queensland blood donors
HGV
________ refers to the syndrome of biliary
obstructive jaundice whereby there is obstruction to the flow of bile from the hepatocyte to the duodenum,
thus causing bilirubin to accumulate in the blood
Cholestasis
Classification of cholestasis
• intrahepatic cholestasis—at the hepatocyte or intrahepatic biliary tree level
• extrahepatic cholestasis—obstruction in the
large bile ducts by stones or bile sludge
Causes of Intrahepatic cholestasis
Alcoholic hepatitis/cirrhosis
Drugs
Primary biliary cirrhosis
Viral hepatitis
Causes of Extrahepatic cholestasis
Cancer of bile ducts
Cancer of pancreas
Other cancer: primary or secondary spread
Cholangitis
Primary sclerosing cholangitis (? autoimmune)
Common bile duct gallstones
Pancreatitis
Post-surgical biliary stricture or oedema
Location of gallstones
\_\_\_\_\_\_\_(asymptomatic up to 75%)—the majority remain here \_\_\_\_\_\_\_\_\_ (biliary ‘colic’ or acute cholecystitis) \_\_\_\_\_\_\_\_ (biliary ‘colic’ or acute cholecystitis) \_\_\_\_\_\_\_\_\_\_—may cause severe biliary ‘colic’, cholestatic jaundice or chola
gall bladder
- neck of gall bladder
- cystic duct
- common bile duct
The investigations of choice for cholestatic
jaundice are ____ and _______
ultrasound and ERCP
This is due to bacterial infection of the bile ducts secondary to abnormalities of the bile duct, especially gallstones in the common duct. Other causes are neoplasms and biliary strictures
Acute cholangitis
Presentation of Acute cholangitis in the eldely?
Older patients can present with circulatory
collapse and Gram-negative septicaemia
_______is the fourth commonest cause of
cancer death in the UK and US
Pancreatic cancer
jaundice + constitutional symptoms
(malaise, anorexia, weight loss) + epigastric
pain (radiating to back) ______
pancreatic cancer
pancreatic cancer prognosis
Prognosis is very poor: 5-year survival is 5%.
Diagnosis is made by abnormal LFTs, positive smooth muscle antibodies, a variety of other autoantibodies and a typical liver biopsy
Autoimmune chronic active
hepatitis (ACAH)
Autoimmune chronic active
hepatitis (ACAH)
If untreated, most patients die within________
3–5 years
Autoimmune chronic active
hepatitis (ACAH)
Treatment is with ______ orally, monitored according to serum ______
prednisolone
alanine aminotransferase levels,
This uncommon inflammatory disorder of the biliary tract presents with progressive jaundice and other features of cholestasis such as pruritus. It is often
associated with ulcerative colitis
Primary sclerosing cholangitis
This is an uncommon cause of chronic liver diseases that often presents with pruritis, malaise and an obstructive pattern of liver biochemistry.
Treatment is with ursodeoxycholic acid orally
Primary biliary cirrhosis
The main effects of alcohol excess on the liver are:
• acute alcoholic liver disease • fatty liver • alcoholic hepatitis (progresses to cirrhosis if alcohol consumption continues) • alcoholic cirrhosis
Alcohol can cause ________, which is almost universal in obese alcoholics
hepatic steatosis (fatty liver)
The overseas traveller presenting with jaundice may have been infected by any one of the viruses— hepatitis ___________
A, B, C, D or E.
Important hepatic disorders in pregnancy leading to jaundice are
cholestasis of pregnancy, acute fatty
liver of pregnancy and severe pre-eclampsia
There are many possible causes of postoperative jaundice
• post-transfusion hepatitis • coincident viral hepatitis • drugs, including anaesthetics • transfusion overload (haemolysis) • sepsis • unmasked chronic liver disease and biliary tract disease • cholestasis: post major abdominal surgery
