Jaundice Flashcards
What are LFT’s and what do they tell you
Bilirubin (SBR) - total and split - liver clearance / function
ALT / AST
Alkaline phosphatase
GGT
What should conjugated bilirubin be
10% of unconjugated
What are other tests and what do they show
PT / INR - clotting APTT - clotting Albumin - produced in liver Blood glucose Ammonia
What causes jaundice
Haem broken down in spleen Bilirubin produced Insoluble can't excrete Goes to liver and conjugates Secreted into bile Becomes urobilinogen Reabsobed into portal and excreted in kidney Or become sterecobilin in stool
What enzymes conjugated
UDP glucoyuntransferase
When does jaundice become visible
Bilirubin >40-50
What are the different types of jaundice with time
Early - <24 hours
Intermediate
Prolonged >2 week or 21 if pre-term
What is always abnormal
Early
What causes early jaundice
Haemolysis ABO / Rhesus mismatch G6PD / Spherocytosis Sepsis - Congenital or early Haematoma Haemorrhage - IVH
What do you do
Urgent SBR if suspect
Other tests
What suggests haemolytic
+ve DAT
What causes intermediate
Physiological - most common Sepsis Haemolysis Abnormal conjugated Cephalohaematoma
What is abnormal conjugated
Gilberts Criger Najar Absence of enzyme to conjugated Isolated hyperbilirubin Do FBC to rule out haemolytic
What causes physiological
Shorter RBC lifespan
Polycythaemic at birth
Immature liver function
Pre-mature and breast fed increase
What is always abnormal
Conjugated bilirubin
Suggest obstruction
Pale stool / dark urine = worry
Need split SBR
What causes obstruction
Biliary atresia - early Dx is key (bile duct narrowed or absent resulting in cholestasis) Gall stone Tumour Hirschprung Cyst Alangile syndrome
How does liver disease present
Jaundice if bilirubin >40
Most prominent in sclera
What are other signs of cholestasis / biliary atresia
Pruritus Dark urine Pale stool Fat malabsorption May have HSM Poor growth / feeding Cardiac murmur if associated abnormality
How do you investigate jaundice at bed site
Bilirubinometer
When can you not use
If <24 hours
What do you do after bilirubinometer
Plot level on Rx line to see what Rx is needed
If <50 below Rx line= SBR
Split is important for biliary atresia
What are other tests
FBC Blood film DAT for haemolytic Blood group G6PD Urine and blood culture Septic screen if unwell U+E LFT TFT Test to exclude a1- anti typisn or CF
What imaging for obstruction
USS
Liver biopsy
How do you treat biliary atresia
UDCA can be given in interim
Urgent Kasai Portoenterostomy
- Blocked bile duct removed and replaced with small intestine
Liver transplant if doesn’t work / severe end stage liver disease / portal HTN
What are choledochal cyst
Cyst in bile duct so don’t get effective flow
How do you Dx choledochal cyst
Split bilirubin
Pale stools
USS of bile duct
What is alagille syndrome
Intrahepatic cholestsasis
Dysmorphism
Congenital cardiac disease
How do you treat physiological jaundice
Phototherapy to breakdown bilirubin and prevent complication Exchange transfusion if very severe Ig if immune process May need transfusion if anaemia - Can do this in the womb Assess need for SCBU Ensure fluid requirements met Monitor regular
What is important to ask in the history if asked to see a baby with jaundice
Age - preterm ? birth trauma? RF infection - maternal fever, PPROM, group B strep Mothers blood group / known Ab Poo / pee / feed bottle or breast FH haemolytic disorder
How would you examine a jaundice child
A B - RR, resp distress, SATS C - CRT - sternal, BP D - temp, movement, BG E
What does jaundice cause
Cross BBB and deposits in brain / basal ganglia causing kernicterus
Clinical acute encephalopathy
What is acute encephalopathy
Poor feed Lethargy Seizure Hypotonia Shrill cry
What does chronic encephalopathy
Severe choreathetoid palsy Sensorineural high freq loss Vision - upward gaze Seizure Hypotonia and hypertonia Hyperreflexia Coma
What are causes of prolonged jaundice that are not obstructive so unconjugated >14 day
Breast milk UTI Sepsis - exclude UTI Cystic fibrosis Hypothyroid Congenital CMV / toxoplasosis Hepatitis A1AT deficiency TPN Haemochromatosis Storage and metabolic disorder
How does phototherapy work
Converts unconjugated bilirubin into isomers that can be exerted without conjugation in liver
What should you do after phototherapy
Measure bilirubin 8-12 hours to ensure levels do not rise
How do you treat
Optimise hydration / feeding
Phototherapy
Exchange transfusion
