Jaundice

Question 1

What form of hyperbilirubinaemia do you get with pre-hepatic jaundice?

Answer 1

Unconjugated hyperbilirubinaemia.

Question 2

Does unconjugated hyperbilirubinaemia enter the urine, and why?

Answer 2

It doesn’t enter the urine as it is water insoluble.

Question 3

What are the causes of pre-hepatic jaundice?

Answer 3

Overproduction:
-	Ineffective erythropoiesis
-	Haemolysis e..g. due to sickle cell anaemia, malaria, G6PD deficiency, PK deficiency, spherocytosis. 
Impaired conjunction:
-	Gilbert’s syndrome (glucoronyl transferase deficiency)
Impaired hepatic uptake:
-	Paracetamol
-	Rifampicin
-	Ischaemic hepatitis

Question 4

What would LFTs show in pre-hepatic jaundice?

Answer 4

Bilirubin: Normal/high
ALT/AST: Normal
ALP: Normal

Question 5

What form of hyperbilirubinaemia do you get with hepatic jaundice?

Answer 5

Mixed conjugated and unconjugated hyperbilirubinaemia.

Question 6

What are the causes of hepatic jaundice?

Answer 6

Viral hepatitis.
CMV.
EBV.
Cirrhosis.
Liver malignancies.
Drug-induced e.g. paracetamol overdose, anti-TB drugs, statins, sodium valproate.
Haemochromatosis (hereditary or secondary to repeated iron infusions).
Wilson’s disease
A1 anti-trypsin deficiency.

Question 7

What would LFTs show in hepatic jaundice?

Answer 7

Bilirubin: High
ALT/AST: High (often very high)
ALP: Elevated, but rarely to very high levels.

Question 8

What form of hyperbilirubinaemia do you get with post-hepatic/obstructive jaundice?

Answer 8

Conjugated hyperbilirubinaemia.

Question 9

What signs are indicative of conjugated hyperbilirubinaemia and why?

Answer 9

Pale stools and dark urine - bilirubin can’t get into stools so goes into urine.

Question 10

What are the causes of post-hepatic/obstructive jaundice?

Answer 10

Hepatocellular dysfunction:
-	Cirrhosis.
-	Viral hepatitis.
-	Alcohol.
-	Tumours/abscesses.
Impaired hepatic excretion:
-	Gallstones.
-	Primary biliary cholangitis.
-	Pancreatic cancer.
-	Flucoxacillin, fusidic acid, steroids.

Question 11

What would LFTs show in post-hepatic/obstructive jaundice?

Answer 11

Bilirubin: High-very high
ALT/AST: Moderate elevation
ALP: High-very high

Question 12

What questions should you ask in the history of a person presenting with jaundice?

Answer 12

IVDU.
Piercings/tattoos.
Sexual history.
Travel history.
FHx.
Alcohol/drug history.
Medications.
Blood transfusions.

Question 13

What investigations should be performed on someone presenting with jaundice?

Answer 13

Blood tests.
USS.
ERCP/MRCP.
Protein and albumin.
Urine sample.

Question 14

What are the possible complications of jaundice?

Answer 14

Renal failure.
Cholangitis.
Deranged clotting.
Relative immunosuppression.

Question 15

How is jaundice managed?

Answer 15

Treat cause.

Obstructive – ERCP can be used for removal of stones, sphincterotomy, stent insertion.