Jaundice

Question 1

How do you classify jaundice?

Answer 1

Prehepatic / Haemolysis

Hepatic

Post-hepatic/ Obstructive

Question 2

How does obstructive jaundice present?

Answer 2

Dark urine = billirubin present in urine but not urobillinogen
Pale Stool
Conjugated = Itchy

Impaired excretion of conjugated bilirubin results is cholestasis. Conjugated bilirubin is water soluble, making the urine dark. Less bilirubin reaches the gut, so pale stools also result. Pruritus also suggests an obstructive problem.

Question 3

How would you investigate a jaundiced patient?

Answer 3

Bloods:

• FBC
• LFTs + billirubin
• Clotting

Imaging: Ultrasound scan

Question 4

History; Questions to ask jaundiced patient?

Answer 4

Any recent travel

Any recent tattoos/ blood transfusion

IV drug use

Question 5

Causes of post-hepatic jaundice

Answer 5

Luminal = stone

Mural = choangiocarcinoma, primary biliary cirrhosis, primary sclerosing cholangitis

Extra-mural = head of pancreas cancer
Mirrizi’s syndrome = gall stone in the cystic duct that presses/ obstructs the common bile duct

Question 6

Causes of pre-hepatic jaundice

Answer 6

Most common: malaria (haemolysis)

Conjugation disorders, such as Gilbert’s disease and Crigler-Naajjar

(Pre-hepatic jaundice results in unconjugated hyperbilirubinaemia, which is not water soluble so cannot enter the urine)

Question 7

Causes of hepatic jaundice

Answer 7

Viruses (hepatitis, CMV, EBV)
Drugs, including paracetamol overdose, halothane, valproate, statins, tuberculosis antibiotics
Alcohol
Cirrhosis
Liver mass (abscess or malignancy)
Haemochromatosis
Autoimmune hepatitis
Alpha-1 antitrypsin deficiency
Budd-Chiari
Wilson's disease