Jaundice Flashcards
What is jaundice?
This is a yellow tinge to the skin or the eyes (icterus) caused by a rise in the serum bilirubin >50 umol/L
It is important to distinguish jaundice from carotenaemia.
Classification of jaundice
Haemolytic jaundice
Congenital Hyperbilirubinaemias
Cholestatic jaundice
What is haemolytic jaundice?
Increased bilirubin for the liver cells.
Resulting jaundice is usually mild as the liver can compensate for the increased load.
Unconjugated bilirubin is not water-soluble and therefore doesn’t pass into the urine, hence ‘achlouric jaundice’
What is congenital hyperbilirubinaemia?
Defects in coagulation.
What is cholestatic jaundice?
Hepatocellular liver disease and bile duct obstruction.
Causes of haemolytic jaundice
Haemolytic anaemia: other features such as splenomegaly, gallstones and leg ulcers may be seen.
What would the investigations show in haemolytic anaemia?
Investigations show haemolysis and elevated unconjugated bilirubin.
Normal serum ALP, transferases and albumin.
Serum haptoglobin is low.
Causes of congenital hyperbilubinaemias
Gilbert syndrome- unconjugated type
Crigler-Najjar syndrome- unconjugated type
Dubin-Johnson and Rotor syndromes- conjugated type
Causes of cholestatic lunge (acquired)
Extrahepatic cholestasis- large duct obstruction of bile flow at any point in the biliary tract distal to the bile canaliculi.
Intrahepatic- occurs because of failure of bile secretion which may be caused by intrinsic defects in bile secretion or inflammation in the intrahepatic ducts.
Clinically in both types, there is jaundice with pale stools and dark urine.
The serum bilirubin is conjugated.
they MUST be differentiated as their clinical management is entirely different.
Clinical features of jaundice
Hepatomegaly (smooth, tender live is seen in hepatitis and in extrahepatic obstruction)
Splenomegaly
Ascites
Is jaundice a diagnosis?
Jaundice is not itself a diagnosis and the cause should always be sought.
What are the most useful investigations for jaundice?
Viral markers for HAV, HBV and HCV.
Ultrasound examination- this is to exclude an extrahepatic obstruction.
Ultrasound will demonstrate the size of bile ducts, which are dilated in extrahepatic obstruction and the level of obstruction.
Liver biochemistry- AST, ALT, ALP.
Biliary excretory function- serum bilirubin, urine bilirubin, serum bile acids, ALP, GGT.
Hepatocyte synthetic function- albumin, coagulation factors (PT and APTT)
Increased RBC destruction increases the level of unconjugated bilirubin.
Hepatocellular damage or biliary tract obstruction will cause elevated conjugated (direct) bilirubin levels.
Spped of onset of jaundice
Within days: Usually acute hepatitis caused by infection, alcohol or drugs.
Within a few weeks: More likely causes are subacute hepatitis or bile duct obstruction.
Fluctuating: drug-induced, ampullary carcinoma, gallstones
Associated symptoms of jaundice
Pain Pale stools Dark urine Anorexia, nausea and vomiting Weight loss Pruritus Fever
Pain with Jaundice
Pain- RUQ can be severe in patients with gallstones or alcoholic hepatitis.
Cholecystitis pain radiates to the right shoulder, right scapula or around the upper abdomen.
Invasive carcinoma of the head of the pancreas can cause epigastric pain radiating to the back.
Most causes of hepatocellular jaundice don’t cause significant pain.
Pale stools and dark urine with jaundice
Cholestatic cause for jaundice.
Stools are coloured by stercobilinogen.
Urine appears darker due to increased urinary conjugated bilirubin excretion.
Anorexia, nausea and vomiting with jaundice
Occurs with gallstones, malignancy or hepatitis.
Weight loss is also seen with these conditions.
Past medical history expected with jaundice
IBD esp. UC causes an increased risk of primary sclerosing cholangitis
Inherited and acquired causes of haemolysis
Previous malignancy
Any abdominal surgery
History of blood transfusions before 1992 (HCV)
Drug and alcohol history expected with jaundice
All recent drugs including non-prescription and illegal drug use.
Quantify alcohol consumption
Other parts of the clinical history of a person with jaundice
Travel: Likelihood of HAV and HBV or parasitic infection.
Sexual: Sex of partner, type of intercourse
Social: Non-sterile tattoos or body piercings. Residence in countries with high HBV cases.
Family: Wilson’s disease, Gilbert’s syndrome, autoimmune hepatitis.
What does Courvoisier’s law states?
Enlargement of the gallbladder with jaundice is likely to result from obstructive carcinoma rather than a stone in the common bile duct.
Urgent considerations in a patient with jaundice
Ascending cholangitis, massive haemolysis and acute alcoholic hepatitis.
Differentials of jaundice
ALD Choledocholithiasis Viral hepatitis Drug-induced liver injury Ascending cholangitis Pancreatic carcinoma Liver Mets Haemolytic anaemia Gilbert's syndrome Wilson's disease Cholangiocarcinoma IgG4 cholangiopathy Hepatocellular carcinoma Post-operative stricture Primary sclerosing cholangitis Parasitic infections
Investigation for Wilson’s disease
Serum ceruloplasmin and urinary copper excretion
