Jaundice Flashcards
How is jaundice categorised?
Haemolytic- increased bilirubin load for the liver cells
Congenital hyperbilirubinaemias- defects in conjugation
Cholestatic jaundice- liver disease and large duct obstruction
What is haemolytic jaundice?
Increased breakdown of RBCs leads to an increase in production of bilirubin
Anaemia, splenomegaly, gallstones, leg ulcers
Unconjugated bilirubin raised
Serum ALP, transferases and albumin are normal
What are the types of unconjugated congenital hyperbilirubinaemias?
Gilberts: reduced UDP-glucuronosyl transferase, bilirubin rises on fasting and mild illness
Crigler-Najjar syndrome: Mutation of gene for UDP-glucuronosyl transferase, transplant only effective treatment
What are the types of conjugated congenital hyperbilirubinaemias?
Dubin-Johnson and Rotor’s- defects in bilirubin handling in the liver
FICI/benign recurrent intrahepatic cholestasis: recurrent attacks without progression to liver disease. Severe pruritus, steatorrhoea and weight loss. Serum y-GT is normal
Intrahepatic cholestasis of pregnancy
What is extra hepatic cholestasis?
Large duct obstruction of bile flow at any point in the biliary tract distal to the bile canniculi
What is intra hepatic cholestasis?
Occurs due to failure of bile secretion
Inflammatory change in ductular cells interferes with bile flow
What are the causes of intrahepatic cholestasis?
Viral hepatitis Drugs Alcoholic hepatitis Cirrhosis Pregnancy Recurrent idiopathic cholestasis
What are the causes of extra hepatic cholestasis?
Common duct stones Carcinoma (bile duct, head of pancreas, ampulla) Biliary stricture Sclerosing cholangitis Pancreatitis
What questions should be asked when determining the cause of jaundice?
Country of origin (hep B)
Duration (short- hepatitis long + weight loss- malignancy)
Shellfish
Drug abuse, injections, tattoos (hep b/c)
Male homosexuality (hep b)
Blood transfusion (hep b/c)
Alcohol consumption
Travel (hep a/e)
Recent anaesthetics (halothane)
Family history (Gilbert’s)
Recent surgery (biliary tract or for carcinoma)
Fevers or rigors (cholangitis or liver abscess)
What investigation should be carried out?
Viral markers for hepatitis
Liver biochemistry
Ultrasound examination
What will an ultrasound examination demonstrate?
Size of bile ducts, dilated in extrahepatic obstruction
Level of the obstruction
The cause of obstruction, tumour and gallstones
How can liver biochemistry aid in diagnosis?
AST or ALT tends to be high early in hepatitis, small rise in ALP
ALP is high with a smaller rise on AST or ALT in extra hepatic obstruction
How can blood tests help diagnose jaundice?
Haemolytic jaundice the bilirubin is raised and other biochemistry is normal Raised white cell count (cholangitis) Leucopenia (viral hepatitis) AMA (primary biliary cirrhosis) A-fetoprotein (hepatocellular carcinoma)
Which drugs cause haemolysis?
anti-malarials: primaquine
ciprofloxacin
sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas
What is G6PD deficiency?
The commonest red blood cell enzyme defect
More common in people from the Mediterranean and Africa
X-linked recessive
Many drugs can precipitate a crisis as well as infections and broad (fava) beans
neonatal jaundice is often seen
intravascular haemolysis
gallstones are common
splenomegaly may be present
Heinz bodies on blood films. Bite and blister cells may also be seen
What is hereditary spherocytosis?
Most common hereditary haemolytic anaemia in people of northern European descent
Autosomal dominant defect of red blood cell cytoskeleton
Biconcave disc shape is replaced by a sphere-shaped
Red blood cell survival reduced as destroyed by the spleen
Failure to thrive
Jaundice, gallstones
Splenomegaly
Aplastic crisis precipitated by parvovirus infection
degree of haemolysis variable
MCHC elevated
What is ascending cholangitis?
Bacterial infection (typically E. coli) of the biliary tree. The most common predisposing factor is gallstones.
What are the symptoms of ascending cholangitis?
Charcot’s triad:
RUQ, fever, jaundice
hypotension and confusion are also common (the additional 2 factors in addition to the 3 above make Reynolds’ pentad)
What are the risk factors for biliary colic?
Fat: obesity is thought to be a risk factor due to enhanced cholesterol synthesis and secretion
Female: gallstones are 2-3 times more common in women. Oestrogen increases activity of HMG-CoA reductase
Fertile: pregnancy is a risk factor
Forty
diabetes mellitus
Crohn’s disease
rapid weight loss e.g. weight reduction surgery
drugs: fibrates, combined oral contraceptive pill
What are the features of biliary colic?
colicky right upper quadrant abdominal pain
worse postprandially, worse after fatty foods
the pain may radiate to the right shoulder/interscapular region
nausea and vomiting are common
What is the best tool for diagnosis of primary sclerosing cholangitis?
ERCP/MRCP
Multiple biliary strictures giving a beaded appearance
What is a common presentations for a complication of cholecystectomy?
Progressive jaundice and pain
Injury or ligation of common hepatic bile duct
