Jaundice Flashcards by Moratwe Masima

What is obstructive jaundice?

It is a type of jaundice that occurs due to narrowing or obstruction of the extrahepatic biliary tract

the blockage causes blockage of the bile and causes hepatitis
the blockage of bile also prevents the bile from goimg into the intestines

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What are the causes of obstructive jaundice?

gallstones
pancreatic CA of the head
cholangitis
pancreatitis
cholangiocarcinoma
choledochal cysts
biliary stricture

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What are the common symptoms that patients with obstructive jaundice present with?

RUQ pain
pale stools, dark urine
pruritis
nausea and vomiting
decolouration of their skin and eyes

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What is Courvoisiers Law?

-the presence of a palpable gallbladder that is non-tender with mild painless jaundice is unlikely to be gallstones but likely to be malignant

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What do we look for in a patient with obstructive jaundice?

vitals: check if patient has fever or haemodynamically stable
inspection: jaundice, pallor
abdo exam:ascites, hepatomegaly, abdominal scars,enlarged gallbladder, splenomegaly
digital rectal exam
cervical and supraclavicular LN
bony tenderness
respiratory exam

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What clinical tests must be done?

1-LFT's to confirm obstructive jaundice
typical picture is elevated bilirubin and ALP 
2-FBC
3. U&amp;E and CRP
4. Amylase
5.Tumour markers(CA19-9)
6.PT/PTT
7. Blood culture

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What does hemoglobin break up into?

heme

2. globin

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What protein carries the unconjugated bilirubin around?

albumin

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Is unconjugated bilirubin lipid soluble or not?

-lipid soluble

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Is conjugated bilirubin water soluble?

Yes

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What are the characteristics of pre-hepatic jaundice?

the urine/stools are normal
unconjugated hyperbilirubinaemia
check stool for (ova, parasites, cysts)
Direct Coombs test for autoimmune haemolytic anaemia

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What are the causes of pre-hepatic jaundice?

inherited anaemias-spherocytosis, sickle cell anaemia, thalassemia, G6DP
acquired: malaria, SLE

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What are the characteristics of hepatic jaundice?

mixed picture with normal stools and dark urine sometimes
decreased albumin
increased AST and ALT
On abdo exam: increased nodulariy and echogenicity in cirrhosis

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What are the causes of hepatic jaundice?

infective causes:
- viral hepatitis(HBV)
- CMV, TB, EBV
Liver cirrhosis
- alcoholic liver disease
- sarcoidosis/amyloidosis
Hepatotoxic drugs:
- alcohol. isoniazid, paracetamol, augmentin
inherited decreased unconjugated bilirubin
- gilberts syndrome
- crigler najjar 1 and 2

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What is the presentation of cholestatic jaundice?

dark urine, pale stools
conjugated hyperbilirubinaemia
increased ALP and GGT before ALT,AST
Abdo ultrasound usually depicts dilated ducts >8mm which you then have to do ERCP,MRCP or PTC

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What are the causes of cholestatic jaundice?

intraluminal
mural
extramural

What are the intraluminal causes?

gallstones

- parasites like schistosomiasis

What are the mural causes?

cholangitis
cholelithiasis
choledochal cysts
biliary strictures caused by post ERCP
biliary strictures caused by gallstones o hronic pancreatitis

What are the extra-luminal causes?

carcinoma of the head of the pancreas

- Mirizzi’s syndrome

What is the function of the biliary tract?

To carry bile from the liver

What is bile made up of?

water
electrolytes
bile pigment which is mostly bilirubin
bile salts
phospholipid
mucus
cholesterol

How is bilirubin formed and how does obstructie jaundice cause pale stools?

Bilirubin is conjugated in the liver and travels down the biliary duct because it is soluble. If there is an obstruction then there is backup of the bilirubin and increased conjugated bilirubin in circulation.
Stercobilinogen is the derivative of bilirubin that causes the brown colour of poo and once absorbed it is urobilongen. So if there is an obstruction then there is no way for the stercobilinogen to get to the stool hence pale stools

Why does the urine still turn dark?

Because of the increased concentration of the conjugated bilirubin

What are bile salts?

Metabolites of cholesterol that are different to bile pigments becuase they actually serve a function and are not just waste

What are the 2 functions of bile salts?

1. Helps absorbs lipids in the GIT 2. To ensure cholesterol is soluble in bile 95% of bile salts are going to be reabsorbed in the terminal ileum and reused by the liver

What happens if the bile salts do not function?

1. malabsorption leading to steatorrhea | 2. pruritis

What is Hartmann's pouch?

It is when a pouch develops adjacent to the cystic duct

What does cholecyskinin do?

It leads to the contraction of the gallbladder and relaxation of the sphincter of Oddi caused by food intake

What are the 2 main causes of obstructive jaundice?

1. gallstones | 2. malignancy

What are the luminal causes of obstructive jaundice?

1. gallstones 2. worms 3. hydatid cysts 4. blood clots as found in haemobilia due to trauma This type is usually associated colicky right upper quadrant pain

What are the biliary wall causes of obstructive jaundice?

1. Congenital: biliary atresia, choledochal cyst 2. Inflammatory: sclerosing cholangitis 3. Trauma 4. malignant cholangiocarcinoma

What are the causes of obstructive jaundice outside of the biliary tract?

1. swollen lymph nodes from TB, gastric cancer, lymphoma 2. adavanced gallbladder pathology like Mirizzi's syndrome, chronic pancreatitis, pancreatic cyst 3. Malignancy like peri-ampullary ca and ca of the pancreatic head

Why does peri-ampullary ca have a better prognosis than pancreatic head ca?

1. It has a slower progression | 2. It affects the biliary tree faster so patients show up earlier

What are the pathophysiological signs and symptoms of obstructive jaundice?

1. hepatomegaly (congestion) 2. raised total bilirubin, raised ALP and GGT 3. low serum albumin, decreased clotting factors 4. Dilation of the biliary tree above the obstruction 5. Increased risk of infection (cholangitis)

What are the pathophysiological signs and symptoms below the obstruction?

1. pale stools 2. decreased stercobilinogen and urobilinogen but still dark urine 3. Acute renal failure 4. decreased absorption of vitamins which leads to deficiency in vitamin k which leads to dysfunction in clotting factors 2, 7, 9, 10

What imaging would you get for obstructive jaundice?

1. chest X-ray 2. Abdominal X-ray to look for gallstones(radio-opaque ones) 3. ultrasound -gold standard 4. Others: - CT - MRCP(magnetic resonance cholangiopancreatogram) which helps us visualise the biliary tract - ERCP-CONTRAST introduced from the bottom(endoscopic retrograde cholangiopancreatogram) - PTC-percutaneous transhepatic cholangiogram

When would an ERCP be indicated?

When we are unsure of the diagnosis and want to take a biopsy, put in a stent or stone removal

What is the peri-operative management of the patient with obstructive jaundice?

1. vitamin K 5-10mg IV daily and fresh frozen plasma 2. Broad spectrum IV antibiotics which treat the cholangitisprevent SIRS 3. Start patient on fluids to maintain renla function 4. Put in catheter to monitor the urinary output