Jaundice

Question 1

What is jaundice?

Answer 1

Refers to yellowing of skin, sclerae and mucosae from increased plasma bilirubin.

It is classified by the site of the problem or by the type of circulating bilirubin.

Question 2

Causes of unconjugated hyperbilirubinaemia.

Answer 2

Water-insoluble = does not enter urine.

Overproduction like in haemolysis (malaria/DIC) and ineffective erythropoiesis

Impaired hepatic uptake - Drugs like paracetamol and rifampicin as well as ischaemic hepatitis.

Impaired conjugation - Gilbert’s, Crigler-Najjar

Physiological neonatal jaundice

Question 3

Causes of intra-hepatic jaundice.

Answer 3

Virus - Hep B, Hep C, CMV, EBV etc…

Alcohol

Cirrhosis

Malignancy/metastases

Abscess

Haemochromatosis

Autoimmune hepatitis

Septicaemia

Leptospirosis

Syphilis

Alpha1-antitrypsin def.

Budd-Chiari

Wilson’s disease

Question 4

Causes of post-hepatic jaundice.

Answer 4

Primary biliary cholangitis (PBC)

Primary sclerosing cholangitis (PSC)

Drugs

Common bile duct gallstones

Pancreatic cancer

Compression of the bile duct

Cholangiocarcinoma

Choledochal cyst

Caroli’s disease

Mirrizi’s syndrome

Question 5

Drugs causing drug-induced jaundice.

Answer 5

Antimalarials like dapsone

Paracetamol overdose

Isoniazid, rifampicin, pyrazinamide

Sodium valproate

Halothane

Statins

MAOi

Sulfonylureas

Flucloxacillin

Fusidic acid, co-amoxiclav and nitrofurantoin

Steroids

Prochlorperazine

Chlorpromazine

Question 6

Causes of jaundice in a previously stable patient with cirrhosis.

Answer 6

Sepsis

Malignancy

Alcohol/drugs

GI bleed

Question 7

History of jaundice.

Answer 7

Ask about blood transfusion, IV drug use, body piercings, tattoos, sexual activity, travel abroad, jaundiced contacts, FH, alcohol use and all medications

Question 8

Examinations of jaundice.

Answer 8

Signs of chronic liver disease

Hepatic encephalopathy

Lymphadenopathy

Hepatomegaly

Splenomegaly

Ascites

Palpable gallbladder

Urine colour

Pale stools?

Question 9

Investigations of jaundice

Answer 9

Urine

Bloods - FBC, clotting, reticulocyte count, Coomb’s test, haptoglobin, LFTs, U&Es, gamma-GT, total protein, albumin.

Paracetamol levels

Microbiology - Blood and other cultures. Hepatitis serology.

Ultrasound

ERCP/MRCP if nothing is improving.

Liver biopsy

CT/MRI if suspecting malignancy.

Question 10

Treatment of jaundice.

Answer 10

Treat underlying cause

Hydrate

Broad-spectrum antibiotics if obstruction

Monitor for ascites, encephalopathy.