Jaundice Flashcards
Hepatic dysfunction in adults
Pruritus, jaundice, asterixis, palmar erythema, spider angioma, ascites, hepatomegaly, gynecomastia, confusion, fatigue
Hepatic dysfunction in neonates
Jaundice, FTT, irritability, poor feeding, pale stool, dark urine, hepatomegaly, vomiting,
Causes of neonatal jaundice (24 hours)
24 h ALWAYS pathologic - sepsis, hemolytic, TORCH infections, ABO incompatibility, Rh
Physiologic cause of jaundice
Breast-feeding, breast milk
Indications for phototherapy in neonates.
Refer to phototherapy nomogram
Effect of unconjugated hyperbilirubinemia
Kernicterus- deposits in basal ganglia
Hypotonia, delayed motor skills, gaze palsy,
mitral regurgitation, sensorineural hearing loss
seizures, mental retardation
Origins of bilirubin in the plasma.
Heme breakdown (80%) Also from heme-containing proteins found in other tissues, (liver and muscles)
Heme metabolism
RBC broken down after 120 days
mainly in spleen, lymph nodes by macrophages
Bilirubin binds to albumin and travel to liver become conjugated
Drug-induced cholestatic jaundice
Slowing of the flow of bile from the liver, due to medication use (ie: cyclosporine, cipro, amoxicillin-clav, azithromycin)
What is MRP2?
Transports conjugated billrubin into bile canaliculi
Enterohepatic recirculation
Bile acids are actively reabsorbed through ileum and carried back to the liver for re-secretion into bile
Prehepatic
Problems before getting to liver
Extra-vascular: hereditary spherocytosis, G6PD deficiency, other structural abnormalities
Intravasular: hemolysis, drug-induced,
Hematoma
Intrahepatic
Liver can't conjugate Cirrhosis (mainly) Gilbert’s (asymptomatic -appears with body stresses (infection, stress, starvation) Crigler-Najjar (fatal early) Dubin-Johnson - similar to gilberts
Post-hepatic
Obstruction Malignancy (pancreatic) Lymphoma Gallstones Drug-induced cholestasis
How does phototherapy work
Causes structural changes to bilirubin molecules, making it more water soluble so it can be excreted in urine
Uses blue to blue-green light (wavelength 460 to 490 nm)
laboratory investigations for adult with jaundice
Liver function tests: Bilirubin Albumin INR, PT Total protein
Liver Enzymes: AST, ALP Hepatitis HIV Direct coombs Blood smear
Hepatitis risk factors
IV drug user Travel to another country Sexual intercourse Recent blood transfusion Direct blood contact
Complications of liver disease
Esophageal varcices, coagulopathy, caput medusa, ascites, hepatic encephalopathy, death
Crigler-Najjar Syndrome
Disorder of the metabolism of bilirubin, high levels of unconjugated bili in babies,
Type 1 is fatal often and needs liver transplant, Type 2 can be treated with phenobarbital
Wilson’s disease
Fault in the metabolism of copper
Causes of cirrhosis
EtOH, NAFLD, viral, autoimmune, PBC, metabolic (hematochromatosis, Wilson’s)
Criteria for cirrhosis
Is not a requirement for transaminases to be elevated. Low platelets, high INR, albumin low, bilirubin high.
Complication of liver disease
SBP - cell count on the para >250 (neutrophil), treat with ceftriaxone, prophylaxis daily if get it once.
HCC - transplant (good luck) - U/S to screen every 6 months. Triphasic and AFP to diagnose
Ascites - lasix/spirono (40/100), sodium restrict, para.
Varices - prevention - scope - non-selective BB (nadolol) reduce portal pressures. PPI, octreotide/ PPI, ceftriaxone, give blood, Blakemore tube
Encephalopathy - lactulose/ abx
Renal dysfunction - hepatorenal - lack of blood flow to the kidney, type of pre-renal AKI - octreotide or midodrine, albumin, trial this for 48 hours.
