Jaundice

Question 1

Hepatic dysfunction in adults

Answer 1

Pruritus, jaundice, asterixis, palmar erythema, spider angioma, ascites, hepatomegaly, gynecomastia, confusion, fatigue

Question 2

Hepatic dysfunction in neonates

Answer 2

Jaundice, FTT, irritability, poor feeding, pale stool, dark urine, hepatomegaly, vomiting,

Question 3

Causes of neonatal jaundice (24 hours)

Answer 3

24 h ALWAYS pathologic - sepsis, hemolytic, TORCH infections, ABO incompatibility, Rh

Question 4

Physiologic cause of jaundice

Answer 4

Breast-feeding, breast milk

Question 5

Indications for phototherapy in neonates.

Answer 5

Refer to phototherapy nomogram

Question 6

Effect of unconjugated hyperbilirubinemia

Answer 6

Kernicterus- deposits in basal ganglia

Hypotonia, delayed motor skills, gaze palsy,
mitral regurgitation, sensorineural hearing loss
seizures, mental retardation

Question 7

Origins of bilirubin in the plasma.

Answer 7

Heme breakdown (80%)
Also from heme-containing proteins found in other tissues, (liver and muscles)

Question 8

Heme metabolism

Answer 8

RBC broken down after 120 days
mainly in spleen, lymph nodes by macrophages

Bilirubin binds to albumin and travel to liver become conjugated

Question 9

Drug-induced cholestatic jaundice

Answer 9

Slowing of the flow of bile from the liver, due to medication use (ie: cyclosporine, cipro, amoxicillin-clav, azithromycin)

Question 10

What is MRP2?

Answer 10

Transports conjugated billrubin into bile canaliculi

Question 11

Enterohepatic recirculation

Answer 11

Bile acids are actively reabsorbed through ileum and carried back to the liver for re-secretion into bile

Question 12

Prehepatic

Answer 12

Problems before getting to liver

Extra-vascular: hereditary spherocytosis, G6PD deficiency, other structural abnormalities

Intravasular: hemolysis, drug-induced,
Hematoma

Question 13

Intrahepatic

Answer 13

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

Question 14

Post-hepatic

Answer 14

Obstruction
Malignancy (pancreatic)
Lymphoma 
Gallstones
Drug-induced cholestasis

Question 15

How does phototherapy work

Answer 15

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)

Question 16

laboratory investigations for adult with jaundice

Answer 16

Liver function tests:
Bilirubin 
Albumin 
INR, PT 
Total protein 

Liver Enzymes: AST, ALP
Hepatitis 
HIV 
Direct coombs 
Blood smear

Question 17

Hepatitis risk factors

Answer 17

IV drug user
Travel to another country 
Sexual intercourse
Recent blood transfusion
Direct blood contact

Question 18

Complications of liver disease

Answer 18

Esophageal varcices, coagulopathy, caput medusa, ascites, hepatic encephalopathy, death

Question 19

Crigler-Najjar Syndrome

Answer 19

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

Question 20

Wilson’s disease

Answer 20

Fault in the metabolism of copper

Question 21

Causes of cirrhosis

Answer 21

EtOH, NAFLD, viral, autoimmune, PBC, metabolic (hematochromatosis, Wilson’s)

Question 22

Criteria for cirrhosis

Answer 22

Is not a requirement for transaminases to be elevated. Low platelets, high INR, albumin low, bilirubin high.

Question 23

Complication of liver disease

Answer 23

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.