Jaundice Flashcards
What are RBCs broken down into and each of their fates
Hb into unconjugated bilirubin that binds to albumin in blood
Iron stored in transferrin proteins
What is other name for conjugated bili
Glucuronate
What is conjugated bili converted to
Urobilinogen
Stercobilinogen
(colourless)
What are stercobilinogen and urobilinogen converted to
oxidised to stercobilin and urobilin
What does high conjugated bili in blood indicate about cause of jaundice
Obstructive
What does high unconjugated bili in blood indicate about cause of jaundice
Pre-hepatic and hepatic
Confusion over post hepatic and hepatic definitions
Post hepatic can include bilie canaliculi or it can be hepatic- confusion over PSC
What is cholestatic jaundice
Jaundice from obstruction of common bile duct
2 causes of cholestatic bile duct
Gallstones
Ileus of commmon bile duct- drug induced
Two categories of increased production of bili
Intra and extravacular in spleen
How can urine be dark in pre hepatic jaundice
Haemoglobin can be broken down an alternative route into haemosiderin which is very dark
How to confirm if jaundice pre hepatic
Blood film see schistocytes or spherocytes
Congenital causes of intravascular heamolysis
SCD
Thalassaemia
PK deficiency
G6PDH deficiency
Acquired causes of intravascular haemolysis
DIC
Blood group mismatch
Malaria
Artificial heart valves
Where does extravascular haemolysis occur
Spleen- macrophages nibble at blood cells causing spherocytes
How does intravascular haemolysis appear on blood film
Schistocytes
Examination finding of extravascular haemolysis
Splenomegaly
Congenital cause of extravascular haemolysis
Hereditary spherocytosis
Acquired cause of extravascular spherocytosis
AI haemolysis
What drugs can induce cholestasis of common bile duct
Co-amoxiclav, the pill, nitrofuarontin
What do fever and diarrorhoea indicatea bout jaundice cause
abcess or infection
What does steatorrhoea indicate about jaundice
Cholestatic
What do signs of diabetes indicate about jaundice
Haemochromatosis
Pancreatic insufficiency
Patient presents with liver problems and also polyuria and polydipsia
Haemochromatosis
What does emphysema suggest about jaundice
Anti-trypsin
What drug can cause extravascular haemolysis
Methyldopa
What drug can cause intravascular aemolysis
Aspirin
Sulphonamides
Must asks in relation to jaundice
Sexual Travel All drugs Transfusions Tattoos
What happens to pulse pressure in dehydration
Narrow
What are signs of stable chronic liver disease
Spider naevi Clubbing Bruising Palmar erythema Gynaecomastia
What does RUQ tenderness indicate about jaundice
Gall bladder inflammations
Acute hepatitis
What to look for in FBC jaundice and further investigation if necessary
Anaemia suggesting haemolysis so do blood film
What to look for in levels of bilirubin
Elevated unconjugated bilirubin suggesting prehepatic
Elevated conjugated suggesting post hepatic
What does elevated AST and ALT suggest and further investigation
Viral serology
Autoantibodies screen- ASMA, AMA, ANA,ANCA
What does elevated GGT and ALP suggest and further investigation
Biliary tree problem so US biliary tree
First line investigations for jaundice
FBC LFTs Van der begh Urinalysis for bilirubin Serum amylase
Jaundice with high reticulocytes
Pre hepatic haemolysis
Microcytic anaemia with jaundice
Thalassaemia
When will you see ALT and AST in thousands
Ischaemic hepatitis
Paracetemol OD
Viral
Why cant use ALP exclusively
Produced in many other cells such as placenta and bones- use GGT as exclusive to biliary tree
How can bilirubin in urine appear
Brown
How is jaundice specific to pregnancy
Acute fatty liver
HELLP syndrome
Intrahepatic cholestasis
Secind line investigations for jaundice
Haemolysis screen
Viral screen
Autoimmune screen
Congential screen
What would be tested in haemolysis screen for jaundice
Coombs- autoimmune haemolysis
Blood film for spherocytes, reticulocytes and schistocytes
Haptoglobins
LDH
What would be tested for viral screen for jaundice
Hep A-C
CMV
HIV
EBV
What would be tested for in autoimmune screen for jaundice
ANA- AIH
ASMA- AIH
AMA- PBC
ANCA- PSC
What would be tested for in congenital screen for jaundice
Haemochromatosis- high ferritin, high transferrin sats
Wilsons- high copper- low caeruplasmin
Antitrypsin- low antitrypsin
What can be picked up by US of liver
Cancer Cirrhosis Cholangiocarcinoma Choledochal cyst Gallstone Vascular causes
If US isnt clear what do you use
MRCP
CT
Endoscopic US
What would consider if biliary outflow a problem but bile duct not dilated
Drugs
PSC
PBC
How long does it take albumin to drop and what are 3 causes
Nephrotic syndrome
Reduced diet
Liver synthesis problems
What is tested for in Hep B serology
Surface and core antigen anitbody
Surface antigen
Just surface suggests vaccine
Prognosis options for Hep B infection
Full recovery- self limiting however can persist in blood and if immunosuppressed can cause infection
Chronic hep b
Carrier status- asymptomatic carrier
Fulminant Hep B- 0.5% get this but 80% mortality
Acute phase management of Hep B
Contact tracing partners and vaccinating them
Safe sex
Avoid toothbrush and razor shaving
Minimise alcohol
Investigation findings for gilberts
Bilirubin lower than 100micros
Low conjugated bili
Management of gallstones
Ultrasound to prove gallstone but if unsure do MRCP
Most pass themselves but if are jaundiced do ERCP
What must be excluded in gallstones
Cholestytitis
Ascending cholangitis
How is cholecystitis differentiated from gallstones
Constant pain and fever
Treatment of cholecystitis
Abx
Analgesia
IV fluids
Cholecystectomy after a few weeks when recovered
Management of ascending cholangitis
Blood cultures
Close monitoring
Abx broad spectrum
ERCP to drain duct of pus
Pathophysiology of PBC
T cell destruction of biliary tree which results in speapage of contents
Imaging to confirm PBC and PSC
MRCP
If strongly suspected would do first before US
FBC finding of someone with cancer
Anaemia
First line imaging for pancreatic cancer
CT
Procedure to remove pancreatic cancer
Whipple
Jaundice with lethargy and tiredness
Haemolysis
What is risk of HIV infection in needlestick injury
0.3
Risk of Hep C infection in needlestick infection
3
Risk of Hep B infection after needlestick infection
30
How to differentiate between chronic and acute Hep B
Chronic will be IgG positve whereas acute IgM
Most common tumours causing obstructive jaundice
Pancreatic
Lymph nodes at porta hepatis
Cholangiocarcinoma much rarer
What is nutritional consequence of obstructice jaundice
Vit ADEK deficiency
