Jaundice Flashcards
Give pre-hepatic causes of jaundice
Intravascular haemolysis
Congenital: G6PD, pyruvate kinase deficiency, sickle cell, thalassaemia, hereditary spherocytosis
Acquired: DIC, malaria, HELLP, artificial heart valves, blood group mismatch, autoimmune haemolysis
Give hepatic causes of jaundice
Reduced uptake: contrast agents, portosystemic shunts
Congenital enzyme problems: Gilbert’s, Crigler-Najjar syndrome
Give post-hepatic causes of jaundice
Vascular - Budd-Chiari syndrome
Infection - viral hepatitis, ascending cholangitis, liver abscess, tapeworm
Trauma - gallstones, stricture (after ERCP)
Autoimmune - hepatitis
Metabolic - Wilson’s, haemochromatosis
Inflammation - primary biliary cirrhosis, PSC, pancreatitis
Neoplasia - metastatic liver cancer, hepatocellular, pancreatic, cholangiocarcinoma
Drugs - alcohol, paracetamol overdose, valproate, rifampicin, co-amoxiclav, nitrofurantoin, OCP
What may cause black urine
Intravascular haemolysis
Free haemoglobin is degraded via an alternative pathway into haemosiderin (dark but water soluble)
What role does ethnic background have in jaundice differentials
West African and Afro-caribbean - sickle cell
Mediterranean, asian - thalassaemia, G6PD def
What significance does current pregnancy have in the cause of jaundice
Consider intrahepatic cholestasis of pregnancy
Pre-eclampsia with HELLP syndrome
Acute fatty liver of pregnancy
What does jaundice with associated RUQ pain, N+V and pruritus suggest
Hepatitis (autoimmune, viral, autoimmune etc.)
What does jaundice with fever or diarrhoea suggest
Infection of liver e.g. viral hepatitis, abscess
What does jaundice with steatorrhoea suggest
Bile flow obstruction
What does jaundice with weight loss, fever and sweats suggest
Malignancy of the liver, bile duct or pancreas
What does jaundice with bronzed skin and signs of DM suggest
Haemochromatosis
What does jaundice with exposure to water/sewage suggest
Risk factor for leptospirosis
What associated symptoms should be asked about with jaundice
RUQ pain N+V Fever Diarrhoea Steatorrhoea Weight loss, fatigue, night sweats, fever Bronzed skin Polyuria, weight los Exposure to outdoor water/sewage
What should be asked about in the past medical history for a jaundiced patient
Gall stones Liver diseases Haemophilia Recent transfusion or surgery DM Ulcerative colitis Emphysema Psychosis
What medications should be asked about specifically in the history for a jaundiced patient
Intravascular haemolysis: sulphonamides, aspirin
Autoimmune, extravascular - Methyldopa
Hepatitis - paracetamol overdose
Cholestasis - co-amoxiclav
What should be asked about in the family history for a jaundiced patient
Gilbert's Haemochromatosis Wilson's disease Sickle cell Thalassaemia Hereditary spherocytosis G6PD deficiency
What should be asked about in social history for a jaundice patient
Excessive alcohol consumption IVDU Unprotected sex or multiple partners Foreign travel (malaria, Hep A, E) Tattoos
What is the recommended alcohol intake and what are the worrying levels
<14 units/week for females
<21 units/week for males
> 35 units/week or >50 units/week (F/M) is very dangerous
What are the signs of dehydration on examination
Tachycardia
Narrow pulse pressure
Hypotension (late sign)
What signs should you look for on inspection
Icteric or jaundice Cachetic (malignancy) Scratch marks (pruritus) Track marks (IVDU) Spider naevi, bruises, clubbing, palmar erythema, dupuytren's contracture, gynaecomastia (CLD) Bronze tan (haemochromatosis) Kayser-Fleischer rings (Wilson's)
What signs should you feel for on palpation
Hepatosplenomegaly or epigastric mass (malignancy, extravascular haemolysis, hepatitis)
RUQ tenderness (acute hepatitis, gall bladder diseases)
Ascites (CLD)
Palpable lymphadenopathy (malignancy)
What investigations should be done initially for jaundice
FBC - check for anaemia Serum bilirubin - confirm jaundice and distinguish between pre and post hepatic cause Liver and biliary enzymes LFTs (Clotting and albumin) Urine bilirubin Serum amylase Pregnancy test
What are the second line investigations (bloods) for jaundiced patients
Haemolysis screen
Consider haptoglobin, LDH, DAT/Coomb’s test, blood film
Viral screen- Hep A,B,C, EBV, CMV
Autoimmune screen 0 ANA, anti smooth muscle antibodies and antimitochondrial antibodies for hepatitis
Congenital screen - haemochromatosis, alpha1 antitrypsin deficiency, Wilson’s disease
What are the second line investigations (imaging) for jaundiced patients
USS Liver- liver cirrhosis or carcinoma
USS Bile duct - obstruction by cholangiocarcinoma, gallstone, pancreatic cancer
MRCP, endoscopic ultrasound, CT abdomen
Prognosis for Hepatitis B
Full recovery in most cases
Can reactivate if there is immunosuppression later in life
10% become asymptomatic carriers
5-10% develop chronic Hep B -> 20% cirrhosis
0.5% develop fulminant hep B (mortality 80%)
Management for viral Hepatitis
Supportive
Practice safe sex until vaccination
Minimise alcohol consumption to <10 units/week
Avoid sharing toothbrushes or razors
Contact tracing
Vaccination of current sexual partners and children
What needs to be demonstrated for diagnosis of Gilbert’s syndrome
Normal liver enzymes
Normal haemoglobin levels
Serum bilirubin <100 microM
No bilirubin on dipstick
What is PBC characterised by
T cell mediated destruction of the biliary ducts -> outflow of bile contents is obstructed
AMA
What is the management of PBC
Referral to herpetologist
Confirming diagnosis via MRCP and liver biopsy
Immunosuppression w/ steroids, methotrexate, ciclosporin
Bile salt replacement w/ ursodexycholic acid
Fat-soluble vitamin replacement (ADEK)
Pruritus w/ cholestyramine and antihistamines
Liver transplantation if cirrhosis
What is PSC and what is it associated with
T cell mediated autoimmune destruction of biliary epithelial cells, leading to mulitfocal scarring of biliary ducts
Associated with ulcerative colitis
pANCA
What is the risk of catching viruses via needle stick injury
HIV - 0.3%
Hep C - 3%
Hep B - 30%
At what level will bilirubin need to be for clinical jaundice
> 40 (normal 3-17)
What is a Klastskin tumour
cholangiocarcinoma at the confluence of right and left hepatic ducts
