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Y3 Oxford Cases > Jaundice > Flashcards

Jaundice Flashcards

1
Q

Give pre-hepatic causes of jaundice

A

Intravascular haemolysis
Congenital: G6PD, pyruvate kinase deficiency, sickle cell, thalassaemia, hereditary spherocytosis

Acquired: DIC, malaria, HELLP, artificial heart valves, blood group mismatch, autoimmune haemolysis

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2
Q

Give hepatic causes of jaundice

A

Reduced uptake: contrast agents, portosystemic shunts

Congenital enzyme problems: Gilbert’s, Crigler-Najjar syndrome

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3
Q

Give post-hepatic causes of jaundice

A

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

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4
Q

What may cause black urine

A

Intravascular haemolysis

Free haemoglobin is degraded via an alternative pathway into haemosiderin (dark but water soluble)

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5
Q

What role does ethnic background have in jaundice differentials

A

West African and Afro-caribbean - sickle cell

Mediterranean, asian - thalassaemia, G6PD def

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6
Q

What significance does current pregnancy have in the cause of jaundice

A

Consider intrahepatic cholestasis of pregnancy
Pre-eclampsia with HELLP syndrome
Acute fatty liver of pregnancy

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7
Q

What does jaundice with associated RUQ pain, N+V and pruritus suggest

A

Hepatitis (autoimmune, viral, autoimmune etc.)

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8
Q

What does jaundice with fever or diarrhoea suggest

A

Infection of liver e.g. viral hepatitis, abscess

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9
Q

What does jaundice with steatorrhoea suggest

A

Bile flow obstruction

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10
Q

What does jaundice with weight loss, fever and sweats suggest

A

Malignancy of the liver, bile duct or pancreas

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11
Q

What does jaundice with bronzed skin and signs of DM suggest

A

Haemochromatosis

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12
Q

What does jaundice with exposure to water/sewage suggest

A

Risk factor for leptospirosis

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13
Q

What associated symptoms should be asked about with jaundice

A 
RUQ pain
N+V
Fever
Diarrhoea 
Steatorrhoea
Weight loss, fatigue, night sweats, fever
Bronzed skin
Polyuria, weight los
Exposure to outdoor water/sewage
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14
Q

What should be asked about in the past medical history for a jaundiced patient

A 
Gall stones
Liver diseases
Haemophilia
Recent transfusion or surgery 
DM
Ulcerative colitis 
Emphysema
Psychosis
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15
Q

What medications should be asked about specifically in the history for a jaundiced patient

A

Intravascular haemolysis: sulphonamides, aspirin

Autoimmune, extravascular - Methyldopa

Hepatitis - paracetamol overdose

Cholestasis - co-amoxiclav

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16
Q

What should be asked about in the family history for a jaundiced patient

A 
Gilbert's 
Haemochromatosis 
Wilson's disease
Sickle cell
Thalassaemia 
Hereditary spherocytosis
G6PD deficiency
17
Q

What should be asked about in social history for a jaundice patient

A 
Excessive alcohol consumption
IVDU 
Unprotected sex or multiple partners
Foreign travel (malaria, Hep A, E)
Tattoos
18
Q

What is the recommended alcohol intake and what are the worrying levels

A

<14 units/week for females
<21 units/week for males

> 35 units/week or >50 units/week (F/M) is very dangerous

19
Q

What are the signs of dehydration on examination

A

Tachycardia
Narrow pulse pressure
Hypotension (late sign)

20
Q

What signs should you look for on inspection

A 
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)
21
Q

What signs should you feel for on palpation

A

Hepatosplenomegaly or epigastric mass (malignancy, extravascular haemolysis, hepatitis)
RUQ tenderness (acute hepatitis, gall bladder diseases)
Ascites (CLD)
Palpable lymphadenopathy (malignancy)

22
Q

What investigations should be done initially for jaundice

A 
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
23
Q

What are the second line investigations (bloods) for jaundiced patients

A

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

24
Q

What are the second line investigations (imaging) for jaundiced patients

A

USS Liver- liver cirrhosis or carcinoma
USS Bile duct - obstruction by cholangiocarcinoma, gallstone, pancreatic cancer
MRCP, endoscopic ultrasound, CT abdomen

25
Q

Prognosis for Hepatitis B

A

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%)

26
Q

Management for viral Hepatitis

A

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

27
Q

What needs to be demonstrated for diagnosis of Gilbert’s syndrome

A

Normal liver enzymes
Normal haemoglobin levels
Serum bilirubin <100 microM
No bilirubin on dipstick

28
Q

What is PBC characterised by

A

T cell mediated destruction of the biliary ducts -> outflow of bile contents is obstructed
AMA

29
Q

What is the management of PBC

A

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

30
Q

What is PSC and what is it associated with

A

T cell mediated autoimmune destruction of biliary epithelial cells, leading to mulitfocal scarring of biliary ducts

Associated with ulcerative colitis
pANCA

31
Q

What is the risk of catching viruses via needle stick injury

A

HIV - 0.3%
Hep C - 3%
Hep B - 30%

32
Q

At what level will bilirubin need to be for clinical jaundice

A

> 40 (normal 3-17)

33
Q

What is a Klastskin tumour

A

cholangiocarcinoma at the confluence of right and left hepatic ducts

Y3 Oxford Cases (29 decks)

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