Jaundice

Question 1

What is jaundice

Answer 1

Accumulation of bilirubin in the skin giving a yellow/orange pigmentation and a significant itch

Question 2

Where is jaundice most noticeable

Answer 2

The sclera of the eye

Question 3

How are patients with jaundice described to look

Answer 3

Icteric

Question 4

How does bilirubin affect the circulation of haem

Answer 4

Haem from RBCs being reprocessed is converted into biliverdin and then into bilirubin which allows the circulation of haem

Question 5

Describe how bile is formed

Answer 5

Haem converted into bilibverdin then bilirubin has to be conjugated and from that bilirubin is excreted from the liver cells into the biliary tree forming bile

Question 6

What is the purpose of the gall bladder

Answer 6

It can store bilirubin or it can contract and squeeze the bilirubin into the small intestine through the biliary duct

Question 7

What happens to bile after it is secreted into the small intestine

Answer 7

Conjugated bilirubin is passed down to the large intestine where it is reabsorbed, converted to urobilinogen which can be excreted through the kidneys, giving urine its colour

Question 8

What is the role of urobilinogen

Answer 8

Can be excreted through the kidneys but some will pass through the stool and give stercobilin - the colour pigment for the stool
Some urobilinogen is reabsorbed into the liver and reprocessed

Question 9

What are the different classifications of jaundice

Answer 9

Pre-hepatic
Hepatic
Post-hepatic

Question 10

Describe pre-hepatic jaundice

Answer 10

Excess of bilirubin being processed and passed into the bile duct
More conjugated bilirubin being produced and still more bilirubin in the blood which can’t be conjugated and therefore will accumulate in the blood and skin causing jaundice but not affecting the urine or stool colours

Question 11

What are common causes of pre-hepatic jaundice

Answer 11

Haemolytic anaemia
Post transfusion - bad match
Neonatal (maternal RBC induced)

Question 12

Describe hepatic jaundice

Answer 12

Problem with hepatic cell therefore the unconjugated bilirubin isn’t conjugated in the liver cell
No conjugated bilirubin is passed into the biliary system and no conjugated bilirubin is passed into the blood

Question 13

What are the signs of hepatic jaundice

Answer 13

No pigment in the stool - it will be pale

No pigment in the urine because unconjugated bilirubin can’t be passed to the kindney

Question 14

Describe post-hepatic jaundice

Answer 14

Conjugated bilirubin being passed into the bile system but a blockage causing this to flow back through the hepatic cells and into the blood

Question 15

What are the signs of post-hepatic jaundice

Answer 15

No pigment passing to the stools - pale stools

An excess of pigment in the blood, passing to the urine causing dark urine

Question 16

What are the common causes of blockage in post-hepatic jaundice

Answer 16

Intrahepatic - primary biliary sclerosis is an autoimmune disease destroying the bile tree and its pathways
Extrahepatic - biliary system can be blocked by either gallstones or tumours

Question 17

When is bile secreted from the gall bladder

Answer 17

Food entering the duodenum will cause a reflex contraction of the gall bladder releasing bile from the common bile duct to enter the duodenum from the ampulla

Question 18

What is cholecystitis and what will this cause

Answer 18

Inflammation of the gall bladder
Because the gall bladder sits against the diaphragm, at the bottom and behind the liver, it will cause inflammation of the diaphragm

Question 19

What are the symptoms of cholecystitis

Answer 19

Referred pain in shoulder tip
Abdominal pain in right side radiating to the back
Pain from eating fatty foods - stimulates bile release
Usually gallstones - rarely cholangiocarcinoma

Question 20

What investigations can be carried out on patients with jaundice

Answer 20

Ultrasound - detects dilated bile channels within the liver and biliary tree
Plain radiographs - can be used to see small vessels within the liver that can’t be seen in an ultrasound
ERCP

Question 21

What is an ERCP

Answer 21

Endoscopic Retrograde Cholangio Pancreatography
Best way to illuminate the biliary system and also allows the possibility of carrying out procedures to the biliary duct eg - stented ampulla

Question 22

How is ERCP carried out

Answer 22

Using an endoscope to put a cannula into the biliary tree from the duodenum
From that, dye is injected that goes towards the pancreatic system and upwards towards the liver where it branches forming the biliary tree to the hepatic cells

Question 23

What tumours may cause an obstruction leading to jaundice

Answer 23

Cholangiocarcinoma - can arise anywhere in the biliary system
Pancreatic cancer - head of the pancreas

Question 24

Give examples of common pancreatic diseases

Answer 24

Pancreatitis

Cystic fibrosis

Question 25

How is pre-hepatic jaundice managed

Answer 25

Identify and treat the cause

Question 26

How is post-hepatic jaundice managed

Answer 26

Remove obstruction:
Gall stones via ERCP
Force open channel with a stent

Question 27

How else can jaundice be managed

Answer 27

Prevention of gall stone recurrence by removing the gall bladder (cholecystectomy)
Prevent build up of bile acid with a low calorie, low cholesterol diet
Prevent bile acid reabsorption from the GIT

Question 28

What is neonatal jaundice

Answer 28

Pre-hepatic jaundice caused by an increased haem breakdown associated with a combination of birth trauma and ABO rhesus incompatibility from maternal and foetal blood mixing during delivery

Question 29

Why does the baby become jaundiced in neonatal jaundice

Answer 29

Ability for baby’s liver to process increased haem load and to produce conjugated bilirubin is reduced therefore unconjugated bilirubin accumulates in the circulation

Question 30

Why is neonatal jaundice especially dangerous

Answer 30

The baby’s blood brain barrier is not yet fully established so the unconjugated bilirubin may pass into the brain causing damage

Question 31

What is it called when there is accumulation of bilirubin in the brain

Answer 31

Kernicterus

Question 32

How is neonatal jaundice treated

Answer 32

Phototherapy - blue light applied to the skin will cause the bilirubin to breakdown so it can pass out through the kidneys
Sunlight contains the same blue light wavelengths so will do the same job