jaundice and ascites Flashcards
case w. jaundice ddx
Liver cirrhosis Liver neoplasm Cholecystitis Choledocholithiasis Primary biliary cirrhosis Hepatitis
what labs to get
CMP: some liver tests: ALT, AST, total bilirubin (may want fractionated also) , alk phos, albumin
hepatitis Abs
INR
CBC: anemia (hemolysis), thrombocytopenia
white count? not always indicates just infection
will see jaundice when levels are
-above 3 mg/dL will lead to jaundice, icterus
LFTs
-characterizes underlying liver disease
-Do not necessarily directly measure liver function
-measurements of serum levels of compounds that are:
Synthesized, metabolized, or excreted by the liver
-The liver has a large reserve capacity and thus liver function tests may remain relatively normal until liver dysfunction is severe
LFTs specifics
Aspartate aminotransferase (AST); Aka - Serum glutamic oxaloacetic transaminase (SGOT)
Alanine aminotransferase (ALT); Aka - Serum glutamic pyruvic transaminase (SGPT)
Serum albumin
Prothrombin time
Serum bilirubin
Serum alkaline phosphatase
Gamma-Glutamyl transferase (GGT)
Serum Albumin
Reflect hepatic capacity for protein synthesis
-Albumin levels fall with prolonged liver dysfunction or in acute liver impairment (Norm: 3.5-5.5 mg/dL)
Prothrombin time
dependent on coagulation factors II, V, VII and X
- Norm = 10.5 to 13 seconds
- Responds rapidly to altered hepatic function
- these are dependent upon Vitamin K and a coexistent vitamin k deficiency must be ruled out*
In light of hypoalbuminemia and normal Prothrombin time – Consider ??
malnutrition, renal or GI losses
screening for hepatobiliary disease
alk phos, ALT, AST
Tests of biliary obstruction and cholestasis and hepatocellular damage
-lack of specificity of these tests; look at overall pattern of tests as well as magnitude of abnormality
Serum Bilirubin
reflects balance btw production, conjugation, and excretion into bile by the liver
Normal = 0.2 – 1 mg/dL
-Conjugated (direct) represents up to 30% of total
-Evaluated in conjunction with other LFTs
-Once insult is resolved – bilirubin takes some time to return to normal levels
Serum Alkaline phosphatase
Group of isoenzymes derived from: Liver, bone, intestine and placenta
Elevation occurs in:
-Cholestasis, partial or complete bile duct obstruction
-Bone regeneration, pregnancy
-Neoplastic, infiltrative, and granulomatous liver diseases
An isolated elevated alkaline phosphatase may be the only clue to pathology
Aspartate (AST/SGOT) and Alanine (ALT/SGPT) aminotransferases
IC amino-transferring enzymes in hepatocytes
After injury or death- released into the circulation
-sensitive (not specific) for liver damage
-Quantity of enzyme level correlates with the severity of hepatic necrosis
ALT
-primarily in hepatocytes
More specific than AST for liver disease
In most hepatocellular disorders, ALT is higher than AST
Except in alcoholic liver disease (where its reversed)
AST
-primarily in liver and cardiac muscle; but also in skeletal muscle, kidneys, brain, lungs pancreas, leukocytes, erythrocytes
Will be higher than ALT in alcoholic liver disease
(Usually 2 or 3x ALT)
GGT
Increased in any cause of acute damage to the liver or bile ducts
- Not very specific and thus not really part of work-up for acute liver dysfunction/injury
- helpful in determining reason for alk phos elevation in serum
- If GGT is low or normal than elevation of Alk Phos is likely due to bone disease rather than liver injury or insult
- A low level or normal level also makes it less likely that the person has consumed alcohol or has liver disease
jaundice: Most bilirubin (80%) is derived from the breakdown of ??
senescent red blood cells (RBCs)
- remainder derives from ineffective erythropoiesis and catabolism of myoglobin and hepatic hemoproteins
- Normal rate of production is about 4 mg/kg body weight daily
Hyperbilirubinemia:
Differentiated by the phase of hepatic bilirubin metabolism
uptake, conjugation, excretion also ategorized as: Prehepatic Hepatic Posthepatic
Bilirubin is detected in biologic fluids by the
van den Bergh reaction
D=C, I=U
(total minus direct)
Unconjugated hyperbilirubinemia
Primary mechanisms:
Overproduction, Impaired hepatic uptake, Decreased conjugation of bilirubin
*Not usually associated with significant hepatic disease
Pre-Hepatic Etiology (UC bili):
Any condition that results in ??
excessive bilirubin production:
Hemolysis, Hematomas, PE
Genetic disorders, G6PD deficiency, SCD anemia
Spherocytosis, Infectious diseases (Malaria)
Pre-Hepatic Etiology: mild or severe?
Jaundice resulting from hemolysis is usually mild
-Serum bilirubin levels rarely exceed 5 mg/dL in the absence of coexisting hepatic diseases
Pre-Hepatic Etiology: Hemolysis can be investigated by examining ??
- Peripheral blood smear (and bone marrow smear)
- Measuring reticulocyte count, haptoglobin, lactate dehydrogenase (LDH), erythrocyte fragility and Coomb’s test (done by specialist, not PC)
Unconjugated hyperbilirubinemia: Hepatic Etiology
Every condition resulting in hepatic injury can cause ??
hepatic jaundice:
- Hepatitis: Infectious, toxic metabolites, drugs, auto-immune disorders, and liver tumors
- Gilbert syndrome, Crigler-Najjar syndrome, Niemann-Pick disease type C
UC hyperbili: Impaired Hepatic Uptake
Causes jaundice that occurs after administering certain drugs: Rifampin, Those involved in treating Gilbert syndrome
UC hyperbili: Impaired Conjugation: can be due to ??
- Crigler-Najjar syndrome
- Acquired defects of UDP glucoronyl transferase (UGT) induced by drugs such as chloramphenicol
Neonatal jaundice: Two primary causes??
Immature hepatic metabolic pathways are unable to conjugate bilirubin as efficiently and quickly as in adults
Bilirubin production is increase, leads to UC bili btw day 2-5, last until day 8 (normal), day 14 in premies, typ. harmless and doesn’t need tx
put on bililytes? if more severe, electrophoresis
neonatal jaundice: Severe pathologic UC bili: usually caused by ??
hemolysis (due to blood group incompatibility) and defective conjugation
-serious condition which requires immediate attention
Can lead to severe hyperbili; risk for permanent neurologic damage (Kernicterus)
tx of choice: Phototherapy
-If there is no response to phototherapy – seek another cause of the jaundice
Conjugated Hyperbilirubinemia: associated with ??
two primary mechs??
impaired formation or excretion of all components of bile (cholestasis)
- defect in the excretion of bilirubin from hepatocytes into bile (intrahepatic cholestasis)
- mechanical obstruction to the flow of bile through the bile ducts
C bili: Impaired hepatic excretion (Intrahepatic cholestasis)
Caused by many conditions
- Drugs – can impair canalicular transport
- Destruction of intrahepatic bile ducts (Primary biliary cirrhosis)
Primary biliary cirrhosis
Chronic, progressive liver disease, Occurs primarily in women
- Destroys small lobular bile ducts
- Leads to progressive cholestasis -> portal inflammation -> fibrosis -> cirrhosis
drugs that can induce cholestasis (impaired hepatic excretion, C bill)
- Nitrofurantoin, oral contraceptives, anabolic steroids
- Erythromycin, cimetidine, chlorpromazine
- Prochlorperazine, imipramine, sulindac, and Penicillins
ALSO Post-operative Jaundice:
Occurs 1-10 days after surgery, 15% incidence after heart surgery
Post-hepatic (Obstructive jaundice, C bili): Due to partial or complete ??
most common causes??
other causes??
obstruction of intrahepatic or extrahepatic bile ducts
- Gallstones in the common bile duct, Pancreatic head tumors
- others: Biliary atresia, ductal carcinoma, strictures of the common bile duct, Pancreatitis, pancreatic pseudocysts, or liver flukes (parasites)
clinical approach to jaundice
good hx (esp. social, travel) and PE
lab tests: Comprehensive metabolic panel [electrolytes, liver enzymes (including direct and indirect-bilirubin)], lipase, complete blood count
imaging: US, CT, MRI, MRCP, ERCP
MRCP: looking at GB, pancreas, biliary duct system, purely diagnostic
ERCP: endoscopy, can go in and remove stone if see it
ascites
most common cause??
Accumulation of excess fluid in the peritoneal cavity
- Liver cirrhosis
- high albumin (greater than 1.1 g/dL): cirrhosis, chronic hep congestion, RVHF, Budd-Chiari, constrictive pericarditis, massive liver metastasis, mycetoma, mixed ascites
- low albumin (less than 1.1 g/dL): peritoneal carcinomatosis, peritoneal TB, pancreatic/biliary disease, nephrotic syndrome
The ?? has replaced the exudative-transudative classification of ascites
an elevated gradient signifies ??
serum ascites-albumin gradient
-An elevated serum ascites-albumin gradient (more than 1.1 g/dL) signifies the presence of portal HTN
-typically ascites is transudative
Ascites becomes clinically detectable with fluid accumulation of greater than ??
most sensitive sign of ascites??
imaging for smaller volumes??
500 mL
- Shifting dullness to percussion
- Ultrasound is able to detect smaller volumes (250 mL)
ascites overflow theory:
Overflow of fluid into the peritoneum resulting from portal HTN and splanchnic vasodilation: Excess renal sodium, Water retention
ascites underflow theory:
Decreased effective circulating BV from systemic arterial vasodilation leading to activation of neurohumoral systems: Sodium and water retention
Intervention is typically done when ??
procedure of choice??
symptomatic: I.e. dyspnea, abdominal pain, etc
Paracentesis: Usually done under ultrasound, Can drain as much as 5-8 liters of fluid
ascites flow chart
hyponatremia–>Na+ and H2O restriction
normal Na+–>Na+ restriction
recurrent ascites–>diuretic: spironolactone and furosemide
ascites flow chart: if refractory ascites despite max diuretic dose OR e-lyte abnormality/renal dysfunction at submax dose
- large-volume paracentesis w. colloid expansion (IV albumin)
- shunt placement: TIPS/sx shunt
- aquaretics?
if these fail, consider liver transplant
P of SOAP: workups of jaundice
Complete blood count Comprehensive metabolic panel Direct and indirect bilirubin Hepatitis panel Prothrombin time RUQ ultrasound ?? CT scan of abdomen ??
how would you tx??
- abx: cephalosporin, usyn, augmentin
- remove stone: cholecystectomy w. intraoperative cholangiagram (look to see if stone), ERCP
