Jaundice and Chronic Liver Flashcards
What is Jaundice?
Yellowing of the skin, SCLERAE, and other tissue caused by excess circulating bilirubin.
What level must bilirubin be for jaundice to be detectable?
Bilirubin >34umol/L
What is the differential diagnosis of jaundice?
Carotenemia
Very rare. Almost always jaundice
How is bilirubin formed and broken down?
Haemoglobin broken down to Biliverdin.
Converted to bilirubin.
Bilirubin hard to secrete so converted to soluble form (Bilirubin Diglucuronide)
Then excreted in stool
What is bilirubin?
Yellow product in the breakdown of heme during clearance of old red blood cells.
Excreted in bile and urine.
Causes yellow colour in bruises.
Yellow colour in urine and brown colour in feces
What are the two types of bilirubin?
Unconjugated and Conjugated
What is unconjugated bilirubin?
Bound to albumin
Makes up 90% of normal bilirubin serum fraction.
Non-polar (loves fat)
Not excreted renally
Large temporary albumin binding
What is conjugated bilirubin?
Soluble form
Makes up 10% of normal bilirubin serum fraction
Polar (not to keen on fat)
Renal secretion
No temporary albumin binding
How do you classify jaundice and what bilirubin is associated?
Pre hepatic- Unconjugated
Hepatic- Conjugated
Post hepatic- Conjugated
Conjugated = soluble form so will be raised in hepatic/ post hepatic jaundice
Describe pre hepatic jaundice
Increased quantity of bilirubin (Haemolysis)
Impaired Transport
Describe pre hepatic jaundice
Defective uptake of bilirubin
Defective conjugation
Defective excretion
Describe post hepatic jaundice
Defective transport of bilirubin by the biliary system
How will pre hepatic jaundice present?
History of anaemia (fatigue, dyspnoea, chest pain)
Acholuric jaundice
How will hepatic jaundice present?
Risk factors for liver disease (IVDU, drug intake)
Decompensation (ascites, variceal bleeds, encephalopathy)
How will post hepatic jaundice present?
Abdominal pain
Cholestasis (pruritus, pale stools, high coloured urine)
Why does cholestasis cause pruritus?
Blockage in bile duct.
Bile leaks into skin and pruritus.
Bilirubin not in stools.
All goes into urine
What are the clinical examination features of pre hepatic jaundice?
Pallor
Splenomegaly
What are the clinical examination features of hepatic jaundice?
Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis
What are the clinical examination features of post hepatic jaundice?
Palpable gall bladder
What will the investigations for pre hepatic jaundice look like?
Unconjugated bilirubin = +
Conjugated = normal
AST or ALT = Normal
Alkaline phosphatase and GGT = Normal
What will the investigations for hepatic jaundice look like?
Unconjugated bilirubin = Normal
Conjugated bilirubin = +
AST or ALT = ++
Alkaline phosphatase and GGT = Normal
What will the investigations for post hepatic jaundice look like?
Unconjugated = Normal
Conjugated = +
AST or ALT = Normal
Alkaline Phosphatase and GGT = ++
What happens to the liver enzymes when the liver is damaged or inflamed?
AST or ALT will rise
What is the most important imaging investigation for jaundice?
Ultrasound
- Differentaites extra hepatic and intrahepatic obstruction
- Delineated site of obstruction
- Delineated cause of obstruction
- Documents evidence of portal hypertension
- Preliminary staging of extent of disease (e.g. cancer spread)
What investigations are involved in a liver screen?
- Hep B&C Serology
- Autoantibody profile, serum immunoglobulins
- Caeruloplasmin and copper
- Ferritin and transferrin saturation
- Alpha 1 antitrypsin
- Fasting glucose and lipid profile
What is the management of obstructive jaundice?
Obstructuve jaundice (ERCP)
- Relief of obstruction
- Prevent complication
- Prevent recurrence
Acsending Cholangitis (ERCP)
Promp drainage
Control infection
What is chronic liver disease?
Liver disease that persists beyond 6 months
Chronic hepatitis Chronic cholestasis Fibrosis and cirrhosis Others e.g. steatosis (fatty liver) Liver tumours
List some of he causes of chronic liver disease
- Alcohol
- Autoimmune
- Haemochromatosis
- Chronic viral hepatitis B+C
- Non-Alcoholic fatty liver disease (NAFLD)
- Drugs (MTX, amioderone)
- Cystic fibrosis, a1 antitryptin deficiency, Wilsons disease
- Vascular problems
- Cryptogenic
What is the clinical presentation of chronic liver disease?
Compensated chronic liver disease
- Routinely detected on screening tests
- Abnormality of liver function tests
Decompensated chronic liver disease
- Ascites
- Variceal bleeding
- Hepatic encephalopathy
Hepatocellular carcinoma
What are the clinical features of ascites?
Dullness in flanks and shifting dullness.
This can be confirmed by ultrasound which is much more sensitive.
Corroborating evidence:
- Spders, Palmar erythema, abdominal veins, fetor hepaticus
- Umbilical nodule (cancer?)
- JVP elevation (heart failure?)
- Flank Haematoma
What should you do with a patient with new-onset ascites?
Diagnostic paracentesis
What studies need to be carried out on fluid aspirated form a paracentesis?
Protein and albumin concentration
Cell count and differential
SAAG (serum-ascites albumin gradient)
How do you know if fluid is from an exudative process?
High protein
Malignancy and inflammatory disease
How do you know if fluid is from a transudative process?
Low protein
More likely liver disease
What do the types of cells from a cell count and differential tell you?
Neutophils = peritonitis
Lymphocytes = chronic condition
What do the results from a SAAG tell you?
> 1.1g/dl portal HTN related
- Portal hypertension
- CHF
- Constrictive pericarditis
- Budd Chiarri
- Myxedema
- Massive liver metastases
When talking about ascites what should you replace the modifier transudative and exudative with?
Transudative = high-albumin gradient
Exudative = Low albumin gradient
What are the treatment options for ascites?
- Diuretics (easiest)
- Large volume paracentesis (drains a large volume quickly)
- TIPS = shunt in liver fixes hypertension (if above treatments don’t work)
- Aquaretics (new drugs)
- Liver transplant (last resort)
How do you initially treat a variceal haemorrhage?
Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy
How do you stop the bleeding in a vatical haemorrhage?
Endoscopic band ligation (suck out vessels and stick a band around)
Can add terlipressin for control
Senstaken-Blakemore tube for uncontrolled bleeding
TIPS for rebleeding after banding
What is a Senstaken-Blakemore?
Balloon inflated in stomach and attached to sandbag.
Pulled out and yanks fundus against bleed.
Works but one of the worst feelings for the patient
What is Hepatic encephalopathy and how is it caused?
Confusion due to liver disease.
Ammonia broken down in the liver.
Liver doesn’t work.
Ammonia not broken down and builds up in the blood
What are the precipitants?
GI bleed Infection Constipation Dehydration Medication esp. sedation
What signs other than confusion may help diagnose hepatic encephalopathy?
Asterixis (bird flapping its wings) Foetor hepaticus (breath of the dead)
How do you treat hepatic encephalopathy?
Treat underlying cause
Laxatives - phosphate enemas and lactulose
(Flush system so colonic bacteria aren’t present to produce more ammonia)
Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
Repeated admissions with HE is an indicator for liver transplant
Describe hepatocellular carcinoma
Commonest cause of liver cancer
Occurs in the background of cirrhosis
Occurs in association with chronic hepatitis B+C
How does hepatocellular carcinoma present?
Decompensation of liver disease Abdominal mass Abdominal pain Weight loss Bleeding from tumour
How do you diagnose hepatocellular carcinoma?
Tumour Markers:
AFP (alpha fetoprotein)
Radiological tests:
- US
- CT
- MRI
Liver biopsy done very rarely because CT and MRI are so good.
How do you treat hepatocellular carcinoma?
Hepatic resection
Liver transplantation
Chemotherapy
Locally ablative treatments
- Alcohol injection
- Radiofrequency ablation
Sorafenib (tyrosinase kinase inhibitor)
Hormonal therapy: Tamoxifen
