Jaundice and Chronic Liver Disease Flashcards
What is jaundice?
Yellowing of the skin, sclerae and other tissues caused by excess circulating bilirubin
When can jaundice be detected?
When the total plasma bilirubin levels exceed 34μmol/L
What is the lifespan of a RBC?
120 days
What happens when a RBC starts to breakdown?
Haem part is converted to biliverdin (Unconjugated - Insoluble form) and is then converted to bilirubin (Conjugated - Soluble form) in the liver
What type of bilirubin is found pre-hepatic?
Unconjugated
What type of bilirubin is found hepatic and post-hepatic?
Conjugated
What is most likely to have happened for post-hepatic jaundice to occur?
An obstruction condition
After conjugation where does most of the bilirubin go?
Most to the stool
A little to the kidneys
What are the features of pre-hepatic jaundice?
Increased quantity of bilirubin Impaired transport - No urine change History of anaemia e.g. Fatigue, Dyspnoea & Chest pain Acholuric jaundice Pallor & Splenomegaly
What are the features of hepatic jaundice?
Defective uptake of bilirubin
Defective conjugation and excretion
Risk factors liver disease and decompensation e.g. Ascites
Stigmata of CLD, Ascites & Asteris (Flapping tremor)
What are the features of post-hepatic jaundice?
Defective transport of bilirubin by the biliary ducts
Abdominal pain
Cholestasis - Bile cannot flow from the liver to the duodenum; may cause pruritus pales stools & high coloured urine
What can cause an enlarged gallbladder?
Obstruction in the bile duct past the cystic causing a build up of bile in the gallbladder
What part of LFTs is raised in hepatic jaundice?
AST & ALT
What part of LFTs is raised in post-hepatic jaundice?
Alk phos and GGT
What is the best course of management for obstructive jaundice?
Obstruction relief, Complication prevention & Prevent recurrence
What is the best course of management for ascending cholangitis?
Prompt drainage & Control infection
What is cholangitis?
Infection of the biliary tract
After what period of time is liver disease classed as chronic?
6 months
What kinds of CLD are there?
Chronic hepatitis Chronic cholestasis Fibrosis Cirrhosis Tumours
List 10 possible reasons for CLD?
Alcohol Autoimmune - PBC/PSC Haemochromatosis Chronic Viral Hepatitis - B & C NAFLD Drugs - Amiodarone CF Vascular problems - Portal hypertension Cryptogenic Others - Sarcoidosis, Amyloid & Schistosomiasis
How does CLD present?
Compensated CLD - Abnormality of LFTs
Decompensated CLD - Ascites, Variceal bleeding & Hepatic encephalopathy
Hepatocellular carcinoma
What volume of fluid is required for ascites to be detected?
1500ml
What evidence corroborates with ascites?
Spider naevi Palmar erythema Abdominal veins Fetor hepaticus Umbilical nodule JVP elevation Flank haematoma
Investigation needed on first ascites evaluation?
Protein & Albumin concentration
Cell count and differential
SAAG - Serum-ascites albumin gradient
What would indicate that the ascites is likely not liver disease?
Exudative process with high protein and inflammation present
What would neutrophils in the ascites indicate?
Peritonitis
What type of ascites indicates liver disease?
Transudative
What causes variceal haemorrhages?
Portal hypertension
Where are variceal haemorrhages seen?
Porto-systemic anastamoses - Skin, Rectal & Oesophageal/Gastric
What types of varices are not as serious?
Posterior abdominal wall veins
Rectal varices
What must the body do with blood if the liver is having problems?
Choose an alternate for the blood to flow
What should be done to manage variceal haemorrhage?
Resuscitate patient
Find good IV access
Blood transfusion as required
Emergency endoscopy - Don’t want to rush this
What percentage of people die with acute GI bleeding?
20%
What can stop the bleeding in the stomach but what is the condition with this treatment?
SB tube - So a balloon inflates the fundus part of the stomach to stop the bleeding however, it can’t be done for longer than 24 hours
What treats portal hypertension and can be a cure to varicies?
TIPPS
What is hepatic encephalopathy?
Confusion due to liver disease
What are precipitants of hepatic encephalopathy?
GI Bleed Infection Constipation Dehydration Medication - Especially sedation
What do you treat for hepatic encephalopathy?
The underlying cause
What do colonic bacteria produce?
Ammonia
How does hepatocellular carcinoma present?
Decompensation of liver disease
Abdominal mass/pain
Weight loss
Bleeding from tumour
What hepatocellular carcinoma occur in the background of?
Cirrhosis
What investigations should be done to diagnose hepatocellular carcinoma?
Tumour markers - AFP
Ultrasounds, CT & MRI
Biopsy - Done rarely
What is treatment for hepatocellular carcinoma?
Hepatic resection Liver transplantation Chemotherapy Locally ablative treatments Sorafenib Hormonal therapy e,g, Tamoxifen *Transplant if both lobes are affected*
What does SAAG stand for?
Serum-ascites albumin gradient
What does a SAAG with >1.1g/dl indicate?
Portal hypertension & Cirrhosis CHF Constrivtive ericarditis Budd chiarri Myxdema Massive liver metastases
What does a SAAG with
Malignancy TB Chylous ascites Pancreatic Biliary ascites Nephrotic syndrome Serositis
How is SAAG treated?
Diuretics Paracentesis if there is a large volume TIPS - A shunt Aquaretics Liver transplant
