Jaundice and chronic liver disease Flashcards
What is jaundice (what is the differential diagnosis)?
- Yellowing of the skin, sclerae, and other tissues caused by excess circulating bilirubin.
- Detectable when total plasma bilirubin levels exceed 34 µmol/L
- Differential diagnosis is carotenemia
What are the causes of cirrhosis?
- Alcohol (90%)
- Autoimmune: Autoimmune hepatitis, PBC (primary biliary cholangitis), PSC (primary sclerosing cholangitis)
- Haemochromatosis
- Chronic viral hepatitis: B and C
- Non-alcohol fatty liver disease (NAFLD)
- Drugs (MTX, amiodarone)
- Cystic fibrosis, α1 antitrypsin, Wilsons disease
- Vascular problems (portal hypertension +/- liver disease)
What is the presentation of cirrhosis?
- Compensated chronic liver disease ○ Abnormality of liver function tests ○ Routinely detected on screening tests - Decompensated chronic liver disease ○ Ascites ○ Variceal bleeding ○ Hepatic encephalopathy - Hepatocellular carcinoma
What are the clinical features of ascites?
- Physical exam reveals dullness in flanks and shifting dullness
- Can be confirmed by ultrasound
- Spider nevi
- Palmer erythema
- Abdominal veins
- Factor hepaticus
- Umbilical nodule
- JVP elevation
- Flank haematoma
What is the treatment of ascites?
- Diuretics
- Large volume paracentesis
- TIPS
- Aquaretic
- Liver transplantation
How do you manage a patient in a medical emergency with ascites?
- Resuscitate patient
- Good IV access
- Blood transfusion as required
- Emergency endoscopy
- Endoscopic band ligation
- Add Terlipressin for control
- Sengstaken-Blakemore tube for uncontrolled bleeding
- TIPSS for rebleeding after bleeding
Why do patients with hepatic encephalopathy present with confusion?
• Liver disease
- If the liver stops working all the metabolites go to the brain and they can immediately go into a coma (which, if treated, will immediately get better)
What are the causes of hepatic encephalopathy?
- GI bleed
- Infection
- Constipation
- Dehydration
- Medication (especially sedation)
What is the treatment of hepatic encephalopathy?
- Treat underlying cause
- Laxatives: phosphate enemas and lactulose
- Neomycin, Rifaximin-broad spectrum non absorbed antibiotic
- Repeated admission with hepatic encephalopathy is an indicator for a liver transplant
What is the background of Hepatocellular carcinoma?
- Commonest cause of liver cancer
- Occurs in the background of cirrhosis
- Occurs in association with chronic hepatitis B and C
What does a liver screen look for?
- Hepatitis B and C serology
- Autoantibody profile, serum immunoglobulins
- Caeruloplasmin and copper
- Ferritin and transferrin saturation
- Alpha 1 and anti-trypsin
- Fasting glucose and lipid profile
What does an ultrasound do?
- Differentiates extrahepatic and intrahepatic obstruction
- Delineates site of obstruction
- Delineates cause of obstruction
- Documents evidence of portal hypertension
- Primary staging of extent of disease e.g. cancer spread
What are the advantages and disadvantages of ultrasound?
- Cheap
- No radiation
- Portable, widely available
- Good for gallstones
- High specificity
- Lower sensitivity
- Examines organs as well as biliary system
What are the advantage and disadvantages of CT/MRI?
- Expensive
- Radiation (only for CT scan)
- Requires CT / MRI scanner
- Better for pancreas
- High specificity
- High sensitivity
- Examines organs (and biliary system)
What is ERCP used for?
Fixing
What are the advantages and disadvantages of ERCP?
- Radiation
- Sedation
- Complications 5%: respiratory, cardiovascular, pancreatitis, cholangitis, sphincterotomy (bleeding, perforation)
- Failure rate 10%
- Only images ducts
- Therapeutic option: dilated biliary tree (+/- visible stones and/or tumour), acute gallstone pancreatitis, stenting of biliary obstruction, post-operative biliary complications
What is MRCP used for
Diagnosing
Explain percutaneous transhepatic cholangiogram (PTC)
- Uses: ERCP not possible due to duodenal obstruction or previous surgery, Hilar stenting
- More invasive than ERCP
Explain Endoscopic ultrasound
- Characterising pancreatic masses
- Staging tumours
- Fine needle aspirate (FNA) of tumours and cysts
- Excluding biliary micro calculi
What are the three classifications of jaundice?
- Pre-hepatic
- Hepatic
- Post-hepatic
Explain pre-hepatic jaundice
- Increased quantity of bilirubin (haemolysis)
- Impaired transport
- History of anaemia
- Acholuric jaundice
Explain hepatic jaundice
- Defective uptake of bilirubin
- Defective conjugation
- Defective excretion
- Risk factor for liver disease (IVDU, drug intake)
- Decompensation (ascites, variceal bleed, encephalopathy)
- Examination: Stigmata of CLD (spider naevi, gynecomastia), ascites, asterixis
Explain post-hepatic jaundice
- Defective transport of bilirubin by the biliary ducts
- Abdominal pain
- Cholestasis (purities, pale stool, high coloured urine)
- Palpable gall bladder (Courvoisier’s sign)
What are the routine tests done when a patient has ascites?
- Cell count
- Protein
- Albumin
What are the optional tests done when a patient presents with ascites?
- Culture
- Glucose
- LDH
- Amylase
- Gram stain
What are the unusual blood tests done when a patient has ascites?
- TB culture
- Cytology
- Triglyceride
- Bilirubin
What are the unhelpful tests for a patient with ascites?
- pH
- Lactate
- Cholesterol
- Fibronectin
- ADA
- CEA
If the SAAG (serum-ascites albumin gradient) is greater than 1.1g/dl, what could the cause of this be?
○ >1.1g/dl portal HTN related § Portal hypertension § CHF § Constrictive pericarditis § Budd Chiarri § Myxoedema § Massive liver metastases
If the SAAG is less than 1.1g/dl, what could the cause of it be?
○ <1.1g/dl nonportal HTN causes § Malignancy § Tuberculosis § Chylous ascites § Pancreatic § Biliary ascites § Nephrotic syndrome § Serositis
What are the tests for hepatocellular carcinoma
• Tumour markers: AFP • Radiological tests - Ultrasound - CT scan - MRI • Liver biopsies can be done very rarely
Explain biliruben
- By product of haeme metabolism
- Generated by senescent RBC’s in spleen
- Initially bound to albumin (unconjugated)
- Liver helps to solubilise it (conjugated)
- Elevated as a result of :
- Pre-hepatic: Haemolysis
- Hepatic: Parenchymal damage
- Post hepatic: Obstructive
Explain Aminotransferase
- Enzymes present in hepatocytes
- ALT more specific than AST
- AST/ALT ratio can point towards ALD
- Suggests parenchymal involvement
What does it mean if Bilirubin and Aminotransferase are raised?
Raised Bilirubin and aminotransferase mean that there is liver damage or failure
Explain alkaline phosphate
- Enzyme present in bile ducts
- Elevated with obstruction or liver infiltration
- Also present in bone, placenta and intestines
Explain Gamma GT
- Non specific liver enzyme
- Elevated with alcohol use
- Useful to confirm liver source of ALP
- Drugs like NSAID’s can raise levels
Explain albumin
- Important test for synthetic function of liver
- Low levels suggest chronic liver disease
- Can be low in kidney disorders and malnutrition
Explain prothromine time
- Extremely important test for liver function
- Tells degree of liver dysfunction
- Used to calculate scores to decide stage of liver disease, who needs a liver transplant and who gets a liver transplant
Explain creatin
- Essentially kidney function
- Determines survival from liver disease
- Critical assessment for need for transplant
Explain platelet count
- Liver is an important source of thrombopoietin
- Cirrhosis results in splenomegaly
- Platelets low in cirrhotic subjects as a result of hypersplenism
- Indirect marker of portal hypertension
