Jaundice and Chronic Liver Disease Flashcards
1
Q
Definition of jaundice
A
Yellowish discolouration of the sclera and mucous membrane
2
Q
When does jaundice manifest?
A
Serum bilirubin > 3mg/dL (51 umol/L)
3
Q
Types of jaundice
A
Haemolytic / pre hepatic
Hepatocellular
Obstructive / post hepatic
4
Q
What is unconjugated bilirubin?
A
Bilirubin = plasma proteins
5
Q
Another name for unconjugated bilirubin
A
Indirect bilirubin
6
Q
Features of unconjugated bilirubin
A
Water insoluble
High molecular weight
7
Q
Can unconjugated bilirubin be excreted into urine by the kidneys?
A
No
8
Q
Where is conjugated bilirubin made?
A
Liver
9
Q
Features of conjugated bilirubin
A
Low molecular weight
Water soluble
10
Q
Can conjugated bilirubin be filtered by the kidneys if needed?
A
Yes
11
Q
Does conjugated bilirubin normally need to be filtered into the urine by the kidneys?
A
No
12
Q
Where does conjugated bilirubin travel from and to?
A
From bile duct
to bowel
to stomach
13
Q
What does conjugated bilirubin do to stools?
A
Makes them brown
14
Q
What particular part of bilirubin makes stools brown?
A
Stercobilin
15
Q
If excretion of conjugated bilirubin is hindered, what happens?
A
It is excreted in the kidneys making the urine dark
16
Q
Causes of haemolytic / pre hepatic jaundice
A
Haemolytic anaemia
Post transfusion
17
Q
In increased RBC destruction, what bilirubin is elevated?
A
Unconjugated
18
Q
Colour of urine in haemolytic jaundice. Why?
A
Normal
As cannot be filtered
19
Q
Colour of stool in haemolytic jaundice
A
Normal
20
Q
LFTS in haemolytic jaundice
A
Serum bilirubin - mainly indirect
ALT and AST - normal
ALP - normal
21
Q
What does ALP stand for?
A
Alkaline phosphatase
22
Q
Causes of hepatocellular jaundice
A
Viral hepatitis
Liver cirrhosis and liver cell failure
Drug induced and liver toxins
23
Q
Two possible pathologies of hepatocellular jaundice
A
- Suboptimal function of hepatocytes
2. Degree of intrahepatic biliary obstruction
24
Q
Pathology of suboptimal function of hepatocytes causing hepatocellular jaundice
A
Suboptimal function of hepatocytes
Bilirubin will be partially conjugated
Increase unconjugated bilirubin due to accumulation, as cannot conjugate the full amount
25
Pathology of intrahepatic biliary obstruction causing hepatocellular jaundice
Inflammation of the hepatocytes so they are swollen / oedematous
So conjugated bilirubin will increase
Urine; dark
Stool colour depends on degree of intrahepatic biliary obstruction
If marked obstruction -> pale stool
If mild obstruction -> may have more normal stool as still have some conjugated bilirubin
26
LFTs in hepatocellular jaundice
Serum bilirubin; direct and indirect
ALT and AST; Markedly increased
ALP; mild increase
27
What are ALT and AST?
Transaminases
28
What are ALT and AST markers of?
Liver cell damage
29
Where is ALP found?
Bile canniculi
30
What is ALP a marker of?
Bile duct obstruction
31
So if ALP is elevated, what does this indicate?
An obstructive process
32
What is gamma GT elevated in?
Obstruction
Alcohol
(therefore less specific)
33
Where is the first place on the body to present with jaundice and why?
Sclera
It has a high affinity for bilirubin
(also last place to get rid of jaundice)
34
What do you have an increased risk of developing if you have spherocytosis?
Gallstones
35
Causes of obstructive / post hepatic jaundice
```
Common bile duct stones
Common bile duct strictures
- iatrogenic injury during cholecystectomy
- cholangiocarcinoma
Periampullary malignancy
Carcinoma of head of pancreas
```
36
LFTs in post hepatic / obstructive jaundice
Serum bilirubin - mainly direct
ALT and AST - mild increase
ALP - markedly increased
37
What type of gallstones do you get in haemolytic anaemia?
Pigmented
38
Urine and stool colours in haemolytic jaundice
Urine - normal
| Stool - normal
39
Urine and stool colours in hepatocellular jaundice
Urine; dark
| Stools; either pale or normal
40
Urine and stool colours in obstructive / post hepatic jaundice
Urine; dark
| Stools; pale
41
What does CBD stand for?
Common bile duct
42
Medical obstructive jaundice is caused by what?
Intrahepatic biliary obstruction i.e. small duct obstruction
43
Surgical obstructive jaundice is caused by what?
Extrahepatic biliary obstruction I.e. large duct obstruction
44
Surgical jaundice is further classified into what?
Calcular obstructive jaundice
| Malignant obstructive jaundice
45
Presentation of calcular obstructive jaundice
```
Biliary colic
No weight loss
Fluctuating jaundice
- with intermittent fever, pain and rigors - charcots triad
- pale lemon to bright orange
Biliary dyspepsia
Dark brown urine
Pale/clay coloured stool
Itching often present (scratch marks)
Bradycardia
Gallbladder usually NOT distended (courvoisiers sign)
```
46
Presentation of malignant obstructive jaundice
Painless / pain continuous epigastric and radiating to back
Weight loss
Progressive jaundice
- deep; could be olive green
Urine dark brown
Stool pale / clay coloured
Itching is marked - scratch marks
Melena (if ulceration of periampullary tumour)
May have enlarged nodular liver (liver mets)
Gallbladder usually distended (Courvoisier's sign)
47
Which gender gets calcular obstructive jaundice more?
F > M (approx. 40 y/o)
48
Which gender gets malignant obstructive jaundice more?
M > F (> 40 usually)
49
What is charcots triad?
RUQ pain
Jaundice
Fever
50
Why would the patient be bradycardic in calcular obstructive jaundice?
Due to inhibitory effect of the bile salts on the SA node
51
What is the saying of Courvoisier's sign?
In the prescence of a palpable gallbladder, jaundice is unlikely to be caused by gallstones
52
How Courvoisiers sign works?
Palpable gallbladder = malignancy
Gallstones are formed over a long period of time, which results in a shrunken fibrotic gall bladder which does not distend easily
Therefore the gall bladder is more often enlarged in diseases which causes obstruction of the biliary tree over a shorter period of time such as pancreatic malignancy
53
What % of renal stones can be seen on plain X Ray compared to gallstones? Why is this?
Renal stones - 90%
Gallstones - 10%
Not a lot of calcium in gallstones
54
What may also be present in spherocytosis and how may this affect management?
Hypersplenism
| So can get a cholestectomy and a splenectomy
55
Definition of obstructive jaundice
Obstruction in the main biliary tree i.e. CHD, CBD, ampulla of water
56
What are benign biliary strictures almost always caused by?
Cholecystectomy
57
In patients who present with jaundice, what do you always have to ask about?
Previous biliary surgery
58
What will a head of the pancreas tumour compress? Why?
Common bile duct
| As some of the duct is in the head of the pancreas
59
What does calcular obstructive jaundice mean?
The stone can move so the symptoms can fluctuate
60
What colour is jaundice urine, and what would general dark urine mean?
Tea coloured
| Dark urine just means concentrated
61
What is biliary dyspepsia?
Dyspepsia due to fatty foods
62
Presentation of pancreatic tail cancer
Deep seated pain
Then infiltrates nerve and get back pain
Very vague presentation and so dont see them early
63
If someone aged 40 - 60 presents with vague upper abdominal pain > 6 weeks which is not getting better with PPIs, send for a what?
CT scan
64
What part of the pancreas if it has a tumour would present the earliest?
Even a tiny tumour in the ampulla of vater
65
What is the key investigation for obstructive jaundice?
USS
66
On USS if there is a dilated biliary tree, what possible investigations could be done next?
CT
ERCP
PTC
MRCP
67
On USS if there is a non dilated biliary tree, what investigation should be done next?
Liver biopsy
68
What % of stones can be visualised in the gallbladder on AUS?
98%
69
What % of stones can be visualised in the common bile duct on AUS?
50%
70
What can AUSS pick up?
```
Dilated biliary tree
Biliary stones
Pancreatic tumours
Enlarged abdominal lymph nodes
Changes in liver texture e.g. cirrhosis, liver mets
Dilated portal vein
```
71
What key investigation is done to look for a dilated biliary tree?
USS
72
What investigations are done to look for tumours/solid masses in pancreas and liver?
CT and MRI
73
What can ERCP detect diagnostically?
Filling defects
Biliary stricture
Dilated biliary tree
Cytology and biopsy
74
Where does ERCP travel from and to?
Scope from oesophagus to 2nd part of duodenum
75
What are the therapeutic reasons for ERCP?
Endoscopic sphincterectomy
| Biliary stent
76
What is endoscopic sphincterectomy?
Cut to get the stone out
77
How does the stent work?
To drain the CBD
Metal - used for malignant
Plastic - used for benign
78
If there is multiple filling defects, what does this indicate?
Gallstones are not the cause
79
Complications of ERCP
Cholangitis
Pancreatitis
Bleeding
Perforation (bile duct / duodenum)
80
Where is the stricture located that is typical of post cholecystectomy?
Where the cystic duct goes in to the common bile duct
81
What % get post ERCP pancreatitis? Is it serious?
3%
| Can be fatal
82
What type of therapy is ERCP reserved for at the moment?
Therapeutic
83
What does PTC stand for?
Percutaneous transhepatic cholangiography
84
How does PTC work?
AUSS to find dilated bile duct
Inject die
Then can see swelling and blockage
85
Diagnostic indications for PTC
Allows visualisation of the proximal biliary tree
86
Therapeutic indications for PTC
Transhepatic placement of biliary stents
87
Complications of PTC
Bleeding (liver)
Biliary peritonitis
Cholangitis
88
Contraindications to PTC
Bleeding tendency
89
Why does biliary peritonitis occur?
Low resistance track for a high pressure system
90
ERCP vs PTC in what they can visualise
ERCP - anatomy DISTAL to obstruction
| PTC - anatomy PROXIMAL to obstruction
91
What does MRCP stand for?
Magnetic resonance cholangiopancreaticography
92
What is MRCP?
A non invasive assessment of CBD
93
What can MRCP visualise?
CBD stones
| Biliary strictures
94
3 possible outcomes when carried out an USS for obstructed jaundice
1. Dilated CBD with gallstones in gallbladder
2. Dilated CBD with no gallstones
3. Non dilated CBD with gallstones
95
Next steps once see a dilated CBD with gallstones in gallbladder on USS
Do MRCP
If shows a stone in the bile duct, then ERCP
If no clear stone, then do not do ERCP
96
Next steps once see a dilated CBD with no gallstones on USS
Think tumour
Do CT
Then ERCP
97
Next steps once see a non dilated CBD with gallstones present on USS
Gallstones very small that spontaneously passes
LFTs take 2- 3 weeks to get back to normal
Do MRCP
If negative, then do EUS
98
Indications for a pancreatico-biliary endoscopic ultrasound (EUS)
Small (< 3cm) pancreatic tumours and ampullary neoplasms
Small ( < 4 mm) bile duct stones
To define vascular invasion in pancreatic and peri ampullary neoplasms
EUS FNA
99
What does OTC stand for?
On table cholangiogram
100
Indications for OTC
Suspected CBD stones
| Verification of the biliary anatomy during cholecystectomy
101
Points to establish during OTC
Complete visualisation of the billiard tree (proximal and distal)
No filling defects
No strictures
Free flow of contrast into the duodenum
102
Risk factors for operative management
Bleeding tendency
Infections
Renal failure
Hepatic failure
103
Definition of choledocholithiasis
Common bile duct stones
104
Why do people with obstructive jaundice have a higher risk of bleeding in surgery?
If no bile -> cannot absorb fat soluble vitamins (e.g. vitamin K)
105
What are the vitamin K dependent factors and what is a way to remember this?
2, 7, 9, 10
| 1972
106
How must vit K be given in obstructive jaundice?
IV
107
How long does vit K take to work?
6 - 8 hours
108
What is obstructive jaundice extremely sensitive to?
Dehydration
109
How long would it take to have hepatic failure after obstruction?
< 4 weeks
110
What % of bile duct stones can CT pick up?
50%
111
Treatment options for choledocholithiasis
1. ERCP, endoscopic sphincterotomy (ES) and CBD stone extraction, followed by laparoscopic cholecystectomy
2. Cholecystectomy, CBD exploration, stone extraction and T tube insertion (laparoscopic / open)
112
Cause of traumatic bile duct strictures
Previous cholecystectomy
113
Presentation of traumatic bile duct strictures
Complete - post op jaundice
| Partial - intermittent cholangitis and jaundice
114
Treatment of traumatic bile duct strictures
Biliary stent
| Roux-en-Y hepatico-jejunostomy
115
Cause of malignant bile duct strictures
Cholangiocarcinoma
116
Presentation of malignant bile duct obstruction
Obstructive jaundice
117
Treatment of malignant bile duct obstruction
If operable
- resection and biliary reconstruction
If inoperable
- CBD stent
118
What is a klatskin tumour?
Hilar cholangiocarcinoma at the bifurcation of the common hepatic duct
119
Treatment of pancreatic head tumour
Pancreatioduodenectomy (Whipples procedure)
| Reconstruction
120
What is a whipples procedure?
```
Pancreaticoduodenectomy
Involves removing
- CBD
- Gallbladder
- Duodenum
- Head of pancreas
```
121
Treatment of inoperable pancreatic carcinomas
Internal biliary stent placed by ERCP or PTC to relief jaundice
Duodenal stent or laparoscopic gasrojejunosomty for relief of gastric outlet obstruction
122
Functions of liver
```
Synthetic function
- clotting factors
- bile acids
- carbohydrates
- proteins - albumin
- lipids (cholesterol, lipoprotein, TG)
- hormones (angiotensin, insulin like growth factor)
Detoxification
- bilirubin metabolism
- urea production from ammonia
- detoxification of drugs
- breakdown of insulin and hormones
Immune function
Storage function
- glycogen
- vit A, D, B12 and k
- copper
- iron
```
123
Differential diagnosis of jaundice
Carotenemia
124
Where is ALP also present?
Bone
Placenta
Intestines
125
What is gamma GT?
Non specific liver enzyme
126
What is albumin levels an important test for?
Synthetic function of the liver
127
What produces albumin?
Liver
128
Causes of hypoalbumineria
Liver problems
Kidney disorders
Malnutrition
129
What does prothrombin time tell you about the liver?
Degree of liver dysfunction
130
What does platelet count have to do with the liver?
Liver important source of thrombopoietin
| Thrombopoietin drives bone marrow to produce platelets
131
What are low platelets an indirect marker for? Why?
Portal hypertension
| As cirrhosis results in splenomegaly, which chews up all the platelets and decreases their count
132
4 symptoms of liver failure
Jaundice
Ascites
Variceal bleeding
Hepatic encephalopathy
133
What is ascites?
Accumulation of fluid in the belly
134
What is variceal bleeding?
Bleeding from engorged veins
135
What is hepatic encephalopathy?
Build up of toxins in the brain due to a failed liver that results in deteriorated brain function
136
Definition of chronic liver disease
Liver disease that persists over 6 months
137
Examples of chronic liver diseases
```
Chronic hepatitis
Chronic cholestasis
Fibrosis and cirrhosis
Steatosis
Liver tumours
```
138
Causes of liver cirrhosis
```
Alcohol 90%
Autoimmune
- autoimmune hepatitis
- PBC
- PSC
Hemochromatosis
Chronic viral hepatitis B and C
NAFLD
Drugs - MTX, amiodarone
CF
a-1 antitrypsin deficiency
Wilsons disease
Portal HTN +/- liver disease
Cryptogenic
Sarcoidosis
Amyloid
Schistosomiasis
```
139
Possible types of presentation of cirrhosis
```
Compensated chronic liver disease
- screening tests
- abnormality of LFTs
Decompensated chronic liver disease
- ascites
- variceal bleeding
- hepatic encephalopathy
Hepatocellular carcinoma
```
140
Clinical features of ascites
Dullness in flanks
Shifting dullness (approx. 1500cc)
USS can detect up to 100cc
141
Supporting features of decompensated liver failure
```
Ascites
Hepatic encephalopathy
Variceal bleeding
Spider naevi
Palmar erythema
Abdominal veins
Fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma
```
142
What does the liver convert oestrogen to?
Testosterone
143
A disproportionate amount of oestrogen due to liver failure can lead to what?
Palmar erythema
Spider naevi
Gynaecomastia
144
Investigations of acites
New onset ascites - paracentesis
Protein and albumin concentration
Cell count and differential
SAAG - serum ascites albumin gradient
145
Levels of SAAG and what they are suggestive of?
```
High = liver disease
Low = not liver disease
```
146
If levels of SAAG > 1.1g/dl, what could be causing the ascites?
```
Portal HTN
CHF
Constrictive pericarditis
Budd Chiarri
Myxoedema
Massive liver metastases
```
147
What is budd chiarri?
VERY RARE
| Occlusion of hepatic veins that drain the liver
148
If levels of SAAG < 1.1g/dl, what could be causing the ascites?
```
SLOW - suggestive of an infiltrative condition e.g. malignancy
Malignancy
TB
Chylous ascites
Pancreatic
Biliary ascites
Nephrotic syndrome
Serositis
```
149
What is chylous ascites?
Milky chyle in peritoneal cavity
150
Treatment of ascites
```
Diuretics
Large volume paracentesis
TIPS
Aquaretics
Liver transplant if all else fails
```
151
What Is TIPS?
Shunts that puncture the intrajugular vein and go into the liver and through the IVC and the shunt into the liver takes care of the blockage. Portal pressure comes down and ascites will get better
152
What is aquaresis?
Excretion of water without electrolyte loss
153
Causes of varices
Portal HTN
154
Where do varices occur?
At porto-systemic anastomoses
- skin (caput medusae)
- oesophageal
- gastric
- rectal
- posterior abdominal wall
- stomal
155
Treatment of variceal haemorrhage
```
Resuscitate patient
Blood transfusion as required
Endoscopic band ligation
Terlopressin for control
Sengstaken blaken tube for uncontrolled bleeding
TIPSS for rebleeding after banding
```
156
Precipitants of hepatic encephalopathy
```
GI bleed
Infection
Constipation
Dehydration
Medication
```
157
Treatment of hepatic encephalopathy
Treat the cause;
- Laxatives - phosphase enemas and lactulose
- broad spec abtibiotics
158
What is an indicator for liver transplant?
Repeated admissions with hepatic encephalopathy
159
What is the commonest cause of liver cancer?
Hepatocellular carcinoma
160
What does hepatocellular carcinoma occur in the background of?
Cirrhosis
161
What does hepatocellular carcinoma occur in association with?
Chronic hepatitis B and C
162
Presentation of hepatocellular carcinoma
```
Decompensation (deterioration) of liver disease
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour
```
163
Investigations for hepatocellular carcinoma
Tumour markers; AFP
USS
CT
MRI
164
What is done to everyone with liver cirrhosis?
Get put on surveillance programme, every 6 months will come in and get investigations checking for hepatic cancer
165
Treatment of hepatocellular carcinoma
```
Hepatic resection
Liver transplantation
Chemotherapy
Locally ablative treatments
- alcohol injection
- radiofrequency ablation
Sorafenib (tyrokinase inhibitor)
Hormonal therapy; tamoxifen
Palliative options
```
166
What are all of the investigations that can be done of the liver?
```
Hep B and C serology
Autoantibody profile
Serum immunoglobulins
Caeruloplasmin and copper
Ferritin and transferrin saturation
Alpha 1 anti trypsin
Fasting glucose
Lipid profile
```
167
What is the first test to be done with anyone with jaundice?
USS
168
Clues in the history/examination which would point to pre hepatic jaundice
```
Fatigue
Dyspnoea
Chest pain
Alcohol
Pallor
Splenomegaly
```
169
Clues in the history which would point to hepatic jaundice
```
IVDU
Drug intake
Ascites
Variceal bleeding
Encephalopathy
Spider naeivi
Gynaecomastia
Asterixis
```
170
Clues in the history which would point to post hepatic jaundice
```
Abdominal pain
Pruritus
Pale stools
Dark coloured urine
Possible Courvoisier's sign
```
171
Definition of asterixis
Flapping tremor due to liver failure
172
Inheritance of gilberts syndrome
Autosomal recessive
173
What is gilberts syndrome?
An autosomal recessive condition of defective bilirubin conjugation due to a deficiency of UDP glucuronosyltransferase
174
Presentation of gilberts syndrome
```
Unconjugated hyperbilirubinaemia
Jaundice may only be seen during
- exercise
- fasting
- intercurrent illness
```
175
Investigations of gilbert syndrome
Rise in bilirubin after a prolonged fast or IV nicotinic acid
176
Treatment of gilbert syndrome
No management required
177
What two vessels are connected in TIPS?
Hepatic vein and portal vein
178
Treatment of patients with ascites secondary to liver cirrhosis
Spironolactone
