Jaundice History Flashcards
Introduction
Wash hands, PPE Introduce yourself Patient ID, DOB Explanation Question - are you in any pain?
Presenting complaint exploration
Onset and progression
Sudden => choledocholithiasis
Gradual => cancer?
Triggers for jaundice
- stress - Gilberts
- recent IV needle use - hemolysis
Key associated symptoms
Pain
-pattern and associations
N+V - liver disease (ALD, NAFLD)
Hematemesis - esophageal varices rupture from liver failure + portal HTN
Dark urine, pale stools - post hepatic cause
Diarrhoea - underlying viral infection?
Steatorrhea - obstructive
Itch
Easy bleeding, bruising - FHx of bleeding disorders, liver disease
Weight loss, ascities, pedal edema - cirrhosis
Systemic review
- systemic
- GI
- CV
Systemic
- weight loss, loss of appetite, night sweats => cholangiocarcinoma, pancreatic cancer?
- fever => infection
GI
- abdo pain
- difficulty swallowing
- reflux
- abdo mass
- change in bowel habits
CV
-SOBOE, easy bruising/bleeding - anemia
Past medical history
Any other medical conditions, how are they being managed
-medications, any problems
Any other medications (prescription, OTC, herbal)
Past surgeries, procedures, hospital visits?
Do you have any conditions that affect your blood?
-sickle cell, thalassemia => hemolysis
Recent blood transfusions?
Past hepatitis infection or vaccinations against hepatitis
Family history
Is there a history of
- liver, gall bladder, pancreatic problems
- easy bleeding, bruising
Social history
- living
- occupation
- substances
- travel
Living
- accommodation
- living with who? carers? dependents?
- level of independence
Occupation
Substances
- smoking => pack years
- alcohol => ALD?
- diet => gallstones? NAFLD?
- IVDU, sexual activity, recent tattoos, piercings => HepB, C
Travel
-Africa, parts of Asia => HepA, E
Further investigations
Abdominal examination
FBC - anemia Viral serology LFT - hepatic or cholestatic Coagulation profile Amylase, lipase => rule out pancreatic causes
US => gallstones
CT => pancreatic cancer
Liver function test interpretation
-ALT, AST, ALP, GGT
High ALT, AST => hepatocellular injury
High ALP, GGT => cholestatic injury
ALT higher than AST => NAFLD
AST higher than ALT =>ALD
Isolated high GGT => high alcohol use Isolated high ALP => bone problems -bone mets, tumour -ViD deficiency -recent fractures
Jaundiced but ALT and ALP are normal => prehepatic cause
- Gilberts
- Hemolysis => blood film. FBC, reticulocyte count
Liver function test interpretation
- albumin
- PT
Low albumin
- decreased prod => liver disease
- acute inflammation
- excess loss => nephrotic, protein losing enteropathy
PT - extrinsic pathway
High - liver disease due to low clotting factor prod
Liver screen, what is assessed
LFT Coagulation Hepatitis serology EBV, CMV AMA, ASMA, ANA, ALKM, pANKA a1antitrypsin Serum copper, ceruloplasmin Ferritin
Differentiating between
- prehepatic
- hepatic
- posthepatic causes of jaundice
KEY DIFFERENTIATOR - PALE STOOLS, DARK URINE
Yes => post hepatic Gallstones -colicky, fatty food triggers Malignancy - pancreatic, cholangiocarcinoma -weight loss, back pain, fatigue Cholangitis -fever, pain, jaundice, shocked, confused => ADMIT Choledocholithiasis
Yes => hepatic Hepatitis - -AE - recent travel, close contact -BCD - IVDU ALD -high alcohol intake NAFLD -poor diet
No => pre hepatic Gilberts -precipitated by stress, self limiting -FHx of periodic jaundice Hemolytic anemia -FHx of bleeding disorders, tendency to bleed
Gilbert syndrome
- risk factors
- core features
- investigations
- management
Risk factors
- FHx
- stress
Core features
Literally just jaundice
Investigations
- elevated bilirubin
- normal liver tests
Management - self limiting with no increased risk of liver disease or complications
Identify and avoid triggers
Hemolytic anemia
- risk factors
- core features
- investigations
- management
Risk factors
- FHx of bleeding disorders
- recent blood transfusion
Core features
Prehepatic jaundice signs
SOB, anemia
Signs suggestive of the underlying cause
Investigations
- urinalysis - high urobilinogen, Hb
- FBC - anemia
- reticulocytosis - increased turnover
- high unconjugated bilirubin - increased hemolysis
- blood smear
Management - depends on cause
Supportive - hematinics (B12, folatee, Fe)
Red cell tranfusions after consulting haem team- if severe
Hepatitis A, E
- risk factors
- core features
- investigations
- management
Risk factors
- recent travel to endemic countries (Africa, South Asia)
- fecaloral transmission
- HepA incubation period - 3wks
- HepE incubation period - 6wks
Core features
Non specific prodrome - fever, fatigue, lost appetite
Active disease - abdo pain, jaundice, dark urine, pale stool, N+V, hepatomegaly
Investigations
LFTs - ALT, AST, bilirubin high
Definitive - HepA IgM, HepE IgM
Management
Supportive - fluids, rest
