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
Hepatitis B, C, D
- risk factors
- core features
- investigations
- management
Risk factors
- blood and sexual fluid transmission (IVDU, unprotected sex)
- healthcare workers
- HepB, C incubation period - 3months
Core features if symptomatic
Non specific prodrome - fever, fatigue, lost appetite
Active disease - abdo pain, jaundice, dark urine, pale stool, N+V, hepatomegaly
Core features if chronic
Asymptomatic in latent disease
Hepatic decompensation - ascities, easy bleeding/bruising, confusion
Investigations LFTs - hepatic HepB AB - differentiate between active disease, vaccinated, chronic disease HepC RNA HepD IgM, IgG
Management Acute - rest, fluids, simple analgesia -notify PHE HepB, C serology to check for chronic disease Chronic - antivirals
ALD, NAFLD
- risk factors
- core features
- investigations
- management
Risk factors
- ALD - high alcohol intake
- NAFLD - obesity, CV risk factors
Core features
Early symptoms
-RUQ pain
-generally unwell - fatigue, lost appetite, N+V, diarrhoea
Late symptoms
- jaundice, ascities, pedal edema
- weight loss, muscle wasting
- easy bleeding bruising
Investigations Hepatic LFTs -AST higher than ALT in ALD -ALT higher than AST in NAFLD Albumin - low in liver damage Coagulation studies - abnormal in liver damage Liver biopsy - degree of scarring US, CT, MRI - degree of scarring
Management for ALD
Alcohol cessation
Withdrawal support - self help (CBT), community groups, IP
Management for NAFLD
Weight loss, CV optimisation, healthy diet, physical activity, smoking cessation
Gallstone related - choledocholithiasis, cholangitis
- risk factors
- core features
- investigations
- management
Risk factors
- obesity, DM, poor diet
- female
Core features in choledocholithiasis
Obstructive jaundice without fever
Core features in cholangitis
Pentad - jaundice, pain, fever, shock, confusion
Investigations - CBD stones rarely seen on US
LFTs - cholestatic
Definitive - ERCP
Management
Supportive - fluids, analgesia (ABx for cholangitis)
Definitive - removal with ERCP
Cholangiocarcinoma, pancreatic cancer
- risk factors
- core features
- investigations
- management
Risk factors for cholangiocarcinoma
- viral hepatitis
- PSC
Risk factors for pancreatic cancer
- older age
- obesity, poor diet
- FHx
- chronic pancreatitis, DM
Core features
Obstructive jaundice
Weight loss, lost appetite, fatigue, abdo pain
Courvoisier’s Law
Investigations
Definitive - biopsy via ERCP/MRCP
Staging - CT PET CAP
Management
Surgery
Radio, chemo
2ww criteria for pancreatic cancer
40+ Jaundiced => 2ww
60+ Weight loss => urgent CT AND -C/D/N/V -back/abdo pain -new DM
Hep B serology interpretation -what do each of the antibodies indicate What are the expected findings for someone who has been -vaccinated -active -chronic -immune
HepB sAG - active infection
HepB sAB - past infection/vaccinated
HepB c IgM - recent infection in last 6months
HepB c IgG - past infection
HepB eAG - active replication and high transmissability
HepB eAB - inactive replication, low transmissability
Vaccinated - sAB
Active infection - sAG, c IgM, c IgG, eAg
Chronic infection - sAG, c IgG, eAG/AB
Immune - sAB, c IgG, eAB
