Jaundice, HSM, Ascites

Question 1

What are causes of hepatomegaly

Answer 1

C - cirrhosis (early) - any cause
C - cancer (craggy) / haematological malignancy
C - congestion (portal hypertension 2 to RHF or cirrhosis, RHF will have pulsatile (COPD)

I - infection (hepatits / CMV / EBV / malaria / abcess)
I - immune - (hepatitis / PSC / PBC)
I - infiltration with amyloid / sarcoid / haem malignancy / haemochromatosis

Question 2

What should you do if abnormal LFT and what is 1st line imaging / other imaging

Answer 2

Liver screen
USS = 1st line to show duct dilatation / mets
MRCP - MRI
ERCP if removing i.e. cholangitis / pancreatitis

Question 3

What is in a liver screen

Answer 3

Hep B,C,E
EBV, CMV, HIV, Yellow fever 
Auto-immune / Ab / Ig
Serum copper -  for Wilson disease 
Ferritin and transferrin - Haemochromatosis
A1-anti-trypsin 
Glucose
Lipids

Question 4

When will liver cause pain

Answer 4

When capsule stretched

Question 5

How do you investigate hepatomegaly

Answer 5

LFT’s
If abnormal = liver screen
FBC - liver disease cause BM suppression / MCV alcohol
U+E - hepatorenal syndrome / malnourishment
CLotting / albumin / bilirubin
CRP
Imaging

Question 6

What is 1st line imaging

Answer 6

USS to show mets / stone / cirrhosis

Question 7

What is jaundice

Answer 7

Visible when serum bilirubin >50mmol/l

Question 8

How is bilirubin metabolised

Answer 8

Haem broken down in spleen
Binds to albumin and transferred to liver (insoluble)
Conjugated = soluble (ADP enzyme)
Secreted into bile
Passes into gut
Taken back up by liver via portal circulation
Converted to urobilinogen
Reabsorbed and excreted by kidney
Or converted to stercobilin and excreted in the stool

Question 9

What are pre-hepatic causes of Jaundice

Answer 9

Haemolysis
- Haemolytic
- Malaria 
- Sickle / G6PD / thalassaemia 
Gilbert / Crigler Naajar - absence of ADP enzyme to conjugate
Post-transfusion
Drugs - rifampicin

Question 10

What are causes of hepatic

Answer 10

All hepatomegaly causes
Drug - paracetamol / statin / valprate
Alcohol 
NAFLD
Hepatits
Haemochromatosis / Wilson
Autoimmune 
Budd-Chairi 
Hypothyroid 
Coeilac 
TPN
Sepsis

Question 11

What are obstructive causes

Answer 11

CBD stone
Stricture e.g. post ERCP 
PBC 
Cholangitis 
Liver mets 
HCC 
Cholangiocarcinoma
Pancreatic cancer 
Mirizzi syndrome
Drugs

Question 12

What does painless slow onset jaundice + weight loss

Answer 12

Cancer

Question 13

What does acute painful jaundice + sepsis suggest

Answer 13

Stone
Cholecystitis
Cholangitis

Question 14

What other symptoms are important in jaundice

Answer 14

Itching = cholestasis
Dark urine / pale stool = suggest obstruction
Fever = infection
Melena? - ulceration of tumour / haemorrhage

Question 15

What does a palpable painless gallbladder suggest

Answer 15

Malignancy
Pancreatic or liver due to portal hypertension
Known as coursevier law - Unlikely to be stones as they form over a long period + shrink gall bladder

Question 16

How do you investigate jaundice

Answer 16

FBC, U+E, LFT, clotting, film, DAT
Liver screen inc malaria
USS = 1st line

Question 17

What do you do after USS

Answer 17

ERCP / PTC if dilated biliary tree and LFT not improving
MRCP if unfit for ERCP / no intervention
CT / MRI if abdo / pancreatic malignancy suspected
Liver biopsy if no dilatation

Question 18

How do you treat jaundice

Answer 18

Treat cause + relieve as high risk of bleeding / infection
Stent for malignancy
Treat clotting 
ERCP / cholocystectomy for gall stone
PTC if ERCP fails for stent 
High dose Ax if infection

Question 19

Haemolytic jaundice

Important Ix

Answer 19

Unconjugated bilirubin
ALT, AST, ALP normal
Urine and stool normal

Do DAT and blood film

Question 20

Hepatic jaundice

Answer 20

Mixed bilirubin
ALT+ AST high
ALP mild increase
Dark urine and normal stool

Question 21

Obstructive jaundice

Answer 21

Conjugated + raised
ALT and AST mild increase
ALP marked increase
Urine dark / pale stool

Require USS / MRCP / ERCP

Question 22

WHat are causes of splenomegaly

Answer 22

Infection - Lyme’s, meningitis, sepsis, TB, rheumatic fever, EBV
Infective endocarditis

DIC / haemolytic anaemia
Malignancy - lymphoma / leukaemia / myeloma

Haemoglobinopathy - Sickle cell / thalassaemia

Autoimmune - Sjogren / SLE / RA / vasculitis
Infiltration - amyloid/ sarcoid

Portal hypertension - cirrhosis or HF

Question 23

What are causes of massive splenomegaly

Answer 23

Malaria
CML
Myelofibrosis
Polycythaemia
Leishmaniasis

Question 24

What is importnat in history of splenomegaly

Answer 24

Fever - infection / TB / malignancy / sarcoid
Lymphadenopathy - glandular / malignancy
Ascites - portal / malignancy
Arthritis / vasculitis/ RA / sjogre / SLE / lyme
Weight loss - malignancy / TB
Purpura - meningitis / DIC /sepsis
Murmur - IE / rheumatic

Question 25

What are RF for jaundice

Answer 25

Blood transfusion
IVDA
Piercing / tattoo
STI
Foreign travel
Alcohol / drugs 
FH

Question 26

What causes mass in RIF

Answer 26

Appendicitis
Caecal cancer / malignancy 
Chron's
Intussception
TB
Kidney malformation / transplant
Undescended testis
Stool

Question 27

What can obstructive jaundice be further classified into

Answer 27

Calcular

Malignant

Question 28

Calcular

Answer 28

F>M
Biliary colic
No weight loss
Fluctuates

Question 29

Malignant

Answer 29

M>F
Painless
Weight loss
Progressive

Question 30

What gets urgent referral

Answer 30

> 40 + jaundice or upper abode mass

Question 31

What do you do if suspect Gilbert

Answer 31

FBC to see if isolated hyperbilirubin or haemolytic

Look to see if any drugs / transfusion could cause

Question 32

How does Gilbert present

Answer 32

Jaundice due to isolated hyperbilirubin
Common after infection
Self limiting
Review after 1 week to see symptoms resolved

Question 33

If liver decompensated

Answer 33

Poor prognosis

Urgent Rx needs