Jaundice, HSM, Ascites Flashcards
What are causes of hepatomegaly
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
What should you do if abnormal LFT and what is 1st line imaging / other imaging
Liver screen
USS = 1st line to show duct dilatation / mets
MRCP - MRI
ERCP if removing i.e. cholangitis / pancreatitis
What is in a liver screen
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
When will liver cause pain
When capsule stretched
How do you investigate hepatomegaly
LFT’s
If abnormal = liver screen
FBC - liver disease cause BM suppression / MCV alcohol
U+E - hepatorenal syndrome / malnourishment
CLotting / albumin / bilirubin
CRP
Imaging
What is 1st line imaging
USS to show mets / stone / cirrhosis
What is jaundice
Visible when serum bilirubin >50mmol/l
How is bilirubin metabolised
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
What are pre-hepatic causes of Jaundice
Haemolysis - Haemolytic - Malaria - Sickle / G6PD / thalassaemia Gilbert / Crigler Naajar - absence of ADP enzyme to conjugate Post-transfusion Drugs - rifampicin
What are causes of hepatic
All hepatomegaly causes Drug - paracetamol / statin / valprate Alcohol NAFLD Hepatits Haemochromatosis / Wilson Autoimmune Budd-Chairi Hypothyroid Coeilac TPN Sepsis
What are obstructive causes
CBD stone Stricture e.g. post ERCP PBC Cholangitis Liver mets HCC Cholangiocarcinoma Pancreatic cancer Mirizzi syndrome Drugs
What does painless slow onset jaundice + weight loss
Cancer
What does acute painful jaundice + sepsis suggest
Stone
Cholecystitis
Cholangitis
What other symptoms are important in jaundice
Itching = cholestasis
Dark urine / pale stool = suggest obstruction
Fever = infection
Melena? - ulceration of tumour / haemorrhage
What does a palpable painless gallbladder suggest
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
How do you investigate jaundice
FBC, U+E, LFT, clotting, film, DAT
Liver screen inc malaria
USS = 1st line
What do you do after USS
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
How do you treat jaundice
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
Haemolytic jaundice
Important Ix
Unconjugated bilirubin
ALT, AST, ALP normal
Urine and stool normal
Do DAT and blood film
Hepatic jaundice
Mixed bilirubin
ALT+ AST high
ALP mild increase
Dark urine and normal stool
Obstructive jaundice
Conjugated + raised
ALT and AST mild increase
ALP marked increase
Urine dark / pale stool
Require USS / MRCP / ERCP
WHat are causes of splenomegaly
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
What are causes of massive splenomegaly
Malaria CML Myelofibrosis Polycythaemia Leishmaniasis
What is importnat in history of splenomegaly
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
What are RF for jaundice
Blood transfusion IVDA Piercing / tattoo STI Foreign travel Alcohol / drugs FH
What causes mass in RIF
Appendicitis Caecal cancer / malignancy Chron's Intussception TB Kidney malformation / transplant Undescended testis Stool
What can obstructive jaundice be further classified into
Calcular
Malignant
Calcular
F>M
Biliary colic
No weight loss
Fluctuates
Malignant
M>F
Painless
Weight loss
Progressive
What gets urgent referral
> 40 + jaundice or upper abode mass
What do you do if suspect Gilbert
FBC to see if isolated hyperbilirubin or haemolytic
Look to see if any drugs / transfusion could cause
How does Gilbert present
Jaundice due to isolated hyperbilirubin
Common after infection
Self limiting
Review after 1 week to see symptoms resolved
If liver decompensated
Poor prognosis
Urgent Rx needs
