Jaundice (My Skin is Looking Yellow)

Question 1

What is the maximum number of units of alcohol NICE advises is safe to consume per week?

Answer 1

14 units

Question 2

Name the enzyme responsible for converting ethanol into acetaldehyde.

Answer 2

Alcohol dehydrogenase

Question 3

Why can high levels of alcohol consumption impair liver function?

Answer 3

Acetaldehyde undergoes lipogenesis to form fatty acids and glycerol, which can accumulate in hepatocytes leading to inflammation (hepatitis).

Question 4

Via what mechanisms can chronic liver disease produce symptoms? (5)

Answer 4

-High oestrogen levels
-Low albumin
-Portal hypertension
-Hepatic encephalopathy
-Sarcopaenia (muscle loss)

Question 5

What symptoms are indicative of high oestrogen levels and subsequently chronic liver disease? (5)

Answer 5

-Palmar erythema
-Gynaecomastia
-Spider naevi
-Loss of secondary body hair (in males)
-Male genital atrophy

Question 6

What is leukonychia?

Answer 6

An abnormal whitening of the nail beds in total, partial or striate form; can be caused by many things including low albumin as seen in chronic liver disease.

Question 7

What three signs are indicative of portal hypertension?

Answer 7

Caput medusae (network of swollen superficial epigastric veins)
Dilated anterior abdominal wall veins
Ascites

Question 8

What causes asterixis (liver flap)?

Answer 8

Impaired function of the diencephalic motor centres of the brain, seen in certain types of organ failure including liver failure, leading to hepatic encephalopathy.

Question 9

What symptoms are clinically indicative of obstructive jaundice? (2)

Answer 9

Darkening urine
Itching

Question 10

What does bilirubin on a urine dipstick tell us about the patient’s blood?

Answer 10

Suggestive of increased conjugated bilirubin in the blood.

Question 11

What condition may raised ferritin in the context of jaundice indicate?

Answer 11

Haemochromatosis

Question 12

What is bilirubin?

Answer 12

A breakdown product of haem molecules in red blood cells.

Question 13

Where does the pre-hepatic phase of red blood cell metabolism mainly take place?

Answer 13

In the spleen

Question 14

What components is haem broken down into? (2)

Answer 14

Iron and protoporphyrin.

Question 15

What is protoporphyrin broken down into? (1)

Answer 15

Unconjugated bilirubin (which is not water soluble)

Question 16

What protein binds to unconjugated bilirubin to transport it to the liver?

Answer 16

Albumin

Question 17

What enzyme converts unconjugated bilirubin to conjugated bilirubin in the liver?

Answer 17

Uridine glucuronyl transferase

Question 18

Where is conjugated bilirubin stored?

Answer 18

In the gallbladder, as bile.

Question 19

What is conjugated bilirubin converted into by microbes in the small intestine?

Answer 19

Urobilinogen

Question 20

What is urobilinogen ultimately converted into? (2)

Answer 20

Stercobilin (excreted in stools) or urobilin (either sent back to liver or excreted in urine)

Question 21

What pattern of jaundice does viral hepatitis cause?

Answer 21

Mixed conjugated and unconjugated bilirubin causing jaundice.

Question 22

What pattern of jaundice do pre-hepatic pathologies cause?

Answer 22

Increased levels of unconjugated bilirubin only.

Question 23

What pattern of jaundice do hepatic pathologies cause?

Answer 23

Increased levels of mainly unconjugated bilirubin (can also increase conjugated bilirubin if biliary tree affected).

Question 24

What pattern of jaundice do post-hepatic pathologies cause?

Answer 24

Increased levels of conjugated bilirubin but normal levels of unconjugated bilirubin.

Question 25

What is Librium?

Answer 25

A brand name for chlordiazepoxide, a long-acting benzodiazepine that NICE recommends for treatment of symptoms associated with acute alcohol withdrawal.

Question 26

What GI conditions is excessive alcohol intake a risk factor for? (5)

Answer 26

-Oesophagitis -Mallory Weiss tears -Gastritis and peptic ulceration -Oesophageal varices (less commonly) -Oesophagogastric malignancy (rarely)

Question 27

What is the NICE definition of alcohol withdrawal?

Answer 27

The physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time.

Question 28

What symptoms may be seen in clinical presentation of acute alcohol withdrawal? (4)

Answer 28

-Autonomic hyperactivity (insomnia, tremor, anxiety, GI upset, anorexia, headache, palpitations, cold sweats) -Withdrawal seizures (generalised tonic clonic) -Alcoholic hallucinosis (usually visual but may be auditory or tactile) -Delirium tremens

Question 29

What is delirium tremens?

Answer 29

Delirium with hallucinations and autonomic disturbances.

Question 30

How can delirium tremens be differentiated from alcoholic hallucinosis? (2)

Answer 30

Patients with alcoholic hallucinations are usually alert, whilst delirium tremens clouds the sensorium. Delirium tremens is also associated with abnormal vital signs, fluid status and electrolyte levels.

Question 31

What is the order of onset of the four symptoms that may be seen in clinical presentation of acute alcohol withdrawal (from earliest to latest onset)?

Answer 31

Autonomic hyperactivity (onset<6hrs) Alcoholic hallucinosis (onset <12-24hrs) Withdrawal seizures (onset <12-48hrs) Delirium tremens (onset 48-96hrs)

Question 32

What tools can be used in hospital to assess severity of alcohol withdrawal? (2)

Answer 32

Clinical Institute Withdrawal Assessment (CIWA) Glasgow Alcohol Score (GAS)

Question 33

What is the Alcohol Use Disorders Inventory Test (AUDIT)?

Answer 33

A screening test that can help identify patients who are hazardous drinkers or have active alcohol use disorders (such as abuse or dependence). Looks at frequency of alcohol consumption and proportion of binge drinking.

Question 34

What is Pabrinex?

Answer 34

A drug given by IV that supplements vitamins B and C to correct deficiencies.

Question 35

What is Wernicke’s Encephalopathy (WE)?

Answer 35

An acute confusion at state classically consisting of delirium, ataxia and ophthalmoplegia due to thiamine deficiency and neurotoxic effects of glutaminergic drive.

Question 36

What is the Korsakoff’s psychosis triad?

Answer 36

Short term memory loss, confabulation and ataxia.

Question 37

What is the maximum infusion rate for potassium chloride?

Answer 37

10mmol/hour, or 20mmol/hour WITH cardiac monitoring

Question 38

When should we admit patients with acute alcohol withdrawal to hospital?

Answer 38

NICE guidelines: when they are at high risk of developing alcohol withdrawal seizures or delirium tremens.

Question 39

How is the Clinical Institute Withdrawal Assessment (CIWA) used to indicate severity of withdrawal?

Answer 39

It measures 10 symptoms of alcohol withdrawal on a scale of severity (0-4 for clouding of sensorium and 0-7 for everything else): -Scores of <8-10 indicate minimal to mild withdrawal -Scores of 8-15 indicate moderate withdrawal -Scores of 15 or more indicate severe withdrawal

Question 40

What are the criteria for suspected pancreatic cancer referral? (2)

Answer 40

Patient aged 40 years or over and has jaundice. OR Patient aged 60 years or over with weight loss and any of the following; diarrhoea, back pain, abdominal pain, nausea, vomiting, constipation or new-onset diabetes.

Question 41

What is first line management for delirium tremens?

Answer 41

Oral lorazepam