Obstructive Jaundice Flashcards

1
Q

Classify the different causes of cholestatic jaundice?

A

Intrahepatic: Inflammatory changes in the ductal cells interfering with the flow, causing there to be no bile secretion.

Extrahepatic: large duct obstruction of bile flow at any point in the biliary tract distal to the bile canaliculi (tube which collects bile from the hepatocytes). Two main causes are gallstones and pancreatic carcinoma.

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2
Q

Describe and explain the classical clinical features of obstructive jaundice?

A

Jaundice: due to build up of bilirubin

Pale stools: due to the obstruction, the bile is not metabolised and excreted as stercobilinogen (the component that give faeces a brown colour).

Poor fat absorption: steatorrhea as bile is not available to emulsify fats

Dark Urine: Reduced bile secretion therefore less urobilinogen in the intestine. There is therefore less absorption and excretion meaning urine urobilinogen levels are low.

However there are large quantities of conjugated bilirubin in the systemic circulation which is excreted by the kidneys giving the urine a very dark colour.

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3
Q

What laboratory and radiological investigations could be done to help make a diagnosis in a jaundiced patient?

A

Urine:

  • Conjugated bilirubin absent/low in non-obstructive causes (as excreted as urobilinogen in the urine and stercobillogen in the bowel)
  • Urobilinogen low in obstructive causes.

Bloods:

FBC:

  • Low Hb in haemolytic causes
  • Raised WBC will indicate an infectious cause, (cholangitis)
  • Leukopenia suggests viral infection.
LFTs:
-Bilirubin conjugated/nonconjugated.
-Hepatocellular damage:
Alcoholic AST:ALT 2:1
V. high ALP suggests obstructive.
Low albumin suggests chronic.

Viral serology for hepatitis

Imaging:
Ultrasound to look for biliary stones/obstruction
Abdominal CT if malignancy suspected (painless jaundice)

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4
Q

Describe the pathophysiology, typical patient and symptoms of cholelithiasis (gallstones)?

A

Gallstones are stones formed from bile when there is to high a ratio of cholesterol to bile salts.

They are more common in the 4F’s:
Fat, Fertile (oestrogen) , Forty yo, Females,

Patients with gallstones may be asymptomatic ‘silent stones’ or may suffer from gallstone attacks.

Gallstone attacks present with severe sudden onset epigastric or right upper quadrant pain. It is often associated with nausea and vomiting.

Gallstone attacks are more frequent at night and are often precipitated by a fatty meal or alcohol.

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5
Q

Describe the potential consequences of cholelithiasis?

A

If a gallstone blocks drainage of bile from the gallbladder it may precipitate cholecystitis (infection of the gallbladder)

If a gallstone blocks another part of the biliary tree it may precipitate cholangitis (infection of the bile duct, medical emergency)

If it blocks drainage from the pancreas (pancreatic duct) it can cause pancreatitis.

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6
Q

Describe the presentation and prognosis of pancreatic carcinoma?

A

Presents with painless obstructive jaundice, (usually severe jaundice), weight loss.

May become painful as the tumour progresses.

Courvoisier’s sign positive: palpable gallbladder which is non tender the pathology is unlikely to be with the gall bladder.

May be lympathendopathy and splenomegaly.

Very poor prognosis 5 year mortality very low even with treatment.

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7
Q

What are the different methods of treating common bile duct obstruction?

A

ERCP (endoscopic retrograde cholangiopancreatography): Can be used particularly in patients that are high risk and may not be suitable for surgery. May be used in place of surgery as it is less invasive.

-Biliary sphincterotomy and endoscopic stone extraction: the sphincter of oddi is cauterised to allow stones to pass and any stones are extracted

Surgical:

  • Laparoscopic cholecystectomy and exploration of the CBD
  • Biliary stenting can be used if stones are irretrievable, if the patient is not fit for surgery or as a palliative procedure in pancreatic Ca as it can minimize the risk of developing cholangitis while relieving jaundice and pruritus.
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