Obstructive Jaundice

Question 1

Can you survive without a liver?

How long does a liver transplant take?

What percentage of a normal liver do you need to survive?

Answer 1

No

A few hours - ranging from half an hour to 2 hours usually

25%

Question 2

What is liver cirrhosis and what percentage of this liver is required to survive?

Answer 2

Cirrhosis = long term damage leading to formation of scar tissue; 40%

Question 3

Can you survive without the pancreas?

What are the 2 clinically important functions of the pancreas?

How would these 2 functions be treated if the pancreas is removed?

Answer 3

Yes

Insulin production to regulate BGL, disgestive enzyme production for disgestion

Insulin = insulin injections; digestive enzymes = disgestive enzyme supplements in capsules taken before a meal

Question 4

Why would it be very difficult to manage diabetes with no pancreas?

Answer 4

Still with damaged islets of langerhans, there is baseline insulin production

Feedback loops / mechanisms non-functioning

Question 5

What two major symptoms would you experience if you didn’t have enough pancreas?

Answer 5

Hyperglycaemia

Diarrhoea - lots of undigested food left behind in the stool lowering the oncotic pressure (so more water is also dragged into the stool)

Eventually leads to malnutrition

Question 6

Label the diagram below:

Answer 6

No clue?

Question 7

What is jaundice? What are some symptoms and signs?

Answer 7

Yellow skin - traditionally associated with the liver; however, more associated with gallstones

Due to too high bilirubin levels

Question 8

Patient case:

Mr Teeth is a 72 year old man. He has been experiencing intermittent colicky right upper quadrant and epigastric pain over the last year. Over the last week the pain has become more frequent and has increased in intensity, this has been accompanied by a sudden onset of jaundice associated with pale stools and dark urine. His liver function tests subsequently confirmed an obstructive picture of his jaundice

Question 9

The function tests for Mr Teeth are shown below. What are the biggest concerns?

Bilirubin (conjugated): 227 [< 8μmol/L]

Alkaline Phosphatase (ALP): 647 [41-133 IU/L]

Aspartate transaminase (AST): 42 [0-35 IU/L]

Alanine transaminase (ALT): 65 [7-56 IU/L]

Gamma-GT (GGT): 160 [9-85 IU/L]

Answer 9

Conjugated bilirubin is too high - bilirubin has been through the liver but obstructed before it reached the small intestine

Alkaline phosphatase it too high - clinically points to partially obstructed bile duct

Question 10

What is the difference between conjugated and unconjugated bilirubin?

Where does the conjugation occur?

Answer 10

Conjugated = bilirubin that has already been through the liver

Unconjugated = not yet arrived and travelled through the liver

In the liver

Question 11

What does it mean if the conjugated bilirubin has passed through the liver but not yet to the intestine?

Answer 11

Bile duct connects the two, so the bile duct (passageway) must be blocked

Question 12

What is the reference range for alkaline phosphatase for a complete blockage of the bile duct?

Answer 12

In the 1000s, however, as Mr Teeth has it in the 100s, it is a partial blockage, not a complete blockage

Question 13

What would the enzyme levels be if the patient has liver failure?

Enzymes:

Alkaline Phosphatase (ALP)

Aspartate transaminase (AST)

Alanine transaminase (ALT)

Answer 13

Much higher, rapid rise - as during liver failure, liver cells are dying (falling apart), so the liver breaks down and all the enzymes within the cells are released

Question 14

What is meant by the terms:

Colicky

Right upper quadrant

Jaundice

Bilirubin

?

Answer 14

Colicky = severe pain that comes and goes and is caused by blockages (pain comes when the obstructed area is trying to contract, pain leaves when the obstructed area relaxes)

Right upper quadrant = clinically the upper right 1/9th corner of the whole abdomen

Jaundice = bilirubin not getting into the stool gives the yellow tinge of the skin

Bilirubin = breakdown product of erythrocytes (Hb), and it is the pigment that gives urine and stool its colour

Question 15

What would be the colour of their stool if there was a complete blockage?

Answer 15

White / v. pale

Question 16

Categorise the key clinical features of the case as either signs or symptoms:

What is the difference between signs and symptoms?

Answer 16

Symptom = what the patient tells you

Sign = information gained from further questioning / testing

Question 17

What questions can be asked to narrow down the probable causes of their jaundice?

What are rigors?

How can cholangitis be treated?

Answer 17

Ask the patient about their pain i.e. confirm their pain history

Is the colicky pain associated with eating fatty food?

Were the jaundice symptoms a sudden onset, or gradual? - sudden = gallstones; gradual = cirrhosis, growth / tumour

Has the jaundice fluctuated or gotten progressively worse? - fluctuate = common bile duct stone or ampullary cancer; progressively worse = other malignant causes

Any fever or rigors? - rigors = shivering accompanied by a rise in temperature - may indicate cholangitis (inflammation of the bile duct system) - treated with IV fluids to rehydrate, IV antibiotics to control the infection and intervention to relieve obstruction of the bile duct

Weight loss or weight gain? - weight loss = malignancy; weight gain = gallstones

Any family history of gallstones?

Question 18

What other blood tests could be run to ensure the person has obstructive jaundice?

Answer 18

1. Serum amylase - to exclude issues associated with acute pancreatitis
2. Prothrombin (clotting) time - clotting time is prolonged but correctable with vitamin K for obstructive jaundice. For prehepatic jaundice clotting time is normal, and for hepatic jaundice is is prolonged and uncorrectable

Question 19

What are the most appropriate radiological investigations (in order of relevance) for obstructive jaundice?

Answer 19

1. Ultrasound scan - confirms dilated bile ducts and level of obstruction, also allows to identify gallbladder / common bile duct stones
2. Unclear ultrasound scan strongly indicates gallstones - can be looked for using an MRCP
3. If both, the ultrasound and MRCP fail, then proceed to a CT scan to exclude other causes

Question 20

If imaging subsequently confirmed common bile duct gallstones, what treatment options should be discussed to relieve their obstructive jaundice?

Answer 20

1. Laparoscopic cholecystectomy - keyhole surgery during which the doctor removes the gallbladder
2. Simultaneous CBD exploration (during the laparoscopic surgery) - check if any other stones are blocking the bile ducts
3. Unlikely, but if unable to remove stones laparoscopically - proceed to an open cholecystectomy and CBD (common bile duct) exploration