Ow: Jaundice + case 5 Flashcards
Mr TS is a 56 y/o man with RUQ pain for 24h
Tender RUQ with guarding - particularly prominant pain when asked to take deep breath with an examining hand just below the right costal margin (murphy’s sign)
Temperature is 38.2 with an elevated WBC
Discuss…
RUQ is typically caused by biliary collic but can also be brought on my pleurisy but would come with resp symptoms. Gastric causes and pancreatitis are typically in the epigastrum but can sometimes be more on the right that the centre.
Biliary colic radiates around the back and sometimes to the shoulder and is postprandial where as gastric pain is general and diffuse and can’t really be localised.
Biliary colic causes?
Gallstones in the:
- Cystic duct
- In the common bile duct
Cholecystitis: inflammation of the gall bladder
- tender and with the murphys sign but not a colicky pain unless it comes with gallstones as well which it often does
What is guarding and what does it imply?
Abdominal wall tightening - Voluntary or involuntary
Voluntary:
- anticipation of pain
- if you have cold hands
Involuntary:
- peritonism (local inflammation of peritoneum due to underlying structures being inflammed)
- often comes with rebound tenderness or percussion tenderness
Diagnosis of Mr TS? initiation of bile release?
Cholecystitis likely initiated by gallstones but may be acalculous cholecystitis with no gallstones.
Gallstones may be caused by concentration of bile precipitating cholesterol
Initiation of the gall bladder is by cholecystokinin
Biliary colic?
Cholelithiasis?
Cholecystitis?
Choledocolithiasis?
Cholangitis?
Cholesterol stones vs pigment stones?
Biliary colic - Is a symptom rather than a diagnosis
Cholelithiasis - presence of GS in the GB
Cholecystitis - inflammation of GB
Choledocolithiasis - GS in the biliary duct
Cholangitis - the presence of infection in the bile duct commonly due to choledocolithiasis
Cholesterol stones (80%) vs pigment stones
He is now found to have elevated GGT, alkaline phosphatase (ALP) and bilirubin. The common bile duct is dilated on US and he has a high fever and rigors?
Diagnosis?
Another potential consequence?
Cholangitis due to choledocolithiasis
The pancreatic duct also drains into and with the biliary duct and so blockage can lead to pancreatitis (check the lipase and amylase)
Common causes of cholestasis?
Think STD-B
- Common causes (GGT and ALP elevated)
- Stones
- tumors
- drugs
- Biliary disease
- primary billiary cirrhosis (PBC)
- Prinmary sclerosing cholangitis (PSC)
Choledocolithiasis?
Most duct stones have migrated from the gall bladder (ie secondary duct stones- usually cholesterol ones) but rarely can form in the duct (ie primary duct stones - usually pigment stones) from infection/stasis
Cholangitis?
Complication of choledocolithiasis
Charcot’s triad: (more likely the more you have)
- Fever
- Jaundice
- RUQ pain
What is MRCP and what do we use it for? ERCP? Further treatment?
MRCP - Magnetic resonance cholangiopancreatography
Useful for acurate visualisation of the biliary tree - is non-invasive but also non-therapeutic. Used if US doesn’t show anything but still have clinical suspicion
ERCP - Endoscopic retrograde cholangiopancreatography
Diagnostic and therapeutic - but doen’t come without risk
This doesn’t stop further stones and so an elective cholecystectomy should still be performed as 85% of stones in the common duct are secondary
68 y/o has been known to have abnormal LFTs for > 10 years
Grandually increased levels of GGT and ALP with normal bilirubin
Now presents with generalised itching
On exam: no jaundice, widespread scratch marks, liver was normal span with a normal Liver US
What can we rule out here?
Because there is no dilation of the common bile duct or hepatic duct then we know there is no GS causing obstruction.
We therefore must have intrahepatic duct obstruction caused by PBC or PSC
What is PBC?
PBC - Primary biliary cirrhosis
- Autoimmune chronic cholestatic liver disease
- Diagnosed by a positive AMA (anti-mitochondrial antibody)
- Affects small intrahepatic bile ducts (not detectable on imaging)
- Requires 2 out of:
- High ALP
- Positive AMA
- Liver biopsy (hardly ever done)
Associations of PBC?
- Associated with striking dyslipidaemia but don’t seem to have an increase in CVS illness
- Associated with osteopenia/osteoporosis but NOT due to vitamin D malabsorption even if they do have it, reversal of deficiency doesn’t fix issue
- Associations with other autoimmune conditions like hypothyroidism
Presentation and progression of PBC?
Approx 50-60% are asymptomatic and usually diagnosed when having LFTs for something else and ALP is elevated
Early symptoms of fatigue, pruritus (itch), steatorrhoea
progressive disease over 10years or so with jaundice and liver cirrhosis due to leakage of bile into hepatocytes (also increases risk of HCC)
Treatrment fo PBC?
UDCA - Ursodeoxycholic acid
- a non-toxic bile acid that improves blood tests and delays the need for liver transplantation
- Does NOT cure the disease
Presentation and progression of PSC?
- Often associated with UC but is asymptomatic in 50% and diagnosed while have LFTs for other reason
- Symptoms:
- Pruritus
- Fatigue
- Msay have steatorrhoea
- Progressive disease → jaundice → repeated episides of cholangitis → Liver cirrhosis and realted complications (including HCC but to a lesser extent)
