Symptom To Diagnosis - Jaundice Flashcards
1
Q
Is conjugated bilirubin REABSORBED by the intestine?
A
NO!
2
Q
Fate of conjugated bilirubin in the intestine:
A
- Can be excreted unchanged in the stool.
2. Can be converted to Urobilinogen by colonic bacteria.
3
Q
Fate of urobilinogen that is produced by colonic bacteria.
A
- Can be reabsorbed, entering portal circulation.
- Some is taken up by the liver and re-excreted into the bile.
- Some bypasses the liver and is excreted by the kidney, thus appearing in the urine in small amounts.
4
Q
UCB is NOT found in the urine. Why?
A
Because it is bound to albumin.
5
Q
1st key point in the DDx of hyperbilirubinemia is?
A
Determining which kind of bilirubin is elevated.
6
Q
Dark, tea-colored urine means?
A
Patient has conjugated Hyperbilirubinemia.
7
Q
Increased bilirubin production - When?
A
- Hemolysis.
- Dyserythropoiesis.
- Extravasation of blood into tissues.
8
Q
Impaired hepatic bilirubin uptake - When?
A
- Heart failure.
- Sepsis.
- Drugs (rifampin, probenecid, chloramphenicol).
- Fasting.
- Portosystemic shunts.
9
Q
Impaired bilirubin conjugation - When?
A
Hereditary: 1. Gilbert syndrome. 2. Crigler-Najjar syndrome. Acquired: 1. Neonates. 2. Hyperthyroidism. 3. Ethinyl estradiol. 4. Liver disease (causes mixed hyperbilirubinemia, usually conjugated). 5. Sepsis.
10
Q
Most patients with UCBemia have?
A
- Hemolysis.
- Gilbert syndrome.
- HF.
- Sepsis.
11
Q
CBemia - etiology if normal liver enzymes:
A
- Sepsis or systemic infection.
- Rotor syndrome.
- Dubin-Johnson syndrome.
12
Q
CBemia - Elevated liver enzymes - Transaminases more than ALP - Hepatocellular pattern:
A
- Acute viral or alcoholic hep.
- Alcoholic or non alcoholic steatohepatitis.
- Chronic hel (viral, alcoholic, autoimmune).
- Cirrhosis of any cause.
- Drugs.
13
Q
CBemia - Cholestatic pattern:
A
- Extrahepatic cholestasis.
- Intrahepatic Cholestasis (due to impaired excretion):
- Viral hep.
- Alcoholic hep.
- Cirrhosis.
- Drugs and toxins.
- Sepsis.
- Total Parenteral nutrition.
- post-op jaundice.
- Infiltrative diseases (amyloidosis, lymphoma, Sarco, TB).
- PSC.
- PBC.
14
Q
AST (SGOT) - Aspect of liver assessed + Origins?
A
Hepatocyte integrity.
- Liver.
- Heart.
- Kidney.
- Skeletal muscle.
- Brain.
- RBC.
15
Q
ALT - Aspect of liver assessed + origins:
A
Hepatocyte integrity + Liver.
16
Q
ALP - aspect of liver assessed?
A
Cholestasis.
- Liver.
- Bone.
- Intestine.
- Placenta.
17
Q
For bilirubin >3 Sens and spec of physical exam is?
A
Sens - 78.4%.
Spec - 68.8%.
18
Q
For bilirubin >15, Sens of physical exam is?
A
96.4%.
19
Q
Traube space?
A
6th rib superiorly, midaxillary line laterally, left costal margin inferiorly.
20
Q
The 2 best historical findings in ascites are:
A
- Increased abdominal girth (LR+ 4.16, LR- 0.17).
2. Ankle swelling (LR+ 2.8, LR- 0.10).
21
Q
The 2 best physical exam findings are:
A
- Fluid wave - LR+ 6, LR- 0.4.
2. Shifting dullness - LR+ 2.7, LR- 0.3.
22
Q
Ultrasound can detect …mL of ascites.
A
100
23
Q
Alcoholic liver disease encompasses a broad spectrum of abnormalities:
A
Steatosis –> Steatohepatitis –> Cirrhosis.
24
Q
Steatosis - Textbook presentation:
A
- Usually asymptomatic.
- Normal/mildly elevated transaminases.
- Hepatomegaly is present in 70% of patients with biopsy proven steatosis.
25
What is the main problem with steatosis?
1. Potentiates liver damage from other insults, such as viral hep or acetaminophen toxicity.
2. Promotes obesity-related liver disease.
26
Steatosis - Reversible?
Yes, but... 1 study found that 18% still progressed to cirrhosis.
27
Steatosis - Cirrhosis develops in ...% who continue to drink.
37%.
28
Alcoholic steatohepatitis - Textbook presentation.
1. Fever.
2. Malaise.
3. Jaundice.
4. Tender hepatomegaly.
29
Alcoholic steatohepatitis - Found in ...-...% of heavy drinkers.
10-35%.
30
Alcoholic steatohepatitis - 3-month mortality:
15% --> Mild alcoholic hep.
| 55% --> Severe alcoholic hep.
31
Mayo End-stage Liver Disease (MELD) score - Components:
1. Total bilirubin.
2. INR.
3. Serum creatinine.
32
MELD score >11 was found to have a sens of ...% and a spec of ...% for 30-day mortality.
86%.
| 82%.
33
Glasgow Alcoholic Hepatitis Score (GAHS) - Components:
1. Age.
2. WBC count.
3. BUN.
4. PT/INR.
5. Total bilirubin.
34
Alcoholic steatohepatitis - Transaminases?
Elevated but generally <6-7 times the upper limit of normal.
35
Alcoholic steatohepatitis - GGT and ALP:
GGT is often elevated.
| GGT/ALP is often >2.5.
36
Alcoholic steatohepatitis - AST/ALT ratio:
Often, but not always >2. (70-80% of cases).
37
Alcoholic cirrhosis - Prognosis:
5-yr survival:
90% if the patient becomes abstinent.
70% if patient continues to consume alcohol.
30-50% once complications of cirrhosis appear.
38
MC presenting complain in pancreatic cancer:
Abdominal pain - 80%.
39
Jaundice in pancreatic cancer - When the caner is in the body or tail?
Due to liver metastases.
40
Rare presentation of pancreatic cancer:
1. Acute pancreatitis.
2. Malabsorption.
3. Migratory thrombophlebitis.
4. GI bleeding.
41
CA 19-9 for pancreatic cancer:
37-40 --> Sens 76-90%, spec 68-98%.
100-120 --> Spec 87-100%.
>1.000 --> Spec 94-100%.
42
Pancreatic cancer prognosis:
If resectable --> 5yr survival is still only 10-25%.
43
How many pancreatic cancers are resectable?
15%.
44
Median survival for non resectable pancreatic cancer?
6 months.
45
When is hepatitis UNLIKELY?
```
When:
1. Nausea.
2. Anorexia.
3. Malaise.
4. Hepatomegaly.
5. Hepatic tenderness.
are absent.
```
46
Prevalence of hep A in the US:
20-40%.
47
Hep A - Symptoms in adults and in children <6.
Symptoms develop in 70% of adults.
| <30% of children under 6.
48
Hep A - Incubation period:
25-30d average. 15-49 range.
49
Course of Hep A:
Incubation for 25-30d --> prodromal symptoms --> Malaise, fatigue, nausea, vomiting, anorexia, fever, RUQ pain --> 1 week later --> Jaundice.
50
Hep A - How many patients have jaundice and how many have hepatomegaly?
70% --> Jaundice.
| 80% --> Hepatomegaly.
51
Hep A - Uncommon EXTRAHEPATIC manifestations:
1. Vasculitis.
2. Arthritis.
3. Optic neuritis.
4. Transverse myelitis.
5. Thrombocytopenia.
6. Aplastic anemia.
52
Hep A - Fulminant course is more common in?
1. Patients with underlying hep C.
| 2. 1.1% fatality rate in adults >40.
53
Hep A - Recovery?
85% fully recover in 3 months, and nearly all by 6 months.
54
Hep A - Transaminases or bilirubin normalize more rapidly?
Transaminases.
55
Prevalence of hep B:
0.1-2% (low) in USA, Canada, Western Europe.
3-5% (medium) in mediterranean countries, Japan, Central Asia, Middle East, Latin and South America.
10-20% (high) in Southeast Asia, China, sub-Saharan Africa.
56
Hep B - Clinical manifestations:
70% --> Have subclinical infection or are anicteric.
| 30% --> Icteric hep.
57
Hep B incubation period:
1-4 months.
58
Transmission of hep B in low prevalence areas:
1. Sexual.
2. Percutaneous inoculation.
3. Needlestick.
4. Tattooing.
5. Body piercing.
6. Contaminated blood transfusion.
59
Transmission of hep B in medium prevalence areas:
Childhood infections occurs from contaminated household objects, via minor breaks in the skin and mucous.
60
Transmission of hep B in high prevalence areas:
Primarily perinatal, occurring in 90% of babies born to HBeAg(+) mothers - It can be prevented by neonatal vaccination.
61
Hep B - Clinical course:
1. Fulminant in 0.1-0.5%.
2. Transaminases normalize in 1-4 months if acute infection resolves.
3. Elevation of ALT for >6months indicates progression to chronic hep.
62
HBsAg:
1. Appears 1-10 weeks after acute exposure.
2. Should be present in patients with acute symptoms.
3. Should clear in 4-6months.
4. LR+ 27, LR- 0.2.
63
HBsAb:
1. Appears after disappearance of HBsAg.
| 2. Window period of several weeks to months between the disappearance of HBsAg and the appearance of HBsAb.
64
IgM hep B core antibody (IgM anti HBc):
Appears shortly after HBsAg and is the only marker of acute infection detectable during the "window period".
LR+ 45.
LR- 0.1.
65
IgM anti HbC can remain detectable for?
2 years and titer can increase during exacerbation of chronic hep B.
66
Chronic hep B - Textbook presentation:
Manifestation can range from Asymptomatic, to isolated fatigue, to cirrhosis with portal HTN.
Often NO history of acute hep B.
67
Risk of progression from acute to chronic hep B varies depending on the host:
1. <1% when the acute infection is acquired by an immunocompetent adult.
2. 90% when the infection is acquired perinatally.
3. 20% when the infection is acquired during childhood.
68
Chronic hep B - What percentage have extrahepatic findings:
10-20% have extrahepatic findings (Polyarteritis nodosa, glomerular disease).
69
HBsAg - Detectable or not on chronic hep B?
Generally detectable for life (0.5-2%/year become HBsAg).
70
Risk factors for progression from chronic hep to cirrhosis:
1. Alcohol intake.
2. Concurrent hep C or HIV infection.
3. High levels of HBV replication.
4. HBV genotype C.
71
Chronic hep B - Screening for HCC?
Screening with US and AFP is recommended every 6-12 months.
72
True cure in chronic hep B:
Rare 1-5%.
73
Hep C - Textbook presentation:
Most are ASYMPTOMATIC - Jaundice develops in less than 25%.
| When symptomatic --> Similar presentation to those of other viral hep and last 2-12 weeks.
74
Prevalence of hep C:
20% of acute hep.
| 1.6% prevalence of infection in the USA.
75
Perinatal transmission occurs in ...-...% of cases.
4.6-10%.
76
Hep C - Average incubation period:
7-8 weeks.
77
Hep C - Extrahepatic manifestations:
Found in about 75% of patients.
1. Fatigue, Arthralgias, paresthesias, myalgias, Pruritus, sicca syndrome are found in >10%.
2. Vasculitis 2o to Cryoglobulinemia --> 1%.
3. Cryoglobulinemia is present in about 40%.
5. Depression and anxiety are more common than in uninfected persons.
78
Hep C - How many patients have clear the infection within 6 months?
15-40%.
79
Percentage of patients who have detectable HCV RNA at 6 months and therefore have chronic hep C.
60-85%.
80
Chronic hep C - Stages:
```
5 stages:
0 - No fibrosis.
1 - Fibrous expansion of portal tracts.
2 - Periportal fibrosis.
3 - Bridging fibrosis.
4 - Cirrhosis.
```
81
Is there a correlation between ALT levels and liver histology?
No correlation.
82
Percentage of patients with chronic hep C that progress to at least stage 1 over 5 years?
27-41%.
83
Cirrhosis in chronic hep C:
Develops in 4-24% of patients after 20 years of infection.
84
Chronic hep C - Predictors to cirrhosis:
1. Liver histology (best predictor).
2. Age at infection (>40 years of age --> More progression).
3. Duration of infection.
4. Consumption of alcohol >50g/d.
5. HIV and HBV Coinfection.
6. Male sex.
7. Higher ALT.
8. Baseline fibrosis, and possible Steatosis.
85
Prevalence of different hep C genotypes:
71. 5% --> Genotype 1.
13. 5% --> Genotype 2.
5. 5% --> Genotype 3.
1. 15% --> Genotype 4.
86
Elevated Transaminases - Non hepatic causes:
1. Celiac sprue.
2. Inherited disorders of muscle metabolism (only AST).
3. Acquired muscle disease (AST only).
4. Strenuous exercise (AST only).
87
Hepatic causes for elevated transaminases:
1. Alcohol.
2. Medication.
3. Chronic hep B and C.
4. Non alcoholic fatty liver disease.
5. Autoimmune hep.
6. Hemochromatosis.
7. Wilson.
8. Alpha-1 antitrypsin.
88
NAFLD - Textbook presentation p:
Patients are often asymptomatic but sometimes complain of vague RUQ discomfort.
It is common to identify patients by finding hepatomegaly on exam or asymptomatic transaminase elevation.
89
NAFLD - Definition:
A spectrum of liver abnormalities all of which include hepatic steatosis in the absence of significant alcohol use.
90
NAFLD - Stages:
1. Steatosis - Fatty liver.
2. NASH.
3. Cirrhosis.
91
Prevalence of NAFLD:
20-30% --> in Western adults, with only 2-3% being NASH.
70% --> in diabetics.
91% in obese patients undergoing Bariatric surgery, with 37% being NASH.
92
MCC of abnormal liver test results in the USA:
NAFLD.
93
NAFLD - Clinical course:
Most patients with pure Steatosis are stable and do not develop progressive liver disease.
About 12-40% develop NASH with early fibrosis after 8-13 years.
94
NAFLD - Blood tests:
1. Transaminase elevation is usually <4 times normal. AST/ALT ratio is usually less than 1, but not if there is advanced disease.
2. Serum ferritin is elevated in 50%.
3. Alkaline PHOSPHATASE and GGT are often mildly elevated.
95
Unconjugated bilirubin binds to?
Albumin.
