tbl 5 clinical: bile & Jaundice Flashcards
Jaundice is an overt manifestation of ___________. There is a clinical spectrum of hyperbilirubinemia extending from a covert condition namely hyperbilirubinemia to an overt condition that is jaundice. There is an overlapping between the concept of cholestasis and hyperbilirubinemia.
__________ refers to reduced human bile flow while hyperbilirubinemia refers to high bilirubin. Hyperbilirunaemia can arise from cholestasis.
This condition may arise from other etiologies such as increased production (hemolysis) or obstruction of the drainage system (namely bile duct obstruction). Cholestasis, hyperbilirubinemia, and jaundice are related terms, but they may not necessarily refer to the same mechanism.
- Cholestasis, hyperbilirubinemia, and jaundice may suggest the issue of bile flow
- The disease may happen at a cellular level, small bile duct, and also larger bile ducts such as common bile duct and hilum of liver. Issues may also arise from a pre-hepatic condition such as hemolysis
- Localisation of the origin of disease and measure the extent of disease severity in certain contexts is the key to the interpretation
hyperbilirubinemia;
Cholestasis
What is the clinical criteria for jaundice?
- A patient is said to have jaundice when serum bilirubin level greater than _________________
in conjunction with a clinical picture of yellow skin and sclera.
- This is better visualized under sunlight. In clinical practice, it is best to expose a patient to _________ for the appreciation of overt jaundice. The sign of jaundice may not be apparent especially when the bilirubin level is near the upper limit of normal.
42.8 to 51.3 μmol/L;
natural light
What is liver function tests (LFT) ?
Liver function tests:
• A group of blood tests that reflect a person’s liver condition
• It can be used to diagnose and monitor liver disease or damage
• It measures enzymes that liver and bile duct cells release in response to damage or disease (ALT, AST, ALP, GGT)
• Some tests measure functions of liver such as albumin production, bilirubin clearance and coagulation (ALB, BIL, PT/INR)
Measurement of enzymes released from damage or diseased bile duct cells is reflected by _________ while measurement of _______ clearance is interpreted from bilirubin. ALP, GGT, Bilirubin are usually interpreted together to identify the pathophysiology and localize the origin of the disease.
ALP, GGT;
bilirubin
As with other clinical conditions, being able to classify jaundice is helpful in understanding, localising and eventually managing the disease. We can classify jaundice into prehepatic, hepatic, and post-hepatic conditions. Each of these subgroups represent different pathophysiologies and disease entities. Within these subgroups, there is also a necessity for further sub-classification of disease mechanism. For example, increased bilirubin levels could occur in both the prehaptic phase from overproduction, as well as in the hepatic phase from decreased conjugation. In the hepatic phase, this is also known as _____________.
Gilbert’s disease
Haemolysis is a sensible differential diagnosis if the patient has risk factors such as __________, autoimmune disease, etc.
Lab tests for haemolysis
- haptoglobin: _____
- Lactate dehydrogenase: _____
- Peripheral blood smear: abnormal rbcs
- reticulocyte count: increased
- unconjugated bilirubin: ____
- urinalysis: urobilinogen, positive for blood
congenital hemoglobinopathy;
decreased;
elevated;
increased
Gilbert’s disease is a relatively common condition in the local population. While the condition is harmless, overt jaundice during times of stress could be alarming. Confirmation of Gilbert’s syndrome requires a _____________.
genetic test
Hepatic jaundice
• Some causes of conjugated hyperbilirubinaemia
‒ Medications
o __________, _____________, Erythromycin, Anabolic steroids
‒ Infections
o CMV, Parasitic infections, Cholangitis, Cholecystitis
‒ Infiltrative disease
o ___________, Lymphoma, Sarcoidosis, Tuberculosis
Some diseases can affect liver parenchymal such as drug-induced liver injury, viral and bacterial injection, and even infiltrative liver disease. Unless the liver damage is substantial, conjugated hyperbilirubinemia is frequently observed in these conditions.
Isoniazid; Chlorpromazine;
Amyloidosis;
Post hepatic jaundice requires us to localise the point of obstruction in the biliary tract. Overt jaundice will occur especially when the obstruction is at the “confluence” of the biliary drainage system. Post-hepatic biliary obstruction is generally divided into 2 groups: extra hepatic and intra hepatic.
Extra-hepatic bile duct obstruction can occur at the _____________, intra-pancreatic portion of the common bile duct, rest of common bile duct, and even the hilum.
Intrahepatic ductal obstruction seldom gives rise to clinical jaundice unless there is a massive obstruction in significant areas within the liver. e.g. extensive liver infiltration with jaundice. It is difficult to tell if the jaundice is from biliary obstruction or _______________ based on visual observation alone. Intrahepatic ductal obstruction is usually detected through imaging studies such as the US, CT, and MRI liver. In this context, interpretation following an assessment of the liver’s synthetic function may be helpful – e.g. presence of hypoalbuminemia, coagulopathy, hepatic encephalopathy, ascites, and liver cirrhosis on imaging may suggest the issue of functional liver reserve. If both biochemistry and radiological tests are unyielding _________ of the biliary system is required to eliminate biliary obstruction as a factor.
ampulla;
liver parenchyma damage;
decompression
Biliary obstruction can be caused by intrahepatic, intramural or extra-hepatic causes. Extrinsic compression is seen in condition such as pancreatic cancer, peri-portal lymphadenopathy and Mirizzi’s syndrome. Mirizzi’s syndrome is caused by gallstone
impaction in cystic duct or ____________ causing compression of common bile duct.
neck of gallbladder
Clinical classification of jaundice
Jaundice can also be classified into:
1) Painful jaundice
• Suggesting of acute biliary obstruction
• This is especially common in gallstone disease and cholangitis
2) Painless jaundice
• Suggesting of slow biliary obstruction with indolent bile duct obstruction process
Painful jaundice includes biliary colic can last for hours and radiate to the ____________.
Painless jaundice needs to be corroborated by further history including unexpected loss of appetite or weight. A _____________ evaluation may be more appropriate than the US for proper evaluation of certain organs such as the pancreas and peri-portal lymphadenopathy.
right shoulder; CT abdomen
Fractionation of bilirubin levels
• Predominantly unconjugated (indirect) hyperbilirubinaemia :
‒ Usually total bilirubin < _________
‒ Direct or conjugated bilirubin over total bilirubin approximately 20-30% OR
‒ Indirect or unconjugated bilirubin over total bilirubin approximately 70-80%
Sometimes fractionating bilirubin assists the clinician in localization of the origin of the disease. Unconjugated hyperbilirubinemia is frequently seen in ____________ It can also be seen in massive liver parenchymal destruction as hepatocytes conjugate bilirubin.
85 umol/L;
hemolysis or Gilbert’s syndrome.;
Classified as cholesterol, pigmented, or mixed stones on the basis of their chemical composition.
- Cholesterol: 90%
- pigmented: 10%
Factors required for stone formation :
1) hepatic secretion of bile supersaturated with __________
(2) ________ of bile within the gallbladder
(3) nucleation of cholesterol molecules to form crystals
Cholesterol gallstones develop in the gallbladder initially from bile supersaturated with cholesterol, which then precipitates out of bile, forming __________________. The relationship between the various components of bile results in the formation of gallstones.
cholesterol;
stasis;
micelles and vesicles
Gallstone risk factors (cholelithiasis)
Cholesterol stones
- western
- female
- _____________
- pregnancy
- obesity
- rapid weight reduction
- gallbladder stasis
- disorder of _______________
- _______ syndromes
Pigment stones
- asians
- hemolysis syndromes
- biliary infections
- Inflammatory bowel disease
- ileal _________ or bypass
- cystic fibrosis
- chronic pancreatitis
oral contraceptives; bile acid metabolism ; hyperlipidemia;
resection
__________ can be used as the first investigation to exclude gallstone disease. Intraductal stone though uncommonly seen as obscured by bowel gas can sometimes be seen if its location is at proximal common bile duct or cystic duct.
More commonly the US report described enlarged CBD diameter and presence of gallstone or sludge within the gallbladder. Rule of thumb for CBD: 60 y/o 6 mm; 70 y/o 7 mm, 80 y/o, 8 mm. Post ____________, CBD dilatation up to 1.2 cm can be normal.
The posterior acoustic shadow of gallstone is used to differentiate against gallbladder polyp. Chronic cholecystitis also points towards gallstone related disorder in the correct clinical context.
Ultrasound ;
cholecystectomy;
Ascending cholangitis • Bacterial infection of \_\_\_\_\_\_\_\_\_\_ • A common complication of choledocholithiasis but rare in malignant obstruction • Charcot’s triad (40% of cases) ‒ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
• Reynold’s pentad
‒ Charcot’s triad + altered mental status + ___________
• Common organisms
‒ E. coli, Klebsiella, Pseudomonas, enterococci, and anaerobic species
Ascending cholangitis can be a life-threatening condition. Prompt recognition, initiation of an appropriate antibiotic, fluid resuscitation and early _______________ is important to ensure the outcome. Reynold’s pentad indicates a more serious state and requires immediate biliary intervention for biliary obstruction such as ERCP or PTC.
bile duct;
biliary pain, jaundice, and chills/rigors;
hypotensive;
biliary decompression
