Week 16 - Case 1 and 2 Flashcards
what are the causes of prehepatic jaundice
Haemolytic anaemia
Drugs
Gilbert’s syndrome
Crigler-Najjar syndrome (rare)
what are the causes of hepatic jaundice
Viral infection
Alcohol
Non-Alcoholic Fatty Liver Disease (NAFLD)
Autoimmune disorders (Primary biliary cholangitis, primary sclerosing cholangitis)
Malignancy of biliary system (HCC, cholangiocarcinoma, gallbladder cancer)
Metabolic (Haemochromatosis, Wilson’s disease)
Drugs (Ciprofloxacin, Co-amoxiclav, phenytoin, erythromycin, nitrofurantoin)
what are the causes of post-hepatic jaundice
Gallstones
Surgical strictures
Extra-hepatic malignancy (pancreatic cancer)
Pancreatitis
high oestrogen levels in chronic liver disease result in what stigmata
– Palmar erythema
– Spider naevi
– Gynaecomastia
– Loss of secondary body hair (in males)
– Male genital atrophy
– Spider naevi
low albumin levels found in chronic liver disease result in what stigmata
– Leukonychia
portal hypertension found in chronic liver disease result in what stigmata
Caput medusae
– Dilated anterior abdominal wall veins
– Ascites
what is a sign of hepatic encephalopathy
- Signs of hepatic encephalopathy including a liver flap (asterixis)
what does one do after an USS abdomen after confirmation of biliary obstruction
CT of abdomen and pelvis
CT chest thorax used to complete staging
what is the clinical definition of jaundice
NICE defines jaundice as the yellow pigmentation of the skin, sclera and mucous membranes resulting from raised plasma bilirubin. Normal plasma bilirubin levels are <21mmol/L.
what is the pre-hepatic pathophysiology behind jaundice
Pre-hepatic – as red cells in the blood reach the end of their lifecycle (approx. 120 days) they are phagocytised by macrophages. This breaks haemoglobin down to haem and globin. Haem is then broken down into iron and protoporphyrin. Protoporphyrin is then broken down into unconjugated bilirubin (not water-soluble). This mainly takes place in the spleen. Albumin in the blood then binds to unconjugated bilirubin and transports it to the liver.
what is the hepatic pathologysiology behind jaundice
Hepatic – Unconjugated bilirubin is then taken up by hepatocytes in the liver and is ‘conjugated’ by enzyme called uridine glucuronyl transferase, creating conjugated bilirubin (this is water soluble). Here the conjugated bilirubin is secreted into bile duct and stored in gallbladder as bile.
what is the post-hepatic pathophysiology behind jaundice
Post-hepatic – when you eat, particularly fatty food, bile is excreted from the gallbladder into the duodenum. Conjugated bilirubin in the bile is converted into urobilinogen by microbes in the small intestine. Some of this urobilinogen is converted into stercobilin, which is excreted in stools giving it the brown colour. The rest of the urobilinogen is reabsorbed into the blood, converted into urobilin and either sent back to the liver or excreted by the kidneys giving urine its yellow colour.
what is librium used to
Librium is a brand name for chlordiazepoxide, a long-acting benzodiazepine that NICE recommends for the treatment of symptoms associated with acute alcohol withdrawal. So, it seems that the triage nurse is concerned that the patient may be withdrawing from alcohol. As a doctor, you will have to decide whether you have enough information available so far to agree with the triage nurse’s diagnosis and prescribe chlordiazepoxide.
what are the physical symptoms of withdrawal
- Anxiety
- Nausea / vomiting
- Insomnia
- Craving for alcohol
- Tremor
- Sweating
- Palpitations
- Diarrhoea
- Confusion
- Hallucinations
- Seizures
why may a patient be at increased risk of an upper GI bleed?
Excessive alcohol may increase the risk of a GI bleed as it is a risk factor for:
- Oesophagitis
- Mallory Weiss tears
- Gastritis and peptic ulceration
- Oesophageal varices ( although these are less common than the above)
- (Rarely oesophagogastric malignancy)
what is the NICE definition of alcohol withdrawal
NICE defines alcohol withdrawal refers to ‘physical and psychological symptoms that people can experience when they suddenly reduce the amount of alcohol they drink if they have previously been drinking excessively for prolonged periods of time.’
what is the order in which alcohol withdrawal symptoms start
autonomic hyperactivity
withdrawal seizures
alcoholic hallucinosis
delirium tremens
what is delirum tremens
Delirium tremens complicates 5% alcohol withdrawal states; starts 48-96 hours, resolves <1-5 days (unlike alcoholic hallucinosis, delirium tremens is a syndrome of severe alcohol withdrawal that is associated with abnormal vital signs, fluid status, and electrolyte levels; another discerning feature is that patients with alcoholic hallucinosis are usually alert whereas delirium tremens clouds the sensorium; it carries a 5% mortality even with prompt identification and management- death is usually from dysrhythmia, pneumonia, or a failure to identify the underlying illness that led to alcohol sensation in the first place such as pancreatitis or hepatitis
what is pabrinex used for
Werrnicke / Korsakoff syndrome
what is the optional alcohol bundle and what does it come with
chlordiazepoxide comes with an optional alcohol bundle including thiamine, pabrinex, and a referral to alcohol specialist nurs
A patient with acute alcohol withdrawal has her CIWA-Ar score calculated and it is found to be 12. What is the correct course of action for this patient?
Administer Chlordiazepoxide 10mg, full set of observations, blood glucose level and reassess in 4 hours.
Wernicke-Korsakoff Syndrome is a condition related to alcohol misuse which is caused by thiamine deficiency. Which of the following are classical features of Wernicke-Korsakoff Syndrome?
Ataxia
Confabulation
Visual changes
Impaired memory
As well as Wernicke-Korsakoff Syndrome, which of the following are also known complications of alcohol misuse?
liver cirrhosis
delirium tremens
seizures
cardiomyopathy
Which of the following symptoms, if present in a patient over 60 with weight loss, would fulfil criteria for urgent imaging to exclude pancreatic cancer?
new onset diabetes
diarrhoea
nausea/vomiting
constipation
back pain
abdominal pain
Which of the following conditions would give rise to an unconjugated hyperbilirubinaemia?
haemolytic anaemia
Gilbert’s disease
