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Oxford Clinical Cases > Jaundice > Flashcards

Jaundice Flashcards

1
Q

What are the three steps of bilirubin metabolism?

A

Production of unconjugated bilirubin
Conjugation of bilirubin
Excretion of bilirubin

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2
Q

How does unconjungated bilirubin travel to the liver?

A

Bound to albumin

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3
Q

Where are blood cells normally broken down?

A

In the spleen by splenic macrophages

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4
Q

What is bilirubin conjugated with in the liver?

A

Glucuronic acid

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5
Q

What is conjugated bilirubin converted to within the intestines and what happens to these products?

A

Urobilinogen and stercobilinogen
Some of the urobilinogen is reabsorbed by the intestines and excreted by the kidneys
Stercobilinogen gets converted to stercobilin, which gives faeces its brown colour

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6
Q

What are the three main types of jaundice?

A

Pre-hepatic
Hepatic
Post-hepatic (obstructive)

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7
Q

What characteristic clinical features are associated with obstructive jaundice?

A

Dark urine

Pale stools

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8
Q

What are the two mechanisms of unconjugated hyperbilirubinaemia?

A

Increased production of bilirubin (increased haemolysis)

Decreased capacity to conjugate bilirubin

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9
Q

Why might patients who are undergoing intravascular haemolysis have dark urine?

A

Free haemoglobin from the haemolysis is degraded into haemosiderin, which is water soluble and very dark

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10
Q

List some congenital causes of intravascular haemolysis.

A

G6PD deficiency
Pyruvate kinase deficiency
Sickle cell disease
Thalassemia

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11
Q

List some acquired causes of intravascular haemolysis.

A 
Artificial heart valves
Blood group mismatch
DIC 
Malaria 
Medications
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12
Q

What might be seen on the blood film of a patient undergoing intravascular haemolysis?

A

Schistocytes

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13
Q

Which clinical sign is likely to be seen in patients undergoing extravascular haemolysis?

A

Splenomegaly

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14
Q

List a congenital and acquired cause of extravascular haemolysis.

A

Congenital – hereditary spherocytosis

Acquired – autoimmune haemolytic anaemia

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15
Q

What can cause reduced uptake of bilirubin by the liver?

A

TIPS (transjugular intrahepatic portosystemic shunt)

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16
Q

Name two congenital enzymatic problems that lead to unconjugated hyperbilirubinaemia.

A

Gilbert’s syndrome

Crigler-Najjar syndrome

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17
Q

Name a congenital cause of obstructive jaundice.

A

Dubin-Johnson syndrome

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18
Q

Using the surgical sieve, list causes of obstructive jaundice.

A

Infection – hepatitis, ascending cholangitis, liver abscess
Neoplasia – HCC, cholangiocarcinoma, pancreatic cancer
Vascular – Budd-Chiari syndrome
Inflammation/Autoimmune – PBC, PSC, autoimmune hepatitis, pancreatitis
Trauma – gallstones, strictures
Endocrine – intrahepatic cholestasis of pregnancy
Degenerative
Metabolic – haemochromatosis, Wilson’s disease
Drugs – alcohol, paracetamol, sodium valproate, co-amoxiclav

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19
Q

List some key features of the history of presenting complaint that you should ask a patient with jaundice.

A

Acute or chronic
RUQ pain, nausea and vomiting – suggests hepatobiliary
Fever and diarrhoea – suggest infection
Steatorrhoea, dark urine, pruritus – suggests obstructive
Weight loss, fever, night sweats – systemic features of malignancy
Bronzed skin and signs of diabetes mellitus – haemochromatosis

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20
Q

List three diseases, exclusive to pregnancy, that can cause jaundice.

A

Acute fatty liver of pregnancy
Intrahepatic cholestasis of pregnancy
HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)

21
Q

Why is it important to check for signs of diabetes mellitus?

A

Haemochromatosis can lead to diabetes mellitus

22
Q

List some key features of the past medical history and explain why they might be significant.

A

Gallstones
Liver disease
Haemophilia – may have received contaminated blood products
Recent blood transfusion or surgery – possible transfusion reaction
Ulcerative colitis
Diabetes mellitus
Emphysema
Psychosis – may result from Wilson’s disease

23
Q 
List some drugs that increase the risk of jaundice by the following mechanisms:
Intravascular haemolysis
Autoimmune, extrvascular haemolysis
Hepatitis
Cholestasis
A 
- Intravascular haemolysis
Sulphonamides
- Autoimmune, extravascular haemolysis
Methyldopa
- Hepatitis
Paracetamol overdose 
- Cholestasis
Co-amoxiclav
24
Q

List some features of the social history that would be significant in a patient with jaundice.

A 
Alcohol abuse 
IV drug use 
Tattoos 
Unprotected sex with multiple partners
Recent foreign travel
25
Q

List some features that you might see on examination of a patient with jaundice.

A 
Signs of dehydration 
Fever 
Conjuctival icterus 
Cachexia
Scratch marks 
Needle tracks 
Signs of chronic liver disease (spider naevi, palmar erythema, clubbing, bruising and gynaecomastia)
Bronzed tan 
Kayser-Fleischer rings
26
Q

Which causes of jaundice are supported by RUQ tenderness?

A

Hepatitis

Gallbladder disease – cholecystitis, ascending cholangitis

27
Q

List some blood tests that may be useful in a patient with jaundice.

A

FBC and reticulocyte count
Serum bilirubin levels
Liver enzymes (AST, ALT, ALP, GGT)
Serum amylase or lipase

28
Q 
State which liver disease is likely if:
Elevation of AST > ALT
Elevation of ALT > AST
Elevation of ALP + GGT
Isolated elevation of GGT
A 
- Elevation of AST > ALT
Alcoholic liver disease 
- Elevation of ALT > AST
Viral hepatitis 
- Elevation of ALP + GGT
Biliary pathology
- Isolated elevation of GGT
Recent alcohol consumption
29
Q

What does the finding of bilirubin in the urine indicate?

A

Post-hepatic obstruction

30
Q

Which test must be performed in young women presenting with jaundice?

A

Pregnancy test – there are some causes of jaundice that are exclusive to pregnant women

31
Q

List the components of the haemolysis screen.

A

Haptoglobins – these bind to free Hb and, hence, will be low in haemolytic states
Lactate dehydrogenase (LDH) – released by red cells when they lyse
Direct Antiglobulin test (Coombs test) – tests for autoantibodies against red cells (AIHA)
Blood film – look for schistocytes, sickle cells, spherocytes, malaria

32
Q

Which diseases are tested for in viral serology?

A

Hepatitis A, B and C
EBV and CMV
HIV

33
Q

Which antibodies should be tested for in an autoimmune screen of a jaundice patient?

A

Anti-smooth muscle antibodies (ASMA) – type 1 autoimmune hepatitis
Anti-mitochondrial antibodies (AMA) – primary biliary cirrhosis
Anti-nuclear antibodies (ANA)

34
Q

Which test results would be consistent with:
Haemochromatosis
Alpha-1 anti-trypsin deficiency
Wilson’s disease

A 
- Haemochromatosis
High ferritin
High transferrin saturation 
- Alpha-1 anti-trypsin deficiency
Low alpha-1 anti-trypsin 
- Wilson’s disease
High serum copper 
Low caeruloplasmin
35
Q

What is the earliest maker of compromised liver function?

A

Prolonged clotting times

36
Q

What are the four possible outcomes for patients with acute viral hepatitis B?

A

Full clinical recovery (virus is rarely completely cleared)
Carrier status
Chronic hepatitis B (some will end up developing cirrhosis and HCC)
Fulminant hepatitis (rare but 80% mortality)

37
Q

Describe the typical presentation of a patient with obstructive jaundice.

A 
Jaundice
RUQ pain 
Steatorrhoea + dark urine 
Nausea 
Raised ALP + GGT
38
Q

Which investigation can be performed to visualise gallstones?

A

Biliary ultrasound

39
Q

Which intervention can be performed to remove gallstones from the CBD and drain pus?

A

ERCP

40
Q

Describe the presentation of acute cholecystitis.

A

Constant, unresolving fever (> 6 hrs)
Tender abdomen
Positive Murphy’s sign
Nausea and (maybe) vomiting

41
Q

Outline the management of acute cholecystitis.

A

Antibiotics
NBM
IV fluids
Cholecystectomy

42
Q

What is Charcot’s triad?

A

RUQ pain
Jaundice
Fever with rigors

43
Q

Outline the management of ascending cholangitis.

A 
EMERGENCY
Blood cultures 
Careful monitoring 
Broad-spectrum antibiotics 
ERCP if necessary – to drain pus from the CBD
44
Q

What is Primary Biliary Cirrhosis (PBC)?

A

Autoimmune disorder characterised by T-cell mediated destruction of the biliary ducts

45
Q

Which liver enzymes will be deranged in PBC?

A

High ALP + GGT

46
Q

Which autoantibody is the hallmark of PBC?

A

Anti-mitochondrial antibodies (AMA)

47
Q

Outline the management of PBC.

A 
Confirm diagnosis – MRCP and biopsy
Immunosuppression
Bile salt replacement 
Fat-soluble vitamin supplementation 
Pruritus management – with cholestyramine 
Liver transplantation
48
Q

What is Primary Sclerosing Cholangitis (PSC)?

A

Autoimmune disorder that lead to T-cell mediated destruction of biliary epithelial cells, leading to multifocal scarring of biliary ducts

49
Q

Which disease is PSC strongly associated with?

A

Ulcerative colitis

Oxford Clinical Cases (29 decks)

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