1. DSA Jaundice Flashcards
Jaundice is caused by hyperbilirubinemia, termed icterus, most present in the sclera. It occurs as a result of overproduction, impaired uptake,conjugation or excretion, or due to regurgitation of unconj/conjugated bilirubin from damaged?
hepatocytes or bile ducts
Jaundice is seen at a bilirubin of >3mg/dl, higher mean levels of bilirubin are seen in white and hispanic men, what alone elevates bilirubin to >7mg/dL?
Hemolysis
Bilirubin is the major breakdown product of hemoglobin released from erythrocytes, initally bound to albumin, transported to liver, conjugated to water soluble form via glucuronosyltransferase to glucuronide, excreted into bile and converted to what in the colon?
Urobilinogen
Urobilinogen is excreted in the stool, a small portion is reabsorbed and excreted by the kidney, bilirubin can be filtered from the kidney only in what form?
Direct or conjugated form
Prehepatic causes of jaundice include transfusions, sickle cell anemia, thalassemia, AI disease, posthepatic causes of jaundice are gallstones, inflammation, scar tissue, or tumors blocking the flow, and what causes intrahepatic jaundice? 5
Hepatitis Cancer Cirrhosis Congeital Disorders (Gilbert) Drugs
What type of cell injury occurs to the hepatocytes, where you see a primary elevation in AST/ALT, with ALT being more specific for liver injury than AST?
Hepatocyte INjury
What type of cell injury occurs in the bile ducts, where there is a primary elevation of alkaline phosphatase and bilirubin, also commonly causing pruritis?
Cholestatic Injury
Liver function tests, (LFTs), are common referred to as AST/ALT, ALP, bilirubin, and LDH/GGT. What are the TRUE liver function tests?4
PT/INR
Albumin
Cholesterol
Ammonia
The most common causes of unconjugated (indirect) bilirubin = jaundice are Hemolytic syndrome, gilbert syndrome, Crigler Najjar syndrome and?
Viral hepatitis (both)
The MCC of conjugated or direct bilirubinemia leading to jaundice is acute/chronic hepatitis, cirrhosis, obstruction, dubin-johnson syndrome and?
Rotor Syndrome
First steps in a pt with jaundice is to determine if hyperbilirubinemia is conjugated or unconjugated, asking is there is pruritis, duration, medications, travel history… a CBC looking for anemia and thrombocytopenia is done (prehepatic source unconjugated), what other blood work is taken?
CMP with AST/ALT, total bilirubin, alkaline phosphatase with FRACTIONED bilirubin (tells u indirect vs direct)
If alkaline phosphatase is elevated- can fractionate by ordering a GGT = gamma glutamyl transferase, if the GGT is elevated then you can expect a liver sournce, if it is normal then consider what source?2
bone, placenta
*ALP elevated in pediatric pt = growing bones
With hemolysis, you should order a CBC looking for anemia and thrombocytopenia, checking reticulocyte (high), LDH (high from cell destruction) and what which should be low?
Haptoglobin
peripheral smear=schistocytes /sickle cells?
In a patient with sickle cell anemia, one can see sickle cells, nucleated red cells consistent with asplenia, RBC with howell holly bodies and what type of cells?
Target cells
What is a benign cause of unconjugated hyperbilirubinemia due to a reduce acitivty of uridine diphosphate glucuronyl transferase (UGT1A1- AR), it causes benign, asymptomatic hereditary jaundice, increases 24-36 hours post fasting, assoc w reduced mortality from CV disease?
Gilbert Syndrome
What is an AR syndrome associated with absent UGT1A1 with no liver pathology and is FATAL in the neonatal period?
Crigler-Najjar Syndrome Type 1
What is an AD with a variable penetrance syndrome associated with decreased UGT1A1 activity, no liver pathology and is generally mild but can cause kernicterus?
Crigler Najjar Syndrome Type 2
hepatitis is inflammation of the liver, recall that chronic hepatitis is greater than 3-6months, serum fibrosure and or US elastography can ID fibrous absence or presence of cirrhosis in chronic hepatitis, when IgM / IgG are present it could indicated acute or chronic hepatitis?
Acute hepatitis : IgM
Chronic Hepatitis: IgG
Acute hepatitis is caused virally, by drugs, ischemia, bud-chiari and more, pt presents with fever malaise, myalgia, arthralgia, anorexia, nausea, vomitting, diarrhea, with an aversion to?
Smoking!
Acute hepatitis pts stools may be acholic, and it is important to review the medication list, on physical exam can see jaundice, hepatomegaly, RUQ pain/tenderness… For dx, one should check viral serology, CBC, CMP, PT/INR, and acetominophen levels (rumack matthew nomogram), complications include what two commonalities?
Cirrhosis of the liver which leads to hepatocellular carcinoma (HCC)
What hepatitis is ssRNA with a prodrome of anorexia, nausea, vomiting, mild RUQ pain, with aversion to smoking, more severe in adults than children, duration is acute and self limited with complete recovery?
Hepatitis A HAV
incubation 2-3 weeks, up to 6
Hepatitis A HAV risk factors is international travel, and fecal-oral contamination, sx include enlarged and tender liver, jaundice, children are symptomatic, also there are acholic stools, characteristic labs include an elevation of both bilirubin, alkaline phosphatase, and what other 2?
MARKEDLY elevated AST/ALT (both liver/bile duct elevated)
in Hepatitis A HAV, both IgG and IgM anti HAV are detectable so after onset, antibody to HAV (anti-HAV) is present early in the course.. the detection of IgG anti-HAV without IgM indicates previous exposure to HAV/non infectivity/immunity, what does IgM anti-body suggest?
current acute hepatitis A (excellent for diagnosis)
**HAV vaccine – ACUTE ONLY
What hepatitis is dsDNA with a prodrome of anorexia, nausea, vomiting, malaise, aversion to smoking, fever, tender hepatomegaly and jaundice, has a 2-26wk incubation (mean 8wks), acute illness subsides in 2-3 weeks and 10-15% progress to chronic?
Hepatitis B (HBV)
