Jaundice

Question 1

Description: What is jaundice?

Answer 1

• Yellowing of the skin, sclerae, and other tissues (i.e mucous membranes) causes by excess circulating bilirubin

Question 2

Description: How is jaundice classified? (3)

Answer 2

• Jaundice is classified on whether it is pre hepatic (unconjugated), hepatic or post hepatic (both conjugated)

Question 3

Aetiology/Risk factors: State the causes of jaundice:

(a) Pre hepatic
(b) Hepatic
(c) Post hepatic

Answer 3

(a) - Haemolysis (premature breakdown of RBs) = Increased quantity of haem = Increased quantity of bilirubin
- Impaired transport

(b) This results from an inability of the liver to take in, conjugate or excrete bilirubin due to liver tissue damage (cirrhosis, hepatitis etc)
(c) - Obstruction of the bile duct leads to defective transport of bilirubin

Question 4

Pathology: Describe the pathway from the breakdown of RBCs to the formation of bilirubin. Include each step and the enzymes involved (3)

Answer 4

• Red blood cells contain haem
• Haem is converted to biliverdin using the enzyme haem oxygenase
• Biliverdin is converted to bilirubin by the enzyme biliverdin reductase

Question 5

Symptoms: What clues do we look out for in the history of a patient with jaundice?

(a) Pre hepatic
(b) Hepatic
(c) Post hepatic

Answer 5

Pre-hepatic history:

• History of anaemia (dyspnoea, fatigue and chest pain)
• Acholuric jaundice (a lot of unconjugated bilirubin)

Hepatic history:

• Risk factors for liver disease (Intravenous drug users, drug intake)
• Decompensated liver disease (ascites, varices and hepatic encephalopathy

Post-hepatic history:

• Abdominal pain
• Pruritis, pale stools and highly coloured urine all due to CHOLESTASIS

Question 6

Signs: What clues do we look for on examination of a patient with jaundice?

(a) Pre hepatic
(b) Hepatic
(c) Post hepatic

Answer 6

(a) Pre hepatic:
- Pallor
- Splenomegaly

(b) Hepatic:
- Stigmata of CLD (spider naevi, gynaecomastia)
- Ascites
- Asterixis

(c) Post hepatic:
- Palpable gall bladder (Courvoisier’s sign)

Question 7

Investigations: What investigations do we do for jaundice? (a) Initial test (1)
(b) Imaging tests (7)

Answer 7

(a) - Liver screen

(b) Imaging tests:
- Ultrasound (of the abdomen)
- CT
- MRI
- ERCP is therapeutic (if dilated biliary tree)
- MRCP
- PTC (if ERCP doesn’t work)
- Endoscopic ultrasound (finds stones that are missed by MRCP)

Question 8

Treatment:

Answer 8

XXX

Question 9

Complications: What are the complications of performing an ERCP?

Answer 9

• Pancreatitis
• Cholangitis
• Perforation
• Bleeding