Gastrointestinal: Jaundice and hepatopancreatobiliary Flashcards
(64 cards)
Describe pre-, intra-, and post-hepatic jaundice
Pre-hepatic: Excessive UNCONJUGATED bilirubin due to increased red cell/haem breakdown
Intra-hepatic: MIXED bilirubin due to impaired conjugation by liver. Cirrhosis will additionally compress the intra-hepatic portions of the liver
Post-hepatic: Excessive CONJUGATED bilirubin. Blocked biliary drainage will prevent conjugated excretion
How can urine point towards which type of jaundice you are dealing with?
Dark urine: intra or post-hepatic
Excessive unconjugated bilirubin will be excreted through urine
What are the bilirubin, ALT/AST and ALP in the three types of jaundice
Pre-hepatic: normal/high bilirubin, others normal
Hepatic: ALT/AST very high, others raised
Post-hepatic: raised ALT/AST others very high
What are three causes of pre-hepatic jaundice?
Pre-hepatic: Increased haem breakdown
Haemolytic anaemia
Gilbert’s syndrome
Criggler-Najjar
List the 3 groups of causes for post-hepatic jaundice
Post-hepatic: blocked drainage
Intra-luminal: Gallstones
Mural: Cholangiocarcinoma, structures
Extramural: Cancers pressing on the duct (pancreatic, lymphomas)
What tests should be ordered in a patient with jaundice
Liver function tests: Assess nature of injury
Coag screen: Assess synthetic function
FBCs: Low Hb and platelets with high MCV in liver disease
Liver screen: Determine acute or chronic cause
What do the following LFTs inform you about:
Bilirubin
Albumin
AST/ALT
ALP
yGT
Bilirubin: Degree of jaundice
Albumin: synthetic function (along with coag PT)
AST/ALT: Hepatocellular injury (ratio >2 = ALD, ~1 viral hepatitis)
ALP: Raised in biliary obstruction (non-specific: bone disease, pregnancy, malignancy)
gGT: Biliary obstruction (more specific)
What viral (2) and non-infective markers (6) make up an acute liver screen?
Viral:
Hep A, B, C, E serology
CMV, EBV
Non-infective Markers:
Paracetamol (overdose)
Caeruloplasmin (copper levels)
ANA and IgGs (AIH, PBC, PSC)
Amylase (pancreatitis)
a-FP and CA 19-9 (hepatic and pancreatic cancer)
a1-antitrypsin (AATD)
What liver screen tests are used to suspect chronic liver injury?
viral
Hepatitis B and C
Non-infective markers
Caeruloplasmin (Wilson’s)
Ferritin and transferritin (Haemochromatosis)
t-TG (coeliac disease)
Autoantibodies: AMA, ASMA (PSC)
What imaging options can help diagnosis of jaundice?
1st line: Abdo US (gross liver or obstructive pathology)
Magnetic resonance cholanigopancreatography (MRCP): Visualise biliary tree for obstructive where US was inconclusive
Liver biospy: Where diagnosis is still unclear
What is considered a raised bilirubin?
>40mg/ml
What investigations should you perform in someone with acute hepatic failure?
LFTs: Assess liver injury and synthetic function
Coag screen: Synthetic function
U+Es: Check renal function
Liver screen
How do you manage acute hepatic failure?
Vitamin K: Increase PT
Lactulose 10-20ml/8hrs: Remove ammonia to improve encephalopathy
Antibiotics: Cefotaxime as prophylaxis
Review drugs and monitor biometrics
Dont give sodium to CLD/ascites patient!
Patient presents with jaundice. On examination they have red palms, distended veins on their abdomen and state they believe they have developed man-boobs. What is the diagnosis?
Chronic liver failure
What are the 6 complications of chronic liver failiure?
1. Malnutrition: damaged liver means reduced glycogenolysis/increased gluconeogenesis. This impairs glucose tolerance
2. Encephalopathy: Increased ammonia production
3. Varices: Cirrhosis presses on portal vein creating a back pressure
4. Ascites/oedema: Back pressure pushes fluid into bodily space
5. Spontaneous bacterial peritonitis: Infection of the ascitic fluid
6. Renal failure: failure of renal vasoconstriction to balance splanchnic vasodilation
How do you manage chronic liver failure?
Malnutrition: high calorie, high protein, low sodium meals every 2-3 hours
Bacterial peritonitis: Ascitic culture then cephalosporin
Encephalopathy: Lactulose
Ascites: Low salt diet +/- furosemide
Varices:
Bleeding: Terlipressin, vit K + FFP, broad spec antibiotics, endoscopic scleroscing
Stable: propanolol, band ligation/sclerotherapy, TIPS
Renal failure: renal failure management
What screening tools can be used for harmful alcohol use?
AUDIT: >= 8 harmful use
CAGE: >=2
Do you ever feel you should Cut down?
Do you ever feel Annoyed when people criticise your drinking?
Do you feel Guilty?
Do you ever drink as an Eye opener (in morning)
How do you manage acute alcoholic hepatitis?
Cease use
acute liver failure measures +/- steroids and pentoxifylline
How can viral hepatitis present?
Nausea, vomiting and anorexia
Fatigue
Jaundice + dark urine (intrahepatic)
RUQ pain
How are each subtype of hepatitis spread?
A+E: Faeco-oral
Blood: B,C,D
What are characterstic features of hepatitis A?
Faeco-oral spread
Flu-like prodrome
What antibodies are present in hepatitis A?
HAV-IgM (1 month after exposure)
HAV-IgG for life
How is HAV managed?
Immunisation (1st: 1 yr, 2nd: 20)
Supportive and alcohol avoidance
What are the defining features of hepatitis B?
Fever
Juandice
Bodily fluids (sex, blood, mother to child)
