Jaundice

Question 1

At what level does plasma bilirubin become visible as jaundice?

Answer 1

> or equal to 60 umol/L

Question 2

How is jaundice categorised?

Answer 2

By site of problem (pre hepatic, hepatocellular and cholestatic/obstructive)
And by type of circulating bilirubin (conjugated and unconjugated)

Question 3

What are the three main causes of unconjugated hyperbilirubinaemia?

Answer 3

Overporduction - haemolysis, impaired erythropoiesis
Impaired hepatic uptake - drugs (paracetamol, rifampicin)
Impaired conjugation (Gilberts)

Question 4

How does conjugated vs unconjugated hyperbilirubinaemia present?

Answer 4

Conjugated is water soluble so is excreted in the urine making it dark, there is also less conjugated bilirubin reaching the faeces so they become pale.
Unconjugated bilirubin is non water soluble so cannot enter the urine

Question 5

What are the two main causes of conjugated hyperbilirubinaemia?

Answer 5

Hepatocellular dysfunction - drugs, cirrhosis, hepatitis, liver mets etc
Impaired hepatic excretion (cholestasis) - Primary biliary cholangitis, primary sclerosing cholangitis, common bile duct gallstones, compression of bile duct

Question 6

What do painful vs painless jaundice indicate?

Answer 6

Painful jaundice indicates obstruction and painless should be a red flag for malignancy

Question 7

When examining a jaundiced patient what are you looking for?

Answer 7

Signs of chronic liver disease, hepatomegaly, splenomegaly, palpable gall bladder

Question 8

What is Courvoisier’s law?

Answer 8

Presence of a palpably enlarged gallbladder which is nontender and accompanied with mild painless jaundice, the cause is unlikely to be gallstones

Question 9

What important investigations should be done for jaundice?

Answer 9

Full liver screen for liver disease
Urinary bilirubin indicates not a pre hepatic cause
Full blood count should be done to look for haemolytic causes

Question 10

What does a high ALP result on liver screening indicate?

Answer 10

This is often combined with a raised gamma GT and indicates an obstructive jaundice or biliary pathology

Question 11

What does a raised ALT and AST indicate?

Answer 11

Hepatocellular damage

Question 12

How do you manage jaundice?

Answer 12

Treat the cause promptly, give fluids and broad spectrum antibiotics if obstructed

Question 13

What are the causes of jaundice (decompensation) in a previously well patient with cirrhosis?

Answer 13

Sepsis
Malignancy e.g. hepatocellular carcinoma
Alcohol
GI bleeding

Question 14

What sort of infections are splenectomy patients susceptible to?

Answer 14

Encapsulated bacteria e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis