Jaundice

Question 1

What are LFT’s and what do they tell you

Answer 1

Bilirubin (SBR) - total and split - liver clearance / function
ALT / AST
Alkaline phosphatase
GGT

Question 2

What should conjugated bilirubin be

Answer 2

10% of unconjugated

Question 3

What are other tests and what do they show

Answer 3

PT / INR - clotting
APTT - clotting
Albumin - produced in liver 
Blood glucose
Ammonia

Question 4

What causes jaundice

Answer 4

Haem broken down in spleen
Bilirubin produced
Insoluble can't excrete
Goes to liver and conjugates
Secreted into bile
Becomes urobilinogen
Reabsobed into portal and excreted in kidney 
Or become sterecobilin in stool

Question 5

What enzymes conjugated

Answer 5

UDP glucoyuntransferase

Question 6

When does jaundice become visible

Answer 6

Bilirubin >40-50

Question 7

What are the different types of jaundice with time

Answer 7

Early - <24 hours
Intermediate
Prolonged >2 week or 21 if pre-term

Question 8

What is always abnormal

Answer 8

Early

Question 9

What causes early jaundice

Answer 9

Haemolysis 
ABO / Rhesus mismatch
G6PD / Spherocytosis
Sepsis 
- Congenital or early 
Haematoma 
Haemorrhage - IVH

Question 10

What do you do

Answer 10

Urgent SBR if suspect

Other tests

Question 11

What suggests haemolytic

Answer 11

+ve DAT

Question 12

What causes intermediate

Answer 12

Physiological - most common
Sepsis
Haemolysis
Abnormal conjugated
Cephalohaematoma

Question 13

What is abnormal conjugated

Answer 13

Gilberts
Criger Najar
Absence of enzyme to conjugated
Isolated hyperbilirubin
Do FBC to rule out haemolytic

Question 14

What causes physiological

Answer 14

Shorter RBC lifespan
Polycythaemic at birth
Immature liver function
Pre-mature and breast fed increase

Question 15

What is always abnormal

Answer 15

Conjugated bilirubin
Suggest obstruction
Pale stool / dark urine = worry
Need split SBR

Question 16

What causes obstruction

Answer 16

Biliary atresia - early Dx is key (bile duct narrowed or absent resulting in cholestasis)
Gall stone
Tumour
Hirschprung
Cyst 
Alangile syndrome

Question 17

How does liver disease present

Answer 17

Jaundice if bilirubin >40

Most prominent in sclera

Question 18

What are other signs of cholestasis / biliary atresia

Answer 18

Pruritus
Dark urine 
Pale stool
Fat malabsorption
May have HSM
Poor growth / feeding 
Cardiac murmur if associated abnormality

Question 19

How do you investigate jaundice at bed site

Answer 19

Bilirubinometer

Question 20

When can you not use

Answer 20

If <24 hours

Question 21

What do you do after bilirubinometer

Answer 21

Plot level on Rx line to see what Rx is needed
If <50 below Rx line= SBR
Split is important for biliary atresia

Question 22

What are other tests

Answer 22

FBC
Blood film 
DAT for haemolytic 
Blood group 
G6PD
Urine and blood culture
Septic screen if unwell
U+E
LFT
TFT
Test to exclude a1- anti typisn or CF

Question 23

What imaging for obstruction

Answer 23

USS

Liver biopsy

Question 24

How do you treat biliary atresia

Answer 24

UDCA can be given in interim
Urgent Kasai Portoenterostomy
- Blocked bile duct removed and replaced with small intestine
Liver transplant if doesn’t work / severe end stage liver disease / portal HTN

Question 25

What are choledochal cyst

Answer 25

Cyst in bile duct so don't get effective flow

Question 26

How do you Dx choledochal cyst

Answer 26

Split bilirubin Pale stools USS of bile duct

Question 27

What is alagille syndrome

Answer 27

Intrahepatic cholestsasis Dysmorphism Congenital cardiac disease

Question 28

How do you treat physiological jaundice

Answer 28

``` Phototherapy to breakdown bilirubin and prevent complication Exchange transfusion if very severe Ig if immune process May need transfusion if anaemia - Can do this in the womb Assess need for SCBU Ensure fluid requirements met Monitor regular ```

Question 29

What is important to ask in the history if asked to see a baby with jaundice

Answer 29

``` Age - preterm ? birth trauma? RF infection - maternal fever, PPROM, group B strep Mothers blood group / known Ab Poo / pee / feed bottle or breast FH haemolytic disorder ```

Question 30

How would you examine a jaundice child

Answer 30

``` A B - RR, resp distress, SATS C - CRT - sternal, BP D - temp, movement, BG E ```

Question 31

What does jaundice cause

Answer 31

Cross BBB and deposits in brain / basal ganglia causing kernicterus Clinical acute encephalopathy

Question 32

What is acute encephalopathy

Answer 32

``` Poor feed Lethargy Seizure Hypotonia Shrill cry ```

Question 33

What does chronic encephalopathy

Answer 33

``` Severe choreathetoid palsy Sensorineural high freq loss Vision - upward gaze Seizure Hypotonia and hypertonia Hyperreflexia Coma ```

Question 34

What are causes of prolonged jaundice that are not obstructive so unconjugated >14 day

Answer 34

``` Breast milk UTI Sepsis - exclude UTI Cystic fibrosis Hypothyroid Congenital CMV / toxoplasosis Hepatitis A1AT deficiency TPN Haemochromatosis Storage and metabolic disorder ```

Question 35

How does phototherapy work

Answer 35

Converts unconjugated bilirubin into isomers that can be exerted without conjugation in liver

Question 36

What should you do after phototherapy

Answer 36

Measure bilirubin 8-12 hours to ensure levels do not rise

Question 37

How do you treat

Answer 37

Optimise hydration / feeding Phototherapy Exchange transfusion