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Phase 3B: Gastroenterology > Jaundice > Flashcards

Jaundice Flashcards

1
Q

What are the differentials of Jaundice

A

Pre-hepatic

  • Haemolytic anaemia
    • G6PD deficiency
    • Haemoglobinopaties
    • acute transfusion reactions
    • malaria
    • cardiac valves
  • Gilbert’s syndrome

Hepatocellular

  • Alcoholic liver disease
  • Viral hepatitis
  • Iatrogenic
    • drug-induced
    • alcoholic liver disease
  • Haemochromatosis
  • Autoimmune hepatitis
  • Primary sclerosing cholangitis
  • Hepatocellular carcinoma

post hepatic

  • Intra luminal cause
    • gallstone
  • Mural cause
    • cholangiocarcinoma
    • strictures
    • drug-induced cholestasis
  • extramural
    • pancreatic cancer
    • abdominal mass
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2
Q

Who gets autoimmune hepatitis?

A

White women, with high frequency of HLA markers

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3
Q

What are the types of autoimmune hepatitis

A

Type 1

  • Human leukocyte antigen - HLA-DR3 & DR4
  • Anti-nuclear antibody (ANA)
  • Smooth muscle antibody (SMA)
  • perinuclear anti-neutrophil cytoplasmic auto-antibody (pANCA)
  • and or
  • anti-soluble liver antigen

Type 2

  • HLA DQB1 & DRB
  • Anti-liver kidney microsomal 1
  • and/or
  • anti0liver cytosol specific positive
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4
Q

What is the pathophysiology of autoimmune hepatitis

A

In a genetically predisposed person, an environmental agent can trigger a pathogenic process leading to liver necrosis and fibrosis

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5
Q

What are the clinical features of autoimmune hepatitis?

A
  • Anorexia
  • Abdominal discomfort
  • Hepatomegaly
  • Jaundice
  • Encephalopathy
  • Pruritus
  • Arthralgia
  • Fever
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6
Q

How do you investigate suspected autoimmune hepatitis?

A

LFTS

  • AST and ALT - high (compared to bilirubin and gamma-GT)
  • Bilirubin - mild increase
  • Gamma-GT - mild increase
  • Alk Phos - mild increase
  • Serum albumin

Prothrombin time - Prolonged

ANA
SMA

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7
Q

How do you manage autoimmune hepatitis

A

Non-severe

  1. Observation
  2. Corticosteroid monotherapy
  3. Combination corticosteroid + immunosuppressant

Severe

  1. Corticosteroid monotherapy
  2. Corticosteroid monotherapy + immunosuppressant
  3. Liver transplant

NB)

  • Taper steroid to a low maintenance dose and continue azathioprine for at least 2-3 years
  • Histological remission lags behind biochemical remission by months
  • Relapse is common, however only 10-20% will require transplantation
  • Recurrence in transplants is 20-30%
  • AIH increases risk of HCC and patients should be regularly screened
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8
Q

How do you define acute vs chronic hepatitis

A

Acute < 6 months

Chronic > 6 months

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9
Q

What are the causes of acute hepatitis

A

Infective

  • Viral
    • Hep A, B+-D, C, E
    • Human herpes viruses e.g. HSV, VSZ, CMV, EBV
    • Other viruses
  • Non-Viral
    • ​​Mycobacteria
    • Baceteria e.g. bartonella
    • Parasites e.g. toxoplasma

Non-infective

  • Drugs
  • Alcohol
  • Other toxins
  • NAFLD
  • Pregnancy
  • Autoimmune
  • Hereditary metabolic
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10
Q

What are the key sx in acute hepatitis ? What are the signs?

A
  • Non specific
    • malaise
    • lethargy
    • myalgia
  • GI upset
  • Abdominal pain
  • Jaundice + pale stools/dark urine

Signs

  • tender hepatomegaly +- Jaundice
  • +- signs of acute liver failure
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11
Q

How might a patient w/ chronic hepatitis present

A

Asymptomatic

Stigmata of chronic liver disease

Transaminases can be normal

Compensated: Liver function maintained

Decompensated: Coagulopathy (increased PT, INR), Jaundice, Low albumin, Ascites, Encehalopathy

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12
Q

How does Hep A spread?

A

Short incubation - 15-50 days

Immunogenic virus –> usually symptomatic in adults

Rarely fulminant

Self limiting

100% immunity after infection

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13
Q

How do you diagnose Hep A

A
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14
Q

How can you manage hep A

A
  • Supportive
  • Monitor liver function
  • Acute liver failure - liase with hepatology
  • Manage contacts
    • Vaccine
    • HNIG
  • Vaccination
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15
Q

How does Hep E present

A
  • >95% asymptomatic
  • Usually self-limiting acute hepatitis - fulminant = rare
  • Extra-hepatic manifestations
    • Neurological e.g. GBS
  • Risk of chronic infection in immunocompromised patients
    • may rapidly to cirrhosis

Serology is similar to Hep A although is unreliable in immunocompromised patients

  • in these patients do HEV RNA in serum +- stool
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16
Q

How do you manage Hep E

A
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17
Q

What is the epidemiology of Hep B

A
18
Q

How do you test for Hep B

A

Surface antigen only produced using active infection

core antibody - present if a patient has ever been infected

surface antibody - if they’ve been infected and have launched a successful immune response

If you’ve been vaccinated, you will have +ve surface antibody, -ve core antibody, -ve surface antigen

19
Q
A
20
Q

How do you manage acute hepatitis B

A
21
Q

What proportion of immunocompetent adults develop chronic hep B after an acute hep B episode?

A

<5%

22
Q

Describe in more detail the medication for treatment of hep B

A

Pegylated interferon - alpha 2a

  • Immunomodulatory
  • Weekly subcutaneous injections, 48/52 course
  • Offers best chance of treatment free control
  • SE:
    • Significant
    • Flu like symptoms
    • Myalgia
    • Depression
    • Stimulate autoimmune disease

Tenofovir

  • Inhibit viral replication
  • Once daily tablet
  • Minimal SE
  • May be lifelong
23
Q

How do we prevent Hep B infections

A
24
Q

What are the types of drug associated liver injury

A

Intrinsic

  • dose related
  • large proportion of individuals will experience (predictable)
  • examples
  • Amiodarone
  • Anabolic steroids
  • Cholestyramine
  • Valproic acid
  • Heparins
  • Statins

Idiosyncratic

  • not dose related, although dose threshold is usually required
  • unpredictable
  • latency
  • Examples
  • Allopurinol
  • Amiodarone
  • Diclofenac
  • Flucloxacillin
  • Isoniazid
  • Lisinopril
  • Phenytoin
  • Statins
  • Sulfonamides
25
Q

How does drug-induced liver injury present

A

Hepatitis picture

  • Jaundice
  • Abdo pain
  • Nausea
  • Pruritus

Cholestatic LFT: hyperbilirubinaemia w/ modest ALT and ALP +

NB) There may be a lag time, may have stopped the drug and develop jaundice weeks later

  • “what drugs have you recently started’
26
Q

What do the LFTs do in cirrhosis and acute alcoholic hepatitis

A

AST>ALT

AST<500, ALT<300

27
Q

What is the most common cause of decompensated liver disease

A

Alcoholic hepatitis - 90%

28
Q

What is the pathophysiology of decompensated cirrhosis? Why are liver patients more susceptible to infection

A

Pathophysiology

  • hyperdynamic circulatory syndrome –> peripheral arterial vasodilation (splanchnic**)
  • Ineffective volaemia –> Organ hypoperfusion (renal system**)

Infection due to:

  • impaired reticulo-endothelial function
  • leucocyte function
  • permeable gut wall
29
Q

How do you manage decompensated cirrhosis

A

The aim is to prevent cirrhosis progression and restore the integrity of liver architecture

30
Q
A
31
Q

How do you manage alcoholic hepatitis

A
  • Start prednisolone 40mg/day if:
    • Negative septic screen
    • Maddrey > 32
  • NAC for 5 days
  • Lille score after 7 days - if it improves, continue
32
Q

What is acute liver failure

A

A complex multisystem illness that occurs after an insult to the liver. Manifests as:

  • Jaundice
  • Coagulopathy INR>1.5
  • Hepatic encephalopathy - liver flap
  • Absence of chronic liver disease
  • Within 12 weeks
33
Q

How is ALF classified

A

O’Gradey

  • Hyper acute - within 7 days (best prog)
  • Acute - 8-28 days
  • Sub acut: 29 days to 12 weeks (worst prog)
34
Q

What are the causes of acute liver failure

A
  • Paracetamol OD
  • Other drugs
  • Viruses e.g. Viral hepatitis A, E, B
  • Autoimmune hepatitis
  • Ischaemic hepatitis
  • Acute fatty liver of preg
  • Wilson’s
  • Budd Chiari
35
Q

What are the symptoms of acute liver failure

A
  • Jaundice
  • Signs of hepatic encephalopathy
  • Abdo pain
  • Nausea
  • Vomiting
  • Malaise
  • Signs of cerebral oedema
    • ​HIgh levels of ammonia, may result cerebral oedema
  • RUQ tenderness
  • Hepatomegaly - acute viral hepatitis, CCF, Budd-Chiari
  • Absences of stigmata of chronic liver disease
36
Q

What are the grades of hepatic encephalopathy

A
  1. Subtly impaired awareness, sleep alterations, shorted attention span… oriented in time and space
  2. Lethargy or apathy, disorientate…asterixis. dyspraxia
  3. Somnolence to semi-stupor, responsive to vocal stimuli, marked confusion…
  4. Coma
37
Q

What ix do you order in acute liver failure

A
  • LFT
  • Prothrombin time/INR - presence of coagulopathy (INR>1/.5) is defining feature of ALF
  • UE –> to assess renal failure
  • FBC –> assess for anaemia
  • ABG
  • Hepatitis serologies…
38
Q

How do you treat acute liver failure

A
  • Intensive care management
  • Assessment: liver transplantation, neurological status, BM
  • Treat underlying causes
    • Paracetamol OD - nAC
    • Methypred - autoimmune hepatitis
    • TIPS - acute wilson’s disease
  • Liver transplant
39
Q

What do the various antibody tests for hepatitis signify?

A

IgM - acute infection

IgG - exposure to hepatitis

cAb (core antibody) - exposure

sAg (surface antigen) - active/acute disease

eAg

  • +ve indicates early and highly infectious disease
  • -ve shows patient has not been exposed in the past
40
Q

How can you determine the cause of jaundice from colour of urine and stools

A

Prehepatic - normal urine & normal stool

Hepatic - dark urine & normal stools

Post hepatic - dark urine & pale stools

Phase 3B: Gastroenterology (24 decks)

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