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Flashcards in Jaundice and Chronic Liver Deck (49)
1

What is Jaundice?

Yellowing of the skin, SCLERAE, and other tissue caused by excess circulating bilirubin.

2

What level must bilirubin be for jaundice to be detectable?

Bilirubin >34umol/L

3

What is the differential diagnosis of jaundice?

Carotenemia

Very rare. Almost always jaundice

4

How is bilirubin formed and broken down?

Haemoglobin broken down to Biliverdin.
Converted to bilirubin.
Bilirubin hard to secrete so converted to soluble form (Bilirubin Diglucuronide)
Then excreted in stool

5

What is bilirubin?

Yellow product in the breakdown of heme during clearance of old red blood cells.

Excreted in bile and urine.
Causes yellow colour in bruises.
Yellow colour in urine and brown colour in feces

6

What are the two types of bilirubin?

Unconjugated and Conjugated

7

What is unconjugated bilirubin?

Bound to albumin

Makes up 90% of normal bilirubin serum fraction.

Non-polar (loves fat)
Not excreted renally
Large temporary albumin binding

8

What is conjugated bilirubin?

Soluble form

Makes up 10% of normal bilirubin serum fraction

Polar (not to keen on fat)
Renal secretion
No temporary albumin binding

9

How do you classify jaundice and what bilirubin is associated?

Pre hepatic- Unconjugated
Hepatic- Conjugated
Post hepatic- Conjugated

Conjugated = soluble form so will be raised in hepatic/ post hepatic jaundice

10

Describe pre hepatic jaundice

Increased quantity of bilirubin (Haemolysis)
Impaired Transport

11

Describe pre hepatic jaundice

Defective uptake of bilirubin
Defective conjugation
Defective excretion

12

Describe post hepatic jaundice

Defective transport of bilirubin by the biliary system

13

How will pre hepatic jaundice present?

History of anaemia (fatigue, dyspnoea, chest pain)
Acholuric jaundice

14

How will hepatic jaundice present?

Risk factors for liver disease (IVDU, drug intake)
Decompensation (ascites, variceal bleeds, encephalopathy)

15

How will post hepatic jaundice present?

Abdominal pain
Cholestasis (pruritus, pale stools, high coloured urine)

16

Why does cholestasis cause pruritus?

Blockage in bile duct.
Bile leaks into skin and pruritus.
Bilirubin not in stools.
All goes into urine

17

What are the clinical examination features of pre hepatic jaundice?

Pallor
Splenomegaly

18

What are the clinical examination features of hepatic jaundice?

Stigmata of CLD (spider naevi, gynaecomastia)
Ascites
Asterixis

19

What are the clinical examination features of post hepatic jaundice?

Palpable gall bladder

20

What will the investigations for pre hepatic jaundice look like?

Unconjugated bilirubin = +

Conjugated = normal

AST or ALT = Normal

Alkaline phosphatase and GGT = Normal

21

What will the investigations for hepatic jaundice look like?

Unconjugated bilirubin = Normal

Conjugated bilirubin = +

AST or ALT = ++

Alkaline phosphatase and GGT = Normal

22

What will the investigations for post hepatic jaundice look like?

Unconjugated = Normal

Conjugated = +

AST or ALT = Normal

Alkaline Phosphatase and GGT = ++

23

What happens to the liver enzymes when the liver is damaged or inflamed?

AST or ALT will rise

24

What is the most important imaging investigation for jaundice?

Ultrasound

-Differentaites extra hepatic and intrahepatic obstruction
-Delineated site of obstruction
-Delineated cause of obstruction
-Documents evidence of portal hypertension
-Preliminary staging of extent of disease (e.g. cancer spread)

25

What investigations are involved in a liver screen?

-Hep B&C Serology
-Autoantibody profile, serum immunoglobulins
-Caeruloplasmin and copper
-Ferritin and transferrin saturation
-Alpha 1 antitrypsin
-Fasting glucose and lipid profile

26

What is the management of obstructive jaundice?

Obstructuve jaundice (ERCP)
-Relief of obstruction
-Prevent complication
-Prevent recurrence

Acsending Cholangitis (ERCP)
Promp drainage
Control infection

27

What is chronic liver disease?

Liver disease that persists beyond 6 months

Chronic hepatitis
Chronic cholestasis
Fibrosis and cirrhosis
Others e.g. steatosis (fatty liver)
Liver tumours

28

List some of he causes of chronic liver disease

-Alcohol
-Autoimmune
-Haemochromatosis
-Chronic viral hepatitis B+C
-Non-Alcoholic fatty liver disease (NAFLD)
-Drugs (MTX, amioderone)
-Cystic fibrosis, a1 antitryptin deficiency, Wilsons disease
-Vascular problems
-Cryptogenic

29

What is the clinical presentation of chronic liver disease?

Compensated chronic liver disease
-Routinely detected on screening tests
-Abnormality of liver function tests

Decompensated chronic liver disease
-Ascites
-Variceal bleeding
-Hepatic encephalopathy

Hepatocellular carcinoma

30

What are the clinical features of ascites?

Dullness in flanks and shifting dullness.
This can be confirmed by ultrasound which is much more sensitive.

Corroborating evidence:
-Spders, Palmar erythema, abdominal veins, fetor hepaticus
-Umbilical nodule (cancer?)
-JVP elevation (heart failure?)
-Flank Haematoma

31

What should you do with a patient with new-onset ascites?

Diagnostic paracentesis

32

What studies need to be carried out on fluid aspirated form a paracentesis?

Protein and albumin concentration

Cell count and differential

SAAG (serum-ascites albumin gradient)

33

How do you know if fluid is from an exudative process?

High protein

Malignancy and inflammatory disease

34

How do you know if fluid is from a transudative process?

Low protein

More likely liver disease

35

What do the types of cells from a cell count and differential tell you?

Neutophils = peritonitis

Lymphocytes = chronic condition

36

What do the results from a SAAG tell you?

>1.1g/dl portal HTN related
-Portal hypertension
-CHF
-Constrictive pericarditis
-Budd Chiarri
-Myxedema
-Massive liver metastases

37

When talking about ascites what should you replace the modifier transudative and exudative with?

Transudative = high-albumin gradient

Exudative = Low albumin gradient

38

What are the treatment options for ascites?

-Diuretics (easiest)

-Large volume paracentesis (drains a large volume quickly)

-TIPS = shunt in liver fixes hypertension (if above treatments don't work)

-Aquaretics (new drugs)

-Liver transplant (last resort)

39

How do you initially treat a variceal haemorrhage?

Resuscitate patient
Good IV access
Blood transfusion as required
Emergency endoscopy

40

How do you stop the bleeding in a vatical haemorrhage?

Endoscopic band ligation (suck out vessels and stick a band around)

Can add terlipressin for control

Senstaken-Blakemore tube for uncontrolled bleeding

TIPS for rebleeding after banding

41

What is a Senstaken-Blakemore?

Balloon inflated in stomach and attached to sandbag.
Pulled out and yanks fundus against bleed.
Works but one of the worst feelings for the patient

42

What is Hepatic encephalopathy and how is it caused?

Confusion due to liver disease.

Ammonia broken down in the liver.
Liver doesn't work.
Ammonia not broken down and builds up in the blood

43

What are the precipitants?

GI bleed
Infection
Constipation
Dehydration
Medication esp. sedation

44

What signs other than confusion may help diagnose hepatic encephalopathy?

Asterixis (bird flapping its wings)
Foetor hepaticus (breath of the dead)

45

How do you treat hepatic encephalopathy?

Treat underlying cause

Laxatives - phosphate enemas and lactulose
(Flush system so colonic bacteria aren't present to produce more ammonia)

Neomycin, Rifaximin-broad spectrum non absorbed antibiotic

Repeated admissions with HE is an indicator for liver transplant

46

Describe hepatocellular carcinoma

Commonest cause of liver cancer
Occurs in the background of cirrhosis
Occurs in association with chronic hepatitis B+C

47

How does hepatocellular carcinoma present?

Decompensation of liver disease
Abdominal mass
Abdominal pain
Weight loss
Bleeding from tumour

48

How do you diagnose hepatocellular carcinoma?

Tumour Markers:
AFP (alpha fetoprotein)

Radiological tests:
-US
-CT
-MRI

Liver biopsy done very rarely because CT and MRI are so good.

49

How do you treat hepatocellular carcinoma?

Hepatic resection

Liver transplantation

Chemotherapy

Locally ablative treatments
-Alcohol injection
-Radiofrequency ablation

Sorafenib (tyrosinase kinase inhibitor)

Hormonal therapy: Tamoxifen