Jaundice and Chronic Liver Disease

Question 1

What is jaundice?

Answer 1

Yellowing of the skin, sclerae and other tissues caused by excess circulating bilirubin

Question 2

When can jaundice be detected?

Answer 2

When the total plasma bilirubin levels exceed 34μmol/L

Question 3

What is the lifespan of a RBC?

Answer 3

120 days

Question 4

What happens when a RBC starts to breakdown?

Answer 4

Haem part is converted to biliverdin (Unconjugated - Insoluble form) and is then converted to bilirubin (Conjugated - Soluble form) in the liver

Question 5

What type of bilirubin is found pre-hepatic?

Answer 5

Unconjugated

Question 6

What type of bilirubin is found hepatic and post-hepatic?

Answer 6

Conjugated

Question 7

What is most likely to have happened for post-hepatic jaundice to occur?

Answer 7

An obstruction condition

Question 8

After conjugation where does most of the bilirubin go?

Answer 8

Most to the stool

A little to the kidneys

Question 9

What are the features of pre-hepatic jaundice?

Answer 9

Increased quantity of bilirubin 
Impaired transport - No urine change
History of anaemia e.g. Fatigue, Dyspnoea & Chest pain
Acholuric jaundice
Pallor & Splenomegaly

Question 10

What are the features of hepatic jaundice?

Answer 10

Defective uptake of bilirubin
Defective conjugation and excretion
Risk factors liver disease and decompensation e.g. Ascites
Stigmata of CLD, Ascites & Asteris (Flapping tremor)

Question 11

What are the features of post-hepatic jaundice?

Answer 11

Defective transport of bilirubin by the biliary ducts
Abdominal pain
Cholestasis - Bile cannot flow from the liver to the duodenum; may cause pruritus pales stools & high coloured urine

Question 12

What can cause an enlarged gallbladder?

Answer 12

Obstruction in the bile duct past the cystic causing a build up of bile in the gallbladder

Question 13

What part of LFTs is raised in hepatic jaundice?

Answer 13

AST & ALT

Question 14

What part of LFTs is raised in post-hepatic jaundice?

Answer 14

Alk phos and GGT

Question 15

What is the best course of management for obstructive jaundice?

Answer 15

Obstruction relief, Complication prevention & Prevent recurrence

Question 16

What is the best course of management for ascending cholangitis?

Answer 16

Prompt drainage & Control infection

Question 17

What is cholangitis?

Answer 17

Infection of the biliary tract

Question 18

After what period of time is liver disease classed as chronic?

Answer 18

6 months

Question 19

What kinds of CLD are there?

Answer 19

Chronic hepatitis
Chronic cholestasis
Fibrosis
Cirrhosis
Tumours

Question 20

List 10 possible reasons for CLD?

Answer 20

Alcohol
Autoimmune - PBC/PSC
Haemochromatosis
Chronic Viral Hepatitis - B & C
NAFLD
Drugs - Amiodarone
CF
Vascular problems - Portal hypertension
Cryptogenic
Others - Sarcoidosis, Amyloid & Schistosomiasis

Question 21

How does CLD present?

Answer 21

Compensated CLD - Abnormality of LFTs
Decompensated CLD - Ascites, Variceal bleeding & Hepatic encephalopathy
Hepatocellular carcinoma

Question 22

What volume of fluid is required for ascites to be detected?

Answer 22

1500ml

Question 23

What evidence corroborates with ascites?

Answer 23

Spider naevi
Palmar erythema
Abdominal veins
Fetor hepaticus
Umbilical nodule
JVP elevation
Flank haematoma

Question 24

Investigation needed on first ascites evaluation?

Answer 24

Protein & Albumin concentration
Cell count and differential
SAAG - Serum-ascites albumin gradient

Question 25

What would indicate that the ascites is likely not liver disease?

Answer 25

Exudative process with high protein and inflammation present

Question 26

What would neutrophils in the ascites indicate?

Answer 26

Peritonitis

Question 27

What type of ascites indicates liver disease?

Answer 27

Transudative

Question 28

What causes variceal haemorrhages?

Answer 28

Portal hypertension

Question 29

Where are variceal haemorrhages seen?

Answer 29

Porto-systemic anastamoses - Skin, Rectal & Oesophageal/Gastric

Question 30

What types of varices are not as serious?

Answer 30

Posterior abdominal wall veins | Rectal varices

Question 31

What must the body do with blood if the liver is having problems?

Answer 31

Choose an alternate for the blood to flow

Question 32

What should be done to manage variceal haemorrhage?

Answer 32

Resuscitate patient Find good IV access Blood transfusion as required Emergency endoscopy - Don't want to rush this

Question 33

What percentage of people die with acute GI bleeding?

Answer 33

20%

Question 34

What can stop the bleeding in the stomach but what is the condition with this treatment?

Answer 34

SB tube - So a balloon inflates the fundus part of the stomach to stop the bleeding however, it can't be done for longer than 24 hours

Question 35

What treats portal hypertension and can be a cure to varicies?

Answer 35

TIPPS

Question 36

What is hepatic encephalopathy?

Answer 36

Confusion due to liver disease

Question 37

What are precipitants of hepatic encephalopathy?

Answer 37

``` GI Bleed Infection Constipation Dehydration Medication - Especially sedation ```

Question 38

What do you treat for hepatic encephalopathy?

Answer 38

The underlying cause

Question 39

What do colonic bacteria produce?

Answer 39

Ammonia

Question 40

How does hepatocellular carcinoma present?

Answer 40

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

Question 41

What hepatocellular carcinoma occur in the background of?

Answer 41

Cirrhosis

Question 42

What investigations should be done to diagnose hepatocellular carcinoma?

Answer 42

Tumour markers - AFP Ultrasounds, CT & MRI Biopsy - Done rarely

Question 43

What is treatment for hepatocellular carcinoma?

Answer 43

``` Hepatic resection Liver transplantation Chemotherapy Locally ablative treatments Sorafenib Hormonal therapy e,g, Tamoxifen *Transplant if both lobes are affected* ```

Question 44

What does SAAG stand for?

Answer 44

Serum-ascites albumin gradient

Question 45

What does a SAAG with >1.1g/dl indicate?

Answer 45

``` Portal hypertension & Cirrhosis CHF Constrivtive ericarditis Budd chiarri Myxdema Massive liver metastases ```

Question 46

What does a SAAG with

Answer 46

``` Malignancy TB Chylous ascites Pancreatic Biliary ascites Nephrotic syndrome Serositis ```

Question 47

How is SAAG treated?

Answer 47

``` Diuretics Paracentesis if there is a large volume TIPS - A shunt Aquaretics Liver transplant ```