Jaundice DSA

Question 1

Hyperbilirubinemia can occur as a result of what 3 things?

Answer 1

Hyperbilirubinemia occurs as a result of:

(1) overproduction
(2) impaired uptake, conjugation, or excretion of bilirubin
(3) regurgitation of unconjugated or conjugated bilirubin from damaged hepatocytes or bile ducts

Question 2

At what bilirubin level is clinical jaundice seen?

Answer 2

Clinical jaundice seen at bilirubin ≥ 3 mg/dL

Normal is 0.2-1.2 mg/dL

Question 3

What is the normal bilirubin level?

Answer 3

Clinical jaundice seen at bilirubin ≥ 3 mg/dL
(Normal is 0.2-1.2 mg/dL)

Normal blood levels of conjugated (direct) bilirubin are 0.1 to 0.3 mg/dL and unconjugated (indirect) bilirubin are 0.2 to 0.9 mg/dL

Question 4

What is the difference between hepatocellular and cholestatic?

Answer 4

Hepatocellular
Primary injury is to the  hepatocytes
Primarily AST/ALT elevation
ALT is more specific for liver injury
than AST

Cholestatic
Primary injury is to the bile ducts
Primarily Alkaline phosphatase
and bilirubin elevated
Failure of bile to reach duodenum
Jaundice and pruritus
Pure cholestasis (no signs of hepatocellular necrosis

Question 5

What are some of the major UNCONJUGATED differentials?

Answer 5

UNCONJUGATED aka Indirect
Hemolytic syndrome
Anemia
Reaction
Gilbert Syndrome
Crigler-Najjar Syndrome
Viral hepatitis (can be both)

Question 6

What are some of the major CONJUGATED differentials?

Answer 6

Hepatitis
Acute/chronic
Infectious/non-infectious
Cirrhosis
Obstruction
Choledocholithiasis
Cholangitis (Obstruction  infection)
Primary biliary cirrhosis (cholangitis)
Primary sclerosing cholangitis
Budd-Chiari
Pancreatic cancer
Dubin-Johnson Syndrome
Rotor Syndrome

Question 7

What is crigler najjar type i?

Answer 7

x

Question 8

what is crigler najjar type 2?

Answer 8

x

Question 9

what is gilberts syndrome?

Answer 9

x

Question 10

viral hepatitis shows a ______ pattern in terms of hyperbilirubinemia

Answer 10

mixed

Question 11

what labs are important to get in the setting of acute hepatitis?

Answer 11

Viral hepatitis serology (see individual slides)
CBC (anemia/leukocytosis/thrombocytopenia?)
CMP (AST/ALT, Total bilirubin (fractionate into direct/indirect), Alk Phos), albumin, renal
function)
PT/INR
Acetaminophen level (*Use Rumack-Matthew Nomogram)

Question 12

what are the potential complications of acute hepatitis?

Answer 12

Hepatic encephalopathy  
Cirrhosis
Hepatocellular carcinoma (HCC)
Fulminant liver failure 
Death
Asterixis

Question 13

what is the main risk factor for hep A?

Answer 13

#1 International travel
Common source outbreaks may still result from contaminated water or food, including inadequately cooked shellfish

Question 14

what is the transmission of hep A?

Answer 14

fecal-oral route/ crowding and poor sanitation

excreted in feces for up to 2 weeks before clinical illness but rarely after the first week of illness

Question 15

what lab values are indicative of hep A?

Answer 15

Normal to low white cell count with large atypical lymphocytes
Markedly elevated aminotransferases (AST/ALT)
Elevated bilirubin and alkaline phosphatase = Cholestasis
Mild proteinuria
Bilirubinuria

Question 16

what antibody serology is seen in hep A?

Answer 16

Antibody to hepatitis A (anti-HAV) appears early in the course of the illness

Both IgM and IgG anti-HAV are detectable in serum soon after the onset.

Detection of IgM anti-HAV is an excellent test for diagnosing acute hepatitis A
IgG anti-HAV (in the absence of IgM anti-HAV) indicates previous exposure to HAV, non-infectivity, and immunity

Question 17

what is the prognosis of hep A?

Answer 17

Good prognosis: Mortality is Low

Fulminant hepatitis A is uncommon