Jaundice & Gallstones

Question 1

Concentration of serum bilirubin required to produce jaundice?

Answer 1

> 2mg/dL

Question 2

What bloods to request when investigating jaundice?

Answer 2

• total bilirubin
• CB

Liver damage

• AST
• ALT
• Alkaline phosphates

Hepatocellular function

• albumin
• PT
• PTT
• INR

Question 3

Blood results indicate prehepatic cause (UCB).

What further labs do you order?

Answer 3

FBC - anaemia
LDH - high
Blood culture - reticulocytosis

Question 4

Prehepatic causes of jaundice

Answer 4

• haemolytic anaemia
• haemoglobinopathies (hereditary spherocytosis, SCD, thalassaemia)
• autoimmune
• malignancy
• drug toxicity

Question 5

Hepatic causes of jaundice

Answer 5

• cirrhosis (inflammation/scarring compresses biliary tree)
• Gilbert’s disease (60% reduction CB)
• NAFLD
• ALD
• CLD
• LF
• HCC
• Viral hepatitis
• sepsis
• drug-induced
• ischaemic/AI hepatitis

Question 6

Post-hepatic causes of jaundice

Answer 6

• gallstone disease
• pancreatic cancer (painless)
• BPH
• bile duct stricture
• pancreatitis (chronic) /pseudocyst
• sclerosing cholangitis

Question 7

How are RBCs haemolysed & excreted?

Answer 7

RBC -> Haem & globin -> Fe & UCB

+glucaronic acid (liver) -> CB (GB) -> UCB + glucaronic acid (duodenum & ileum)

• > UBG -> stercobilin (intestinal bacteria)

Question 8

Charcot’s triad

Answer 8

Gallstone disease:

1. RUQ pain
2. Fever (raised WCC)
3. Jaundice

Question 9

What is biliary colic?

Answer 9

1/3 Charcot’s: post-prandial RUQ pain

• stones in Hartmann’s pouch
• I-cells release CSK after fatty meal
• intermittent colicky pain as GB contracts against stones in outlet

Question 10

Risk factors for gallstone disease:

Answer 10

Fat
Forty
Female
Fertile
Fair (Caucasian)

• sudden WL
• COCP
• Crohn’s

Question 11

How does cholecystitis present?

Answer 11

2/3 Charcot’s: RUQ pain & fever
(No jaundice as prox to cystic duct)

Question 12

How does ascending cholangitis present?

Answer 12

3/3 Charcot’s

Question 13

What is Reynold’s Pentad?

Answer 13

1. RUQ pain
2. Fever
3. Jaundice
4. Shock (hypotension)
5. Confusion

= biliary sepsis

Question 14

How can ascending cholangitis cause pancreatitis?

Answer 14

Gallstone distal to pancreatic duct (ampulla of Vater) = inflammation of pancreas

Question 15

Management of ascending cholangitis

Answer 15

• USS or MRCP
• ERCP/lithotripsy
• fluids, IV Abx, manage symptoms

Question 16

What is gallstone ileus?

Answer 16

Gallstones in ileum (through ampulla of vater or through abscess)

• oft at ileocoecal valve (ICV)

Question 17

Bouveret syndrome

Answer 17

Gastric outlet obstruction at ampulla of Vater = compression of duodenum

Question 18

What is Rigler’s triad?

Answer 18

Gallstone ileus findings:

1. SBO
2. pneumobilia
3. ectopic GSD

Question 19

Primary Biliary Cholangitis (PBC)

Answer 19

Disease of small intrahepatic bile ducts

• middle-age, F
• feverish
• other AID
• AMA (antimitochondrial abd)

Question 20

Sjögren’s syndrome

Answer 20

Dryness - eyes, mouth, skin, vagina
(AID)

• linked to PBC as both affect exocrine glands of organ systems (biliary epithelia)

Question 21

Primary Sclerosing Cholangitis (PSC)

Answer 21

Disease of larger intrahepatic & extrahepatic bile ducts

• young, M (25-35)
• UC
• p-ANCA (antineutrophil cytoplasmic abds) = autoimmune vasculitis. +ve

Question 22

Mirizzi syndrome

Answer 22

CHD obstruction from extrinsic compression by impacted stone in cystic duct or GB infundibulum

• presents with Charcot’s triad

Question 23

How might GSD cause paralytic ileus?

Answer 23

Hypokalaemia (flatus, SBO)