Gi Week 4 Pbl Objective 2

Front 1

What is the critical issue in managing a jaundiced patient?

Back 1

It may indicate a MEDICAL EMERGENCY such as in massive hemolysis, ascending cholangitis, and acute hepatic failure.

Front 2

What are 12 questions you can ask to get a better understanding of the etiology of the jaundice?

Back 2

1. Do you have any abdominal pain?
2. Have you noticed a change in the colour of your urine and/or stool?
3. Have you lost or gained any weight recently?
4. Have you traveled internationally recently?
5. IVDU?
6. Have you had unprotected sex recently?
7. Have you ever had a blood transfusion?
8. Have you ever had abdominal surgery?
9. Has anyone in your family ever experienced a similar yellowing of the skin?
10. What medications (prescription, OTC, herbal) are you currently taking?
11. How much alcohol do you drink on a daily basis?
12. Are you, or could you be pregnant?

Front 3

Why should you enquire about abdominal pain?

Back 3

Abdominal pain in the presence of jaundice suggests biliary obstruction, or marked inflammation of the hepatic parenchyma or other biliary structures such as the gallbladder. Painless jaundice is characteristic of cancer of the head of the pancreas

Front 4

Why should you enquire about changes in the colour of urine and stools?

Back 4

Dark urine and pale stools that tend to float suggest cholestatic jaundice

Front 5

Why should you enquire about losses or gains of weight?

Back 5

Weight loss is a common sign in malignant disease (such as pancreatic carcinoma) and infiltrative hepatic diseases (such as sarcoidosis, tuberculosis, granulomatous diseases). Ascites associated with cirrhosis can cause weight gain

Front 6

Why should you enquire about travel history?

Back 6

Certain granulomatous diseases that are likely to be acquired overseas, such as tuberculosis, may present with jaundice. Hepatitis A, B, and C viruses may also be contracted from foreign travel

Front 7

Why should you enquire about IVDU?

Back 7

Hepatitis B, C, and D viruses are parenterally acquired and more common in intravenous drug users

Front 8

Why should you enquire about recent, unprotected sex?

Back 8

Unprotected intercourse with an individual with hepatitis B, C, or D infection is a risk factor

Front 9

Why should you enquire about blood transfusions?

Back 9

Massive transfusions can cause unconjugated hyperbilirubinemia due to the shorter lifespan of transfused cells
AND, there was no screening for Hep C in blood products prior to 1989

Front 10

Why should you enquire about abdominal surgeries?

Back 10

Previous surgery on the biliary tree suggests a known hepatobiliary disease, e.g. cholecystectomy indicates a history of gallstones that may recur. Biliary surgery also is a risk factor for postoperative infection and inflammation that may result in jaundice due to stricture formation.Certain inhalational anesthetics are known to be hepatotoxic. Solid organ transplant recipients are at risk of graft vs host disease, which may present with jaundice

Front 11

Why should you enquire about family members with jaundice?

Back 11

Several hereditary disorders are associated with jaundice, including hereditary hemolytic anemias (unconjugated hyperbilirubinemia), dyserythropoietic disorders (thalassemia, sickle cell anemia), Gilbert's syndrome, (a disorder of bilirubin conjugation, hence unconjugated hyperbilirubinemia), Wilson's disease (defective copper metabolism causing toxic hepatic accumulation of copper), hereditary hemochromatosis (excessive iron uptake leads to toxic accumulation in the liver), and alpha-1-antitrypsin deficiency

Front 12

Why should you enquire about current medications?

Back 12

Certain medications are known to be associated with unconjugated bilirubinemia (rifampicin), while others are known hepatotoxins (alcohol, acetaminophen, isoniazid, phenytoin, cytotoxic agents), particularly when taken in excess. Medications known to cause hepatic inflammation include chlorpromazine and erythromycin. Estrogens, oral contraceptives, anabolic steroids, and total parenteral nutrition (TPN) can all cause cholestasis. Clinical features that point to a possible drug-induced cholestasis include rash and arthralgias

Front 13

Why should you enquire about alcohol use?

Back 13

Alcoholic hepatitis and cirrhosis are both causes of jaundice. Remember that chronic users of excessive alcohol are unlikely to give a candid response to this question

Front 14

Why should you enquire about pregnancy?

Back 14

There are several cholestatic disorders seen in pregnancy. In the first trimester, hyperemesis gravidarum may occasionally be accompanied by jaundice. Intrahepatic cholestasis of pregnancy, acute fatty liver of pregnancy, and pre-eclampsia are all typically seen during the third trimester. Intrahepatic cholestasis of pregnancy usually presents with pruritus that is more prominent than jaundice, resolves within 2 weeks of delivery, and tends to recur with future pregnancies. Acute fatty liver of pregnancy is a much more serious condition, usually accompanied by nausea, abdominal pain, and encephalopathy. Prompt delivery is imperative to prevent maternal death. In approx. 10% of cases of pre-eclampsia the liver is involved and jaundice may be observed as part of the medical emergency HELLP syndrome (hemolysis, elevated liver enzymes, low platelets)

Front 15

What should you be looking for during the inspection portion of the physical exam?

Back 15

toxic appearance, and face, skin, sclerae, and mucous membranes for jaundice; palms, mucous membranes for anemia; degree of pigmentation; signs of previous surgery; stigmata of chronic liver disease; visible weight loss; injection marks from intravenous drug use; and erythema nodosum

Front 16

What should you assess for in palpation during the physical exam?

Back 16

ascites, (tender) hepatomegaly, splenomegaly

Front 17

In what jaundice-associated conditions might you find the liver to be enlarged?

Back 17

1. Hepatomegaly in chronic liver disease
2.Tender hepatomegaly suggests acute or chronic hepatitis, or malignancy
3.Hepatosplenomegaly in hemolysis

Front 18

If you suspected cirrhosis to be the underlying cause of jaundice, what might you find on physical examination?

Back 18

1. knobbly, hard, shrunken liver
2. ascites

Front 19

What is the mechanism of splenomegaly in chronic liver disease?

Back 19

Portal HTN producing congestion in the splenic vein, leading to splenomegaly

Front 20

Why should you do a mental status exam in a jaundiced patient?

Back 20

To look for hepatic encephalopathy = medical emergency!

Front 21

What should you assess for in palpation during the physical exam?

Back 21

ascites, (tender) hepatomegaly, splenomegaly

Front 22

In what jaundice-associated conditions might you find the liver to be enlarged?

Back 22

1. Hepatomegaly in chronic liver disease
2.Tender hepatomegaly suggests acute or chronic hepatitis, or malignancy
3.Hepatosplenomegaly in hemolysis

Front 23

If you suspected cirrhosis to be the underlying cause of jaundice, what might you find on physical examination?

Back 23

1. knobbly, hard, shrunken liver
2. ascites

Front 24

What is the mechanism of splenomegaly in chronic liver disease?

Back 24

Portal HTN producing congestion in the splenic vein, leading to splenomegaly

Front 25

Why should you do a mental status exam in a jaundiced patient?

Back 25

To look for hepatic encephalopathy = medical emergency!