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76 Cards in this Set
- Front
- Back
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What are the 3 major categories for mechanism of juandice? |
1. Obstructive - extrahepatic - intrahepatic 2. Hepatocellular 3. Haemolytic |
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What is jaundice defined as? |
Serum bilirubin level > 19umol/L |
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When does clinical jaundice manifest? |
When bilirubin level >50 umol/L *Difficult to detect visually below 85 umol/L when lighting is poor |
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What are the 6 most common causes of jaundice recorded in general practice population (in order)? |
1. Viral hepatitis 2. Gallstones 3. Pancreatic cancer 4. Cirrhosis 5. Pancreatitis 6. Drugs |
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Name at least 5 serious diagnosis of jaundice not to be missed |
1. Malignancy - Pancreas - Biliary tract - Hepatoceullar (hepatoma) - Metastases 2. Severe infections - Septacaemia - Ascending cholangitis - Fulminant hepatitis - HIV/ AIDS 3. Wilson syndrome 4. Reye syndrome 5. Acute fatty live of pregnancy |
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Rise in bilirubin level during infections (e.g. influenza) and episodes of fasting Otherwise normal LFTs History of intermittent mild jaundice Family history Vague RUQ pain = |
Gilbert syndrome * No rx required (benign) |
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Name at least 5 drugs that can cause jaundice |
Haemolysis: - Methyldopa Hepatocellular damage: - Paracetamol - Antidepressants e.g. MAOIs - Statins e.g. simvastatin Cholestasis: - Antibiotics e.g. erythromycim, flucloxacillin, Augmentin - Antithyroid drugs Others: - Allopurinol - Nitrofurantoin - Vit A (mega dosage) |
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List 4 red flags for jaundice |
1. Unexplained weight loss 2. Progressive jaundice including painless jaundice (painless obstructive jaundice common in elderly population) 3. Oedema 4. Cerebral dysfunction e.g. confusion, somnolence |
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What are some specific history questions you can ask in a patient with jaundice? |
Abdo pain Change in colour of faeces and urine Recent overseas travel Exposure to blood or blood produces Needle-stick injuries or exposure to needles e.g. acupuncture, tattooing, IVDU Contacts with jaundice |
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What is the differential diagnosis of pain in the right hypochondrium? |
Gallstones Acute hepatitis (a constant ache) Cholecystis |
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What is the differential diagnosis of anorexia, dark urine and fever? |
Viral hepatitis probable Alcoholic liver disease possible Drug-induced hepatitis possible |
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What is the differential diagnosis of puritis in liver disease? |
Cholestasis probably Possible with all liver dieases |
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What is the differential diagnosis of arthralgia and rash in liver disease? |
Viral hepatitis Autoimmune hepatitis |
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What signs might you look for on examination of liver disease? |
General: jaundice, loss of body hair, fever EBV: lymphandeopathy, tonsillitis Liver: large or small on palpation, enlarged gall bladder (carcinoma head of pancreas) Tremor: Wilsons syndrome, hepatic flap Other: alcoholic facies, spider naevi, scratch marks, gynaecomastia, splenomegaly, dilated abdominal veins (cirrhosis), needle marks, liver palms, leuconychia, testicular atrophy |
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What is the likely diagnosis based on the following investigation results: Bilirubin + to +++ ALP + (<2x normal) ALT +++ (>5x normal) GGT N or + Albumin N or - Globulin N or + |
Hepatocellular (viral) hepatitis |
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What is the likely diagnosis based on the following investigation results: Bilirubin + (unconjugated) ALP, ALT, GGT, Albumin and Globulin all Normal |
Haemolytic jaundice |
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What is the likely diagnosis based on the following investigation results: Bilirubin + to +++ ALT N or + GGT ++ Albumin N Globulin N |
Obstruction |
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What is the likely diagnosis based on the following investigation results: Bilirubin + up to 50 unconjugated ALP, ALT, GGT, Albumin and Globulin all normal |
Gilbert syndrome |
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What is the likely diagnosis based on the following investigation results: Bilirubin + to N ALP ++ to +++ ALT + GGT + Albumin N to - Globulin N |
Liver metastases/ abcess |
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What is the likely diagnosis based on the following investigation results: Bilirubin + to N ALP + ALT + GGT +++ Albumin N to -- Globulin N to + |
Alcoholic liver disease |
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Other than LFTs what blood tests might you consider in a jaundiced patient? |
FBC - for haemolytic causes Hep A, B and C EBV CMV CEA - for liver secondaries esp. colorectal AFP - for hepatocellular carcinoma (mild elevation with cirrhosis) Serum ceruloplasmin level - low in Wilson syndrome |
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What are the diagnostic markers for the different types of hepatitis on blood tests? |
Hep A: IgM antibody (HAV Ab) Hep B: surface antigen (HBsAg) Hep C: HCV antibody (HCV Ab) |
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What imaging might you consider in the diagnosis of jaundice? |
Plain abdo xray: 10% of gallstones Transabdominal USS: most useful for gallstones and dilatation of the common bile duct, also liver mets HIDA scintiscan: acute cholecystitis CT scan: esp. pancreatitis or pancreatic cancer Percutaneous transhepatic cholangiography ERCP: for obstructive causes MRCP: non-invasive Ix for obstructive causes Liver isotopic scan: for liver cirrhosis esp. of left lobe |
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What invasive special test can you consider for liver disease? |
Liver biopsy |
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Anorexia, nausea +/- vomiting Malaise Headache Distaste for cigarettes in smokers Mild fever +/- diarrhoea +/- upper abdominal discomfort Recent travel or contaminated food consumption = |
Hepatitis A - Pre-icteric (prodromal) phase |
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Dark urine Pale stools Hepatomegaly Splenomegaly (palpable in 10%) +/- jaundice (many do not develop) = |
Hepatitis A - Icteric phase |
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What investigations should you conduct in a patient with suspected Hep A virus? |
LFTs IgM hepatitis antibodies for diagnosis (anti-HAV IgM) - IgG antibodies means past infection and lifelong immunity (anti-HAV IgG) Consider USS to exclude bile duct obstruction |
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What treatment should you provide to a patient with Hep A virus? |
Reassurance and education Rest as appropriate Fat-free diet Avoid etoh, smoking and hepatotoxic drugs (until recovery) Hygiene at home to prevent spread Do not handle food for others with fingers Do not share cutlery and crockery during meals Do not use tea towels to dry dishes Recovery in 3-6 weeks |
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What preventative options are there for Hep A? |
Good sanitation Effective garbage disposal Hand washing Hep A vaccination |
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Who should be given Hep A vaccination? How many doses? How long does it last? |
Anyone travelling to endemic areas, ATSI kids between 18 months and 6 years in north QLD, healthcare and child care workers, MSM, IVDU, pts with chronic liver disease of any aetiology 2 doses - 1st dose starts working in 14-21 days Lasts at least 10 years |
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What is the difference in symptoms between Hep A and Hep B? |
Same symptoms but less abrupt in onset and more severe in long term May also have a serum sickness-like immunological syndrome with transient rashes (e.g. urticaria or a maculopapular rash) and a polyarthritis effecting small joints - 25% of cases in prodromal period |
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How is Hep A and Hep E spread? |
Faecal -> oral |
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How are Hep B, C and D spread? |
Blood and other body fluids e.g. sexual transmission, perinatal spread or close prolonged family contact |
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What percentage of patients who contract Hep B go on to become chronic carriers of the virus? |
5% |
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What blood test investigations would you do in a person with suspected Hep B? |
Hepatitis B surface antigen (HBsAg) – acute or persistant infection, may disappear or persist, must have for 6 months in Hep B chronic HBeAg - highly infectious Hepatitis B surface antibody (HBsAb) – past infection and immunity Hepatitis B virus DNA (HBV DNA) – circulating and replicating virus Anti-HBc IGM - recent infection Anti-HBc IgG - past infection LFTs – blood tests that givean indication of the level of liver inflammationor damage. Includes the ‘ALT’ (or alanineaminotransferase) test that is used to decideon the timing of treatment |
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What other investigations (other than bloods) would you consider in a person WITH Hepatitis B? |
• Liver ultrasound scan – performed every six months is used as a screening test to see if any new lumps or nodules have developed in the liver • Alpha-fetoprotein – a blood test that can sometimes detect liver cancer. It is often performed every six months along with ultrasound • Liver biopsy – the removal of a tiny piece of liver under local anaesthetic using a special needle passed through the skin. This is used on occasion to assess damage in the liver • Fibroscan® – this is a non-invasive scan used to assess how much scar tissue or fibrosis has developed in the liver |
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How often should you monitor LFTs, HBeAg and HBV DNA in a person with Hep B? |
Every 6-12 months |
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What do the following tests indicate? 1. Negative HBeAg and HBV DNA (with anti-HBe) 2. Positive HbeAg and HBV DNA |
1. Full recovery 2. Replicating and infective |
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What are the indications for referral of a patient with Hep B? |
Replicating and infective patient ALT elevated |
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What treatment options are there for Hep B? |
None initially - educate and reassure as per Hep A Advise about prevention of transmission e.g. safe sex and no sharing of needles Pegylated interferon alpha and lamivudine for patients with chronic Hep B and abnormal LFTs Also Adefovir and entecavir - new drugs, expensive |
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Who should be offered Hep B vaccination? |
Babies and young children Household contacts and sexual partners of people with acute and chronic hepatitis B Immunocompramised e.g. Dialysis, chemo, HIV ATSI Migrants from countries where hepatitis B is endemic IVDU Sex industry workers MSM Recipients of certain blood products Individuals with chronic liver disease and/or hepatitis C Inmates and staff from long-term correctional facilities Healthcare workers, dentists and all people directly involved in patient care and/or the handling of human tissue, blood or body fluids |
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At what time intervals should the Hep B vaccine be given in: 1. Children? 2. Adults? |
Children born after the 1st of May 2000 receive hepatitis B vaccine shortly after birth while they are in hospital and further doses at 2, 4 and 6 months of age. Children in Year 7 or adolescents aged between 11 and 15 years receive a two-dose course of adult hepatitis B vaccine given 4 to 6 months apart. In order to obtain maximum protection against hepatitis B, adults should receive three doses of the vaccine at zero, 1 and 6 months intervals. |
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When should you do a blood test to check immunity from Hep B vaccine? |
4 weeks after the 3rd dose in adults |
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What percentage of people with acute hepatitis C will become chronically infected? Then how many progress to cirrhosis? |
60-80% - chronic 10-25% - cirrhosis |
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What is the most reliable way to assess the severity of hepatitis C? |
Liver biopsy |
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What blood tests might you consider to diagnose a patient with Hep C virus? |
HCV Ab (anti-HCV): +ve = exposure (current or past), takes 6 weeks to 6 months to become positive HCV-RNA: +ve = chronic viraemia -ve = spontaneous clearance Positive within 2 weeks of infection CD4/HCV = viral load LFTs: raised ALT indicated disease activity, if persistently normal = good prognosis ALT ++ requires referral for rx HCV genotype: determines rx |
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Other than viral load, LFTs and HCV genotype, what other investigations are generally required before treatment? |
INR FBC/ EUCs Fibroscan *Consider tests for HIV and Hep B |
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What are the new treatment options for hepatitis C? |
Daklinza® (daclatasvir) Harvoni® (sofosbuvir + ledipasvir) Ibavyr® (ribavirin) Sovaldi® (sofosbuvir) Viekira Pak® (paritaprevir + ritonavir + ombitasvir + dasabuvir) Viekira Pak RBV® (paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin) |
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What are the advantages of the new Hep C treatments? |
More effective, resulting in a cure for 90-95% of people Taken as tablets only, and have very few side-effects Taken for as little as 8-12 weeks in most cases Provide interferon-free treatment options for all common genotypes in Australia |
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What are the restrictions for prescribing the new Hep C treatments? |
Must be done in conjunction with a gastroenterologist Must be over 18 and have medicare * Can be accessed by IVDU and people in prisons |
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What follow up should be offered to patients who have been cured of Hep C? |
Early-stage fibrosis with sustained viral response: -Do not require long-termfollow-up - Advise hepatitis Cserology tests will remain positive, but that it isnot protective and repeat exposure may leadto re-infection. Cirrhosis: -Need to remain in longtermfollow-up to monitor for complications includingportal hypertension and hepatocellular carcinoma. - Best coordinated by a gastroenterologist. - Patients with comorbid liver disease, such asnon-alcoholic steatohepatitis, will also requirespecific management. |
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Who gets hepatitis D? |
Patients with hepatitis B Spread parentally If chronic associated with progressive disease with a poor prognosis |
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How is hepatitis E spread? |
Enterically (behaves like Hep A) * High case fatality rate (up to 20%) in pregnant females |
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Jaundice (greenish tinge) Dark urine and pale stools Puritis - worse on plams and soles Abdo pain that varies from none to severe = |
Cholestatic jaundice |
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What are the two main groups of cholestatic jaundice? |
1. Intrahepatic cholestasis - at the hepatocyte of intrahepatic biliary tree level 2. Extrahepatic cholestasis - obstruction in the large bile ducts by stones or bile sludge |
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What are the 4 significant causes of intrahepatic cholestasis in adults? |
Alcoholic hepatitis/ cirrhosis Drugs Primary biliary cirrhosis Viral hepatitis |
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What are the 8 significant causes of extrahepatic cholestasis in adults? |
Cancer of bile ducts Cancer of pancreas Other cancer: primary or secondary spread Cholangitis Primary sclerosing cholangitis (? autoimmune) Common bile duct gallstones Pancreatitis Post-surgical biliary stricture or oedema |
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What are the investigations of choice for cholestatic jaundice? |
USS and ERCP |
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Jaundice + constitutional symptoms (malaise, anorexia, weight loss) + epigastric pain (radiating to back) = |
Pancreatic cancer |
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What are the clinical features of a patient that presents with pancreatic cancer? |
M>F Mainly > 60 years of age Obstructive jaundice Pain (>75%) - epigastric and back Enlarged gall bladder (50-75%) |
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How do you diagnose pancreatic cancer? |
USS or CT may show mass ERCP |
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What is the prognosis for pancreatic cancer? |
Poor 5 year survival is 5% |
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What symptoms might a patient with cirrhosis present with? |
Anorexia, nausea +/- vomiting Swelling of legs Abdominal distension Bleeding tendency |
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What signs might you find in a patient with cirrhosis? |
Spider naevi Palmar erythema of hands Peripheral oedema and ascites Jaundice (obstructive or hepatocellular) Enlarged tender liver (small liver in long-term cirrhosis) Ascites Gynaecomastia +/- Splenomegaly (portal hypertension) |
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What complications can occur with cirrhosis? |
Ascites Portal hypertension and GIT haemorrhage Portosystemic encephalopahy Hepatoma Kidney failure |
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Young female (10-40 years) Insidious and progressive fatigue, anorexia and jaundice Abnormal LFTs Dx? |
Autoimmune chronic active hepatitis (ACAH) |
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What investigations confirm the diagnosis of ACAH? |
Abnormal LFTs Positive smooth muscle antibodies Variety of other autoantibodies Typical pattern on liver biopsy |
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What is the treatment for ACAH? |
Prednisolone PO, monitored according to serum alanine aminotransferase levels Supplemented with azathioprine *80% respond while 20% develop chronic liver disease If not rx'd most die within 3-5 years |
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What is primary sclerosing cholangitis? |
Uncommon inflammatory disorder of biliary tract Presents with progressive jaundice and features of cholestasis e.g. puritis Associated with ulcerative colitis Dx based on characteristic cholangiographic findings No specific Rx |
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What are the 4 most common causes of fatty liver disease? |
• Obesity (about 20% of people considered obese have fattyliver disease) • High blood cholesterol and triglycerides • Type 2 diabetes mellitus • Heavy alcohol use |
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What are some less common causes of fatty liver disease? |
• Underactive thyroid • Certain drugs • PCOS • Complications late in pregnancy |
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What is NASH (non-alcoholic steatohepatitis? |
NASH is a chronic disease in which accumulated fat in liver cellscauses liver inflammation * More likely if you also have another liverdisease, such as hepatitis C or B, or excess alcohol consumption NASH typically occurs in people who are overweightand diabetic, with high blood cholesterol andtriglyceride levels |
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How is fatty liver diagnosed? |
Asymptomatic Usually mildly deranged LFTs or nothing USS of liver Liver biopsy - rarely necessarg |
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What treatment options are there for fatty liver? |
Improve diet and exercise Modify risk factors e.g. diabetes and cholesterol Avoid etoh Avoid hepatotoxic drugs |
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What is a good screening test for etoh abuse? |
A raised GGT + a raised MCV |
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What can be done for the prevention of hepatocellular carcinoma? |
1. Immunise all people with Hep B vaccination esp. at risk populations e.g. ATSI 2. Screening - For Hep B and C in all people - For hepatocellular carcinoma with AFP and USS in patients with chronic liver disease 3. Advise behavioural modification in at risk people e.g. overweight/obese, etoh abuse, IVDU 4. Chemoprophylaxis - treat Hep B and C where appropriate |
