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Common Jaundice exam questions for medical finals, OSCEs and MRCP PACES

 

Question 1.

How are the causes of jaundice classified?

  • Pre-hepatic, hepatic and post-hepatic

 

Question 2.

What are the pre-hepatic causes of jaundice?

  •  Congenital cell issues
    • Cell shape
      • Sickle cell disease
      • Hereditary spherocytosis
      • Hereditary elliptocytosis
    • Enzyme
      • G6PD deficiency
      • Pyruvate kinase deficiency
    • Haemoglobin
      • Thalassemia
  • Drugs
    • Penicillins
    • Sulphasalazine
  • Infections
    • Malaria
  • Autoimmune
    • Warm/cold
  • Mechanical
    • Metallic valve prostheses
    • DIC
  • Transfusion reactions
  • Paroxysmal nocturnal haemoglobinuria

What are the hepatic causes of jaundice?

  • Conjugated causes include:
    • Cirrhosis (see chronic liver disease for further causes)
    • Malignancy
    • Viral hepatitis
    • Drugs
      • Hepatitis: isoniazid, rifampicin, atenolol, enalapril, verapamil, nifedipine, amiodarone, ketoconazole, cytotoxics, halothane
      • Cholestasis: Ciclosporin, azathioprine, chlorpromazine, cimetidine, erythromycin, nitro, ibuprofen, hypoglycaemics
    • Enzymes
      • Dubin-Johnson syndrome
        • Autosomal recessive (cMOAT gene) with excretion of conjugated bilirubin.
          • Leads to pigmented liver.
        • Increase in conjugated bilirubin with no other enzyme changes
        • High coproporphyrin
      • Rotor syndrome
        • Similar to DJS
        • Liver not pigmented
        • Normal coproporphyrin
  • Unconjugated causes (sometimes classified as pre-hepatic causes)
    • Gilbert’s syndrome
      • Congenital hypo-activity of conjugation enzyme UGT-1. Benign and common (5%)
      • Normal LFTs except mildly elevated bilirubin, especially in times of physiological stress/illness
      • Normal life expectancy
    • Crigler-Najar syndrome
      • Autosomal recessive (I) or dominant (II). Severe unconjugated hyperbilirubinaemia.
      • Congenital absence (I) or decrease (II) of glucoronyl transferase.
      • Normal liver histology.
      • Treatment is liver transplant (only type II survive to adulthood)

What are the post-hepatic causes of jaundice?

  • Biliary tree obstruction
    • Gallstones
    • Compression  e.g. pancreatitis, pancreatic tumour, lymph nodes Biliary atresia
    • Cholangiocarcinoma
    • Post-operative stricture
  • Primary biliary cirrhosis (see PBC section)
    • M:F = 1:9
    • ANA and Anti- mitchondrial antibodies
      • And anti-centromere for prognosis (though more association with CREST)
  • Primary sclerosing cholangitis (see PSC section)
    • 80% of PSC have UC
    • ANCA, anti-smooth muscle antibodies
    • Association with cholangiocarcinoma

 

Question 3.

What tests are in a routine liver screen?

  • Assuming FBC, U&E, liver function (ALP, ALT, AST, GGT) and clotting has already been done
    • Autoimmune screen (ENA, ANA, ANCA)
    • Viral screen (Hep A,B,C)
    • Alfafetoprotein (AFP)
    • Serum caeruloplasmin
    • Ferritin
    • Consider

What three blood tests examine synthetic liver function?

  • Clotting (PT)
    • Examining vitamin-K dependent clotting factors
  • Platelets
  • Albumin
  • The rest of the LFTs reflect liver processing ability. The synthetic function tests are the most important in assessing how well the liver is working. Note, for example, that ALT and AST can be normal or low in advanced liver failure.