0.2 Diseases and their management

Juandice

jaundice background info

causes yellowing of skin and eyes

colour comes from build up of bilirubin a by-product of old red blood cells

could indicate liver diseases as damaged liver cells can’t proces bilirubin so it goes into the blood causing jaundice

physiology of bilirubin metabolism

• Formation: RBCs break down after ~120 days in the spleen; heme is converted to biliverdin, then reduced to bilirubin.

• Types of Bilirubin:

  • Unconjugated (Indirect): Not water-soluble; travels bound to albumin in the blood to the liver.

  • Conjugated (Direct): Converted in the liver via glucuronic acid addition (making it water-soluble) for biliary excretion.

• Excretion: Secreted into bile and eliminated via feces and urine.

• Levels: Normal total bilirubin is < 1.2 mg/dL; jaundice occurs when levels exceed > 2.5 mg/dL.

3 types of causes of jaundice

pre hapatic

hepatic

post hepatic

pre-hepatic causes

before bilirubin reaches the liver

Haemolytic Anaemia: Conditions where RBCs are destroyed faster than they can be made (e.g., sickle cell disease).
Gilbert’s Syndrome: A genetic condition leading to mild increases in unconjugated bilirubin due to decreased conjugation.

hepatic causes

liver dysfunction

Hepatitis: Inflammation of the liver caused by viral infections (e.g., Hepatitis A, B, C), alcohol, or autoimmune diseases.
Cirrhosis: Scarring of the liver from chronic liver disease, affecting its ability to process bilirubin.
Liver Tumours: Malignancies that impair liver function.

post-hepatic causes

after bilirubin leaves the liver

:Obstructive Jaundice: Blockage in the bile ducts (e.g., gallstones, tumours) preventing bilirubin from being excreted into the intestine.

symptoms of jaundice

• Primary Symptoms: Yellowing of the Skin and Eyes: The most recognizable symptom of jaundice.

• Dark Urine: Indicates excess conjugated bilirubin being excreted in urine.

• Pale or Clay-Coloured Stools: Lack of bilirubin in bile can result in stool color change.

• Associated Symptoms: Fatigue: General feeling of tiredness.

• Abdominal Pain: Particularly in the upper right quadrant where the liver is located.

• Nausea and Vomiting: May occur if liver function is severely compromised.

• Pruritus: Itching due to bile salt accumulation in the bloodstream.

diagnosis of jaundice

• Clinical Evaluation:  A healthcare provider will assess the patient’s medical history and conduct a physical exam, focusing on the liver and abdominal area.
   

• Laboratory Tests:
  Liver Function Tests: ALT (Alanine Aminotransferase) and AST (Aspartate Aminotransferase): Enzymes that indicate liver cell injury.
  Alkaline Phosphatase (ALP): Often elevated in cholestatic disease (bile flow obstruction).
  Bilirubin Levels: Total and fractionated bilirubin levels are measured to determine the type of jaundice.

• Imaging Studies: Ultrasound: The first-line imaging modality used to check for gallstones, liver enlargement, or other abnormalities.

• CT or MRI: Advanced imaging may be warranted if ultrasound findings are inconclusive.

treatment of jaundice

aries depending of the underlying cause

• Haemolytic Anaemia: May require corticosteroids or other medications to manage the immune response.

• Hepatitis: Antiviral medications based on the type of virus (refer to NICE guidelines for specific recommendations).

• Obstructive Jaundice: Surgical procedures (e.g., cholecystectomy for gallstones) or endoscopic interventions to relieve bile duct obstructions.

• Symptomatic Management: Pruritus Relief: Antihistamines (e.g., cetirizine) or cholestyramine can be prescribed to alleviate itching (as outlined in the BNF).

• Supportive Care: Nutritional support and monitoring liver function.

2 tpres of cirrhosis?

Compensated

• reversible

• Liver still functions

• 210-12 year prognosis

decompensated

• irriversiable

• Liver can’t function properly

• 1-2 year prognosis

What is cholangitis?

Inflammation of bile duct

Caused by bacterial infection, obstructed with gallstones/tumour

Symptoms - jaundice, pain,fever, oily stool

Primary biliary cholangitis - autoimmune disorder

Treatment depends on cause

Symptoms Liver Impairment

Early stages - asymptomatic/fatigue, nausea, vomiting, loss of appeptite

Late stages - weight loss, clinical jaundice (susceptibility to infection)