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Medicine

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Liver & GIT

Question
10 out of 18
 

A young pt presents with jaundice. Total bilirubin is 21, direct is 18.6, alkaline phosphatase 284 KA units. Diagnosis is:



A Hemolytic jaundice

B Viral hepatitis

C Chronic active hepatitis

D Obstructive jaundice

Ans. D Obstructive jaundice

Approach to a case of jaundice

1. Isolated elevation of bilirubin (Normal AST, ALT, ALP)

a. Direct / Conjugated hyperbilirubinemia (Direct >15%)

Inherited disorders: i. Dublin Johnson ii. Rotors

b. Indirect / Unconjugated hyperbilirubinemia (Direct <15%)

i. Hemolytic disorders ii. Ineffective erythropoiesis

iii. Drugs: Rifampicin, Probenecid

iv. Inherited disorders v. Gilbert’s syndrome vi. Crigler Najjar syndrome

2. Bilirubin elevated along with derangement in other liver tests. i.e. ALT/AST & Alkaline phosphatase

a. ALT/AST Elevated out of proportion to alkaline phosphatase

Hepatocellular cause

i. Viral hepatitis ii. Toxic hepatitis iii. Wilson’s disease iv. Cirrhosis

b. Alkaline phosphatase elevated out of proportion of AST/ALT

Obstructive cause

i. Extrahepatic cholestasis ii. Intrahepatic cholestasis

Condition

Serum Bilirubin

Urine

Urobilinogen

Urine Bilirubin

SGOT / SGPT

ALP

Hemolytic anemia

Indirect

Increased

Absent

Normal

Normal

Hepatitis

Direct and indirect

Increased

Present

Increase +++

Increase +

Obstructive

jaundice

Direct

Absent

Present

Increase +

Increase +++

Extra Edge: Clinical features in cholestatic jaundice

Early features

Jaundice, Dark urine, Pale stools, Pruritus

Late features

1. Xanthelasma and xanthomas (Hyperpigmentation in chronic cholestatic Jaundice (Harrison, 18th edition, page 1920)

2. Malabsorption

a. Weight loss b. Steatorrhea c. Osteomalacia d. Bleeding tendency

Clinical feature of Cholangitis: Fever, Rigors, Pain

Extra Edge: Clinical Features suggesting an underlying cause of cholestatic jaundice.

1. Jaundice: Carcinoma (Static or increasing jaundice), Stone (Fluctuating jaundice), Stricture, Pancreatitis, Choledochal cyst

2. Abdominal pain: Stone, Pancreatitis, Choledochal cyst

3. Cholangitis: Stone, Stricture, Choledochal cyst

4. Irregular hepatomegaly: Hepatic carcinoma

5. Palpable gallbladder: Carcinoma below cystic duct (usually pancreas)

6. Abdominal mass: Carcinoma, Pancreatitis (Cyst), Choledochal cyst

7. Occult blood in stools: Papillary tumour

Extra Edge:

1. Biliary atresia 2. Neonatal hepatitis 3. Gall stone, 4. Ca head of pancreas cause conjugated or direct hyperbilirubinemia.

Lab Investigation in a case of liver disease

1. Blood ammonia

Ammonia is produced in the body during normal protein metabolism and by intestinal bacteria in the colon.

The liver detoxify ammonia by converting it to urea Q which is excreted by the kidney.

Serum ammonium levels are raised in liver disease in patients with mental status changes Q.

2. Serum enzymes:

Enzymes that reflects damage to hepatocytes:

a. Aminotransferase are sensitive indicators of liver cell injury Q. They are aspartate amino transferase (AST) and Alanine amino transferase (ALT).

b. AST is found in liver > cardiac ms > skeletal muscle > kidney > brain > pancreas > lung > leucocyte > RBC.

c. ALT is found predominantly in liver. Q

d. Causes of raised hepatic enzyme SGOT – SGPT

i. Viral hepatitis Q.

ii. Ischemic liver injury. Q

iii. Toxin Amanita phalloides or PCM drug induced Q liver damage.

iv. Auto immune hepatitis

e. The AST:ALT ratio of >2:1 is suggestive of alcoholic liver disease. Q

f. The Amino transferases are usually not greatly elevated in obstructive jaundice

g. Lactic dehydrogenase (LDH) – LDH-5 isomer is elevated in liver disease.

Liver & GIT Flashcard List

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