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2463805164455Causes of Raised Bilirubin00Causes of Raised Bilirubin15170155165090Jaundice seen when bilirubin >40; normal proportion of bilirubin unconjugated = 70%; normal proportion conjugated bilirubin = 30% Unconjugated hyperbiliruibinaemia (indirect = prehepatic / hepatic = urobilinogen and bilirubin in urine)Prehepatic: Aetiology: Haemolysis (<2% jaundice) - neonatal, transfusion reaction Gilbert’s syndrome (glucuronyl transferase deficiency; 5% incidence; bilirubin rarely >85) Crigler-Najjar syndrome (glucuronyl transferase deficiency) Symptoms: Maybe back/joint pain, splenomegaly Investigations: Normal LFT’s, >70% indirect, Normal USSHepatic: Aetiology: Hepatitis, hepatic abscess, sarcoid, amyloid, cirrhosis, drugs (ETOH, paracetamol, mushrooms, erythromycin, flucloxacillin, phenothiazides), cancer, R heart failure, sepsis Symptoms: Malaise, fever, anorexia; Mild tender hepatomegaly Investigations: ALT >5x normal; ALP 2-3x normal; high INR; <50% indirect bilirubin; normal USS Conjugated hyperbilirubinaemia (direct = posthepatic / hepatic) Hepatic: Aetiology: Dubin-Johnson syndrome (impaired hepatocellular excretion of bilirubin) Rotor’s syndrome (impaired hepatocellular excretion of bilirubin) Symptoms: Jaundice, dark urine, pale stools; Mild tender hepatomegaly Investigations: ALT 2-5x normal; ALP >3x normal; high INR; <50% indirect bilirubin; normal USS Post-hepatic: Aetiology: extra-hepatic obstruction (most common cause of jaundice; stones, stricture, sclerosing cholangitis, cholangiocarcinoma, head of pancreas / ampullary cancer) Symptoms: Jaundice, dark urine, pale stools, pain; Tender hepatomegaly; maybe gallbladder Investigations: ALT 2-3x normal; ALP >3x normal; high INR; <50% indirect bilirubin; dilated CBD on USS 00Jaundice seen when bilirubin >40; normal proportion of bilirubin unconjugated = 70%; normal proportion conjugated bilirubin = 30% Unconjugated hyperbiliruibinaemia (indirect = prehepatic / hepatic = urobilinogen and bilirubin in urine)Prehepatic: Aetiology: Haemolysis (<2% jaundice) - neonatal, transfusion reaction Gilbert’s syndrome (glucuronyl transferase deficiency; 5% incidence; bilirubin rarely >85) Crigler-Najjar syndrome (glucuronyl transferase deficiency) Symptoms: Maybe back/joint pain, splenomegaly Investigations: Normal LFT’s, >70% indirect, Normal USSHepatic: Aetiology: Hepatitis, hepatic abscess, sarcoid, amyloid, cirrhosis, drugs (ETOH, paracetamol, mushrooms, erythromycin, flucloxacillin, phenothiazides), cancer, R heart failure, sepsis Symptoms: Malaise, fever, anorexia; Mild tender hepatomegaly Investigations: ALT >5x normal; ALP 2-3x normal; high INR; <50% indirect bilirubin; normal USS Conjugated hyperbilirubinaemia (direct = posthepatic / hepatic) Hepatic: Aetiology: Dubin-Johnson syndrome (impaired hepatocellular excretion of bilirubin) Rotor’s syndrome (impaired hepatocellular excretion of bilirubin) Symptoms: Jaundice, dark urine, pale stools; Mild tender hepatomegaly Investigations: ALT 2-5x normal; ALP >3x normal; high INR; <50% indirect bilirubin; normal USS Post-hepatic: Aetiology: extra-hepatic obstruction (most common cause of jaundice; stones, stricture, sclerosing cholangitis, cholangiocarcinoma, head of pancreas / ampullary cancer) Symptoms: Jaundice, dark urine, pale stools, pain; Tender hepatomegaly; maybe gallbladder Investigations: ALT 2-3x normal; ALP >3x normal; high INR; <50% indirect bilirubin; dilated CBD on USS 7018655442722000701865537179250015208254314191Massive: myelofibrosis, CML, malariaModerate: leukaemia, lymphoma, thalassaemia, portal HTN, shcistosomiasis, typhoid, brucellosisMild: CMV, EBV, SBE, sarcoid, amyloid, rheumatoid arthritis, SLE, polyarteritis nodosa, haemolytic anaemia, polycythaemia00Massive: myelofibrosis, CML, malariaModerate: leukaemia, lymphoma, thalassaemia, portal HTN, shcistosomiasis, typhoid, brucellosisMild: CMV, EBV, SBE, sarcoid, amyloid, rheumatoid arthritis, SLE, polyarteritis nodosa, haemolytic anaemia, polycythaemia2463804314190Causes of Splenomegaly00Causes of Splenomegaly15170153667760Massive: alcoholic fatty liver, myeloproliferative disease, metastases, hepatoma, RHFModerate: diabetic fatty liver, leukaemia, lymphoma, haemachromatosis, tropical diseasesMild: CMV, EBV, hepatitis, sarcoid, amyloid00Massive: alcoholic fatty liver, myeloproliferative disease, metastases, hepatoma, RHFModerate: diabetic fatty liver, leukaemia, lymphoma, haemachromatosis, tropical diseasesMild: CMV, EBV, hepatitis, sarcoid, amyloid2463803668395Causes of Hepatomegaly00Causes of Hepatomegaly15201903123565Cirrhosis: <8cm span; associated with jaundice, encephalopathy and ascitesFulminant liver failure and chronic liver disease00Cirrhosis: <8cm span; associated with jaundice, encephalopathy and ascitesFulminant liver failure and chronic liver disease2463803123565Causes of Small Liver00Causes of Small Liver2463801937385Causes of Liver Noises00Causes of Liver Noises15208251937385Friction rubs: malignancy, following liver biopsy, infective and inflammatory conditionsVenous hums: portal venous HTN, AV malformation, hepatic haemangioma; due to communication between umbilical / paraumbilical and abdominal wall veins; low pitched, soft, continuous; systolic and diastolic components; louder of inspiration, changes with position, ? with stethoscope pressureArterial bruits: liver tumour, alcoholic hepatitis; high pitched, loud, systolic, may ? with inspiration, unchanged with stethoscope pressure00Friction rubs: malignancy, following liver biopsy, infective and inflammatory conditionsVenous hums: portal venous HTN, AV malformation, hepatic haemangioma; due to communication between umbilical / paraumbilical and abdominal wall veins; low pitched, soft, continuous; systolic and diastolic components; louder of inspiration, changes with position, ? with stethoscope pressureArterial bruits: liver tumour, alcoholic hepatitis; high pitched, loud, systolic, may ? with inspiration, unchanged with stethoscope pressure246380964565Epidemiology00Epidemiology1520190962660At least 50% elderly people with abdominal pain admitted 30-40% have OT, 40% initially misdiagnosed, 10% mortality; in elderly: cholecystitis > small bowel obstruction > perforation > appendicitis > large bowel obstructionNon-specific abdominal pain: if <50yrs, diagnosed in 40%; most common cause of abdominal pain in paediatrics; in elderly, 15%00At least 50% elderly people with abdominal pain admitted 30-40% have OT, 40% initially misdiagnosed, 10% mortality; in elderly: cholecystitis > small bowel obstruction > perforation > appendicitis > large bowel obstructionNon-specific abdominal pain: if <50yrs, diagnosed in 40%; most common cause of abdominal pain in paediatrics; in elderly, 15%246380330200General Gastroenterology / Surgery00General Gastroenterology / Surgery306705467360LFT’s00LFT’s1586865467361Aminotransferases: markers of hepatocellular disease and hepatobiliary dysfunction In 100’s = ongoing inflammatory hepatocellular damage In 1000’s = hepatocyte necrosis ALT: more specific for hepatocellular AST: AST:ALT >2:1 suggests ETOH disease; AST also found in heart, smooth muscle, kidney, brain, rhabdomyolysis; can be caused by drugsALP: associated with biliary obstruction and cholestasis (suggested if >4x normal); isolated ? ALP seen in primary biliary cirrhosis and sclerosing cholangitis; disproportionately high in hepatoma; X2 in pregnancy; also found in bone, intestine, kidney, malignancyGGT: alcohol, phenobarbitone, warfarin; pancreatitis, MI, rheumatoid arthritis, diabetes, COPDLDH: non-specific; haemolysisAmmonia: if ?, suggests failure of hepatic metabolic function; ? levels do not correlate with worsening hepatic function in cirrhosis; suggestive of fulminant hepatic failureAlbumin (wks) / INR (days): indicator of hepatic synthetic function ? life of albumin = 3/52, so not good indicator of acute decline; suggests poor short term prognosis; also low in malnutrition, nephrotic syndrome INR will ? in days in ALF; ? Vitamin K dependent 2,7,9,10; indicates severe disease00Aminotransferases: markers of hepatocellular disease and hepatobiliary dysfunction In 100’s = ongoing inflammatory hepatocellular damage In 1000’s = hepatocyte necrosis ALT: more specific for hepatocellular AST: AST:ALT >2:1 suggests ETOH disease; AST also found in heart, smooth muscle, kidney, brain, rhabdomyolysis; can be caused by drugsALP: associated with biliary obstruction and cholestasis (suggested if >4x normal); isolated ? ALP seen in primary biliary cirrhosis and sclerosing cholangitis; disproportionately high in hepatoma; X2 in pregnancy; also found in bone, intestine, kidney, malignancyGGT: alcohol, phenobarbitone, warfarin; pancreatitis, MI, rheumatoid arthritis, diabetes, COPDLDH: non-specific; haemolysisAmmonia: if ?, suggests failure of hepatic metabolic function; ? levels do not correlate with worsening hepatic function in cirrhosis; suggestive of fulminant hepatic failureAlbumin (wks) / INR (days): indicator of hepatic synthetic function ? life of albumin = 3/52, so not good indicator of acute decline; suggests poor short term prognosis; also low in malnutrition, nephrotic syndrome INR will ? in days in ALF; ? Vitamin K dependent 2,7,9,10; indicates severe disease ................
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