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JAUNDICE AND ASCITES

JAUNDICE AND ASCITES. An Approach to the Patient with Suspected Liver Disease. Objectives:. 1. discuss the pathophysiology of jaundice and ascites 2. do a complete history and physical examination on a patient with liver disease 3. know the significance of liver-laboratory tests

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JAUNDICE AND ASCITES

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  1. JAUNDICE AND ASCITES An Approach to the Patient with Suspected Liver Disease

  2. Objectives: • 1. discuss the pathophysiology of jaundice and ascites • 2. do a complete history and physical examination on a patient with liver disease • 3. know the significance of liver-laboratory tests • 4. evaluate a patient with liver disease

  3. Hyperbilirubinemia • 1. overproduction of bilirubin • 2. impaired uptake, conjugation, or excretion of bilirubin • 3. regurgitation of unconjugated or conjugated bilirubin from damaged hepatocytes or bile ducts • Unconjugated hyperbilirubinemia • Conjugated hyperbilirubinemia

  4. Evaluating a patient with jaundice • 1. determine whether conjugated or unconjugated hyperbilirubinemia • 2. determine presence of other abnormal laboratory tests

  5. In a patient with jaundice, a careful history, physical examination, and review of standard laboratory tests should permit a physician to make an accurate diagnosis in 85% of cases. Franz Ingelfinger, MD 1958

  6. Causes of Jaundice • 1. viral hepatitis • 2. alcohol-induced liver disease • 3. chronic active liver disease • 4. drug-induced liver disease • 5. gallstones and their complications • 6. carcinoma of the pancreas • 7. primary biliary cirrhosis • 8. sclerosing cholangitis

  7. Clinical History • Related to viral hepatitis • Blood transfusions • IV drug use • Sexual practices • Contact with jaundiced persons • Needle stick exposure • Work in renal dialysis unit • Body piercing/tattoos • Travel to endemic areas

  8. Clinical History • Medication related • Review all prescription medications • Over-the-counter drugs • Use of vitamins, especially vit A • Herbal preparations • Food supplements • Home remedies purchased in health food store

  9. Clinical History • Alcohol use • Detailed quantitative history of both recent and previous alcohol from patient and family members • History of withdrawal symptoms • CAGE criteria • Evidence of alcohol associated illnesses (pancreatitis, perpheral neuropathy)

  10. Quantification of alcohol intake • 1 oz whiskey contains 10-11 g alcohol • 1 12-oz beer contains 10-11 g alcohol • 4 oz red wine contains 10-11g alcohol • Ingestion of >3 units/day everyday or 21 units/week every week is excessive. • Threshold for alcohol-induced hepatic injury appears to be 30 gm for women and 60 gm for men if ingested >10 yrs

  11. CAGE criteria • 1. has the patient tried to cut back on alcohol use? • 2. does the patient become angry when asked about his alcohol intake? • 3.does the patient feel guilty about his alcohol use? • 4. does the patient need an eye opener in the morning?

  12. Clinical History • Miscellaneous • Pruritus • Evolution of jaundice • Recent changes in menstrual cycle • History of anemia • Symptoms of biliary tract disease • Family history of liver disease, gallbladder disease • Occupational history

  13. Physical Examination • General inspection • Scleral icterus • Pallor • Wasting • Needle tracks • Skin excoriations • Ecchymosis/petechiae • Muscle tenderness and weakness • Lymphadenopathy • Evidence of congestive heart failure

  14. Physical Examination • Peripheral stigmata of liver disease • Spider angiomata • Palmar erythema • Gynecomastia • Dupuytren’s contracture • Parotid enlargement • Testicular atrophy • Paucity of axillary and pubic hair

  15. Physical Examination • Abdominal examination • Hepatomegaly • Splenomegaly • Ascites • Prominent abdominal collateral veins • Bruits and rubs • Abdominal masses • Palpable gallbadder

  16. Liver • Liver span is about 10-12 cm in men, and 8-11 cm in women • Normal liver is non-tender, sharp-edged, smooth and not hard, left lobe not palpable • Modest hepatomegaly in viral hepatitis, chronic hepatitis, cirrhosis • Marked enlargement in tumors, fatty liver, severe congestive heart failure • Pulsatile liver in tricuspid regurgitation

  17. Spleen • Normally not palpable • Enlarged in portal hypertension because of cirrhosis • Splenomegaly also seen in infections, leukemias, lymphomas, infiltrative disorders, hemolytic disorders, etc

  18. Gallbladder • Not normally palpable • Palpable in 25% of cancer of the head of the pancreas (Courvoisier’s law) • Palpable in about 30% of cholecystitis, usually because of stone impacted in neck of gallbladder • Palpable in the RUQ at the angle formed by the lateral border of the rectus abdominis muscle and the right costal margin

  19. Ascites • Assessed on physical examination by: • Shifting dullness • Fluid wave • Puddle sign • Bulging flanks

  20. Both shifting dullness and fluid wave test will not uniformly detect fluid less than 1000 ml • Both tests have a sensitivity of about 60% when compared with ultrasound • Confirmation of presence of ascites by imaging procedures • Tests can be spuriously positive in obese patients

  21. Causes of ascites: • 1. cirrhosis • 2. congestive heart failure • 3. nephrosis • 4. disseminated carcinomatosis

  22. Laboratory findings • Because many of the clinical features of liver injury are non-specific, the history and physical examination are routinely supplemented by “liver function” tests, which are so widely available that they have become a standard and esssential component of the evaluation.

  23. Biochemical Liver Tests • Hepatocellular Necrosis Aminotransferases Lactic Dehydrogenase • Cholestasis Alkaline Phosphatase Gamma Glutamyl Transpeptidase Bilirubin • Hepatic Synthetic Activity Prothrombin time Albumin

  24. Aminotransferases • Increased levels results from leakage from damaged tissues, released from damaged hepatocytes following injury or death • AST not exclusive for liver, also found in heart, muscle, kidney, brain, pancreas and erythrocytes. • Confirm liver injury by doing ALT which is almost exclusive to liver

  25. Aminotransferases • Acute elevations to >1000 IU reflect severe hepatic necrosis and usually seen in viral hepatitis, toxin-induced hepatitis and hepatic ischemia. • AST/ALT >2 with AST level of <300IU is suggestive of alcohol-induced liver disease. Higher AST levels in viral hepatitis, ischemia and other liver injuries.

  26. Aminotransferases AST and ALT levels • Poorly correlates with the extent of hepatocyte injury • Not predictive of outcome • Azotemia can lower AST level • Persistent elevation of AST from macroenzyme complex with albumin

  27. Etiology of mild ALT/AST elevations • ALT predominant • Chronic hepatitis B & C • Acute hepatitis A & E • Steatosis / steatohepatitis • Medications / toxins • autoimmune hepatitis • AST predominant • Alcohol-related liver disease • Steatosis / steatohepatitis • cirrhosis

  28. Etiology of mild ALT/AST elevations • Nonhepatic • Hemolysis • Myopathy • Thyroid disease • Strenuous exercise

  29. Time Course of ALT Ischemia/Toxin 5000 Viral/Drug ALT (U/L) 1000 0 Weeks 1 2 3 4

  30. Lactic Dehydrogenase (LDH) • Wide tissue distribution • Massive but transient elevation in ischemic hepatitis • Sustained elevation with elevated alkaline phosphatase in malignant infiltration of the liver

  31. Alkaline Phosphatase • Major sources: bone and liver • Others: intestine, placenta, adrenal cortex, kidney and lung • Increased levels because of increased synthesis and release from damaged cells • Marked increase in infiltrative hepatic disorders or biliary obstruction

  32. Alkaline Phosphatase • Marked increases seen in ductular injury – intrahepatic cholestasis, infiltrative process, extrahepatic biliary obstruction, biliary cirrhosis, malignancy and organ rejection • Lesser increase in viral hepatitis, cirrhosis and congestive hepatopathy

  33. Gamma Glutamyl Transpeptidase (GGTP) • Wide distribution • Not found in bone • Main use: determine if elevation in AP is liver rather than bone in origin • Induced by alcohol and drugs • GGTP/AP ratio > 2 suggests alcohol abuse • Isolated elevations are non-specific, most cases not associated with clinically significant liver disease

  34. 5 ‘ Nucleotidase • Wide distribution • Significant elevations in liver disease • Sensitivity comparable to AP detecting obstruction, infiltration, cholestasis

  35. Measurement of serum bilirubin(van den Bergh reaction) • Direct fraction = conjugated bilirubin = B1 - fraction that reacts with diazotized sulfanilic acid in the absence of an accelerator • Total bilirubin - amount that reacts with diazotized sulfanilic acid in the presence of an accelerator • Indirect fraction = unconjugated bilirubin = B2 - the difference between total and direct fraction

  36. Normal serum bilirubin • Total bilirubin 3.4-15.4 uml 0.2-1 mg/dL • Direct bilirubin 5.1 uml 0.3 mg/dL

  37. Bilirubin • Serum bilirubin level normally almost unconjugated • Bilirubin in urine is conjugated thus indicative of hepatobiliary disease • In chronic hemolysis with normal liver, levels usually not more than 5 mg/dl • Magnitude of elevation useful prognostically in alcoholic hepatitis and acute liver failure

  38. Urine bilirubin • Bilirubin found in the urine is conjugated bilirubin • Unconjugated bilirubin is bound to albumin in the serum; it is not filtered by the kidney; and is not found in the urine

  39. Prothrombin Time • Most important predictor of outcome in acute liver failure • Useful in monitoring hepatic synthetic function • Useful indicator of liver failure in both acute and chronic hepatic injury provided that cholestasis with malabsorption of Vit K has been excluded

  40. Albumin • Half life of 20 days • Less useful than prothrombin time in monitoring acute liver disease because of long half life • Correlates with prognosis in chronic liver disease- used for grading system

  41. Characteristic Biochemical Patterns:

  42. Characteristic Biochemical Patterns:

  43. Characteristic Biochemical Patterns:

  44. History & PE Laboratory tests Isolated elevation Of bilirubin Bilirubin & other Liver tests elevated

  45. Isolated elevation of bilirubin Direct hyperbilirubinemia (Direct > 15%) Indirect hyperbilirubinemia (Direct < 15%) Drugs: Rifampicin Probenecid Inherited disorders: Dubin-Johnson syndrome Rotor’s syndrome Inherited disorders: Gilbert’s syndrome Hemolytic disorders Ineffective erythropoieisis

  46. Bilirubin & other liver tests elevated Hepatocellular pattern: ALT/AST elevated out of proportion to alkaline phosphatase Cholestatic pattern: Alkaline phosphatase out of proportion ALT/AST

  47. Hepatocellular pattern • Viral serologies • Hepatitis A IgM • Hepatitis B surface • antigen & core antibody • Hepatitis C RNA • 2. Toxicology screen • Acetaminophen level • 3. Ceruloplasmin (if patient less • than 40 yrs of age) • 4. ANA, SMA, LKM, SPEP Results (-) Results (-) Additional virologic testing: CMV DNA, EBV capsid antigen Hepa D antibody (if indicated) Hepa E IgM (if indicated) Liver biopsy

  48. Cholestatic pattern Ultrasound Results (-) AMA (+) Dilated ducts Extrahepatic cholestasis Ducts not dilated Intrahepatic cholestasis Serologic testing: AMA Hepatitis serologies Hepatitis A, CMV, EBV Review drugs CT/ERCP ERCP/ Liver biopsy Liver biopsy

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