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30yo male with tea-coloured urine since the evening before & he has…
30yo male with tea-coloured urine since the evening before & he has not been feeling well for the past 5-6 days. GP also noted that he was jaundiced.
Intra-Hepatic
α-1-antitrypsin Deficiency
Hx:
FHx of liver disease, abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine, emphysema
PE:
necrotising panniculitis, generalised wasting, gynaecomastia, ascites, altered sensorium, cachectic, ill-appearing
1° Biliary cirrhosis
Hx:
female, pruritus, fatigue, abdominal pain, generalised malaise, weight loss, anorexia, pale stool, dark urine, keratoconjunctivitis, xerostomia
PE:
xanthelasma, hepatosplenomegaly, RUQ pain, fatty subcutaneous deposits
Inherited Defects:
Dubin-Johnson:
Canalicular organic anion transport
No Pruritus, Usu asymptomatic, mild icterus.
Rotor syndrome:
Sinusoidal reuptake of conjugated bilirubin
Hepatitis
Infection
Hx:
N/V, Dark urine, White stool, Abdo pain (RUQ).
Fatigue, Low-grade fever, chills, Pruritus, Joint pain.
A, E: Oral-fecal
B, C, D: High risk sexual hx, IV drug use, Travel/Contact hx.
PE:
Hepatomegaly, Splenomegaly
Alcohol
Hx:
alcohol abuse. abdominal pain, pruritus, generalised malaise, weight loss, cachexia, pale stool, dark urine, melaena, haematemesis
PE:
parotid gland enlargement, Dupuytren's contracture, gynaecomastia, ecchymosis/petechiae, spider angioma, thenar eminence loss, palmar erythema, caput medusa, ascites, hepatosplenomegaly/small liver, pleural effusion, right heart failure, positive rectal examination (blood)
Autoimmune
Hx:
abdominal pain, arthralgias, pruritus, N/V, pale stool, dark urine; may have associated haemolytic anaemia, thyroiditis, ulcerative colitis, diabetes, Sjogren's syndrome
PE:
advanced disease: ascites, hepatomegaly, cirrhosis, spider angioma, mental confusion
Infiltrative diseases
(Amyloidosis, Lymphoma, Sarcoidosis, Tuberculosis)
Conjugated
Urine: Tea-colored
Stool: Normal
Pruritus: +
AST/ALT, PT: ↑↑
ALP/GGT: ↑
Non-alcoholic steatohepatitis
Hx:
Usu. asymptomatic, obesity, diabetes, hypertension, high triglyceride level, low HDL cholesterol, fatigue, malaise, dull ache in RUQ, pruritus
PE:
advanced disease: hepatosplenomegaly, ascites, spider angioma, oesophageal or intestinal varices
Drugs
Hx:
Paracetamol, HIV ART, NSAIDs, Antibiotics, Ca2+ channel blockers, ACE inhibitors, OCPs, Ascorbic acid etc.
RUQ pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine
PE:
Tender hepatosplenomegaly
Post-hepatic
Extrahepatic Cholestasis
(Biliary Obstruction)
Pancreatitis
Alcohol, Smoking, Systemic (SLE, CF, ↑PTH, ↑TG)
Hx:
Abdo pain (Severe, RUQ/Epigastric, Radiates to back, Relieved by sitting upright/leaning forward, Worse after eating), N/V. Loose, greasy, foul smelling stool.
PE:
Abdomen tender upon palpation. Abdo distention, Hypoactive bowel sounds ,
Pancreatic carcinoma
Hx:
Usu. asymptomatic until late disease, depression, weight loss, early satiety, new-onset diabetes, abdominal pain, pruritus, generalised malaise, fatigue, anorexia, pale stool, dark urine
PE:
+Courvoisier's sign, palpable gallbladder, ill-appearing, cachectic
1° Sclerosing Cholangitis
Hx:
Usu. asymptomatic, hx of ulcerative colitis or Crohn's disease; chills, night sweats, abdominal pain, pruritus, generalised malaise, weight loss, fatigue, anorexia, pale stool, dark urine
PE:
Abdo pain (RUQ), Jaundice, Hepatomegaly,
Splenomegaly Skin excoriations may be present.
Malignancy
(Cholangiocarcinoma)
Hx:
Jaundice, Pruritus, Clay-colored stools, Dark urine, Abdo pain (Dull, RUQ, 30-50%), Weight loss (30-50%). Malaise, Fatigue, Night sweats may be present.
PE:
Cachectic, Jaundice, Hepatomegaly (25-40%), RUQ mass (10%)
Choledocholithiasis
(Gallstones in bile duct)
Hx:
RUQ pain, aggravated by meals, fever
PE:
RUQ abdominal tenderness, fever
Budd-Chiari
Syndrome
Hx:
Abdo pain, ascites, hepatomegaly from hepatic vein occlusion, due to thrombosis (often with predisposing factors) or pregnancy. May be chronic.
PE:
Fever, abdominal pain, abdominal distension (from ascites), lower extremity edema, jaundice, gastrointestinal bleeding (from varices or portal hypertensive gastropathy), and/or hepatic encephalopathy
Cholangitis
Hx:
Chills, pain, pale stools, dark urine, pruritus, generalised malaise, weight loss, fatigue, anorexia
PE:
Charcot's triad (Fever, RUQ tenderness, jaundice)
Conjugated
Urine: Dark
Stool: Pale
Pruritus: ++
AST/ALT, PT: ↑
ALP/GGT: ↑↑
Pre-hepatic
↑Bilirubin Production
Inherited RBC hemolysis
G6PD deficiency, Spherocytosis, Thalassemia, Sickle cell anemia, Wilson's disease
Acquired RBC hemolysis
Autoimmune (infective, neoplastic), Microangiopathic hemolytic anemia, Mechanical hemolysis, Malaria
↓Hepatic uptake
& processing
Drugs
CHF, Portosystemic shunts, Gilbert’s syndrome, Crigler-Najjar syndrome
Unconjugated
Urine: Normal / Dark (Intravascular hemolysis)
Stool: Normal / Dark
Pruritus: ≠
AST/ALT, ALP/GGT, PT: Normal