Tiêu đề Jaundice ✅

JAUNDICE: Defined as yellow pigmentation of the skin and eyes and mucous membrane as a result of excess bilirubin in the circulation, clinically detectable when levels are >40mmol/L (normal:<22mmol/L) HX → state where site of jaundice, don’t say jaundice only Direct/conjugated hyperbilirubinemia: >20% of total bilirubin Hyperbilirubinemia: bilirubin concentration in blood exceeds 1 mg/dL. When the concentration reaches 3 mg/dL, bilirubin diffuses into tissues. Conjugated bilirubin deconjugated to urobilinogen by bacterial proteases → urobilinogen 90% to feces + 10 % to portal vein Obstructive jaundice Intraluminal causes Mural causes Extrinsic causes -Choledocholithiasis -Infections : Clonorchis sinensis, ascariasis, schistosomiasis -Sclerosing cholangitis -cholangiocarcinoma -Strictures (traumatic/post surgical) -Head of pancreas ca -Periampullary ca -Mirizzi syndome Iman, Nisa, Izzaty, Lissa 3/2/2021 Forti
Iman, Nisa, Izzaty, Lissa 3/2/2021 Forti

jaundice (if Choledocholithiasis / Mirizzi syndrome) T: for several hours E: ingestion of fatty food S -History of Biliary Colic previously -Repeated episodes→ chronic cholecystitis Risk Factors Age > 50 Female Caucasians Diabetes Obesity Rapid weight loss Terminal ileal disease (eg Crohn's disease), Cholestyramine usage Pregnancy Cystic fibrosis Cal Chole 4F: Female, Fertile, Fat, Fair, and Forty Critical illness Prolong fasting Prolong TPN→ biliary stasis Sepsis Major surgery Severe burn /trauma) Immunosuppression Acal Chole DDX -Choledocholithiasis, -Ascending cholangitis, hepatic causes -Pancreatitis -PUD -renal colic -GERD -inferior MI -lower lobe pneumonia Abdominal PE ● Palpation at RUQ - +ve Murphy sign (temporary apnoea on inspiration upon deep palpation at costal margin) 1.Palpate right subcostal area within the midclavicular line 2. Ask patient to breath in deeply #Deep inspiration causes the gallbladder to descend toward and press against the examining fingers - Focal tenderness - Muscle guarding - Palpable enlarged gallbladder→ empyema (Courvoisier's sign) tro compx Complications of Acute Cholecystitis • Mirizzi syndrome: extra-luminal compression of CBD/CHD due to large stone in cystic duct • empyema of gallbladder: suppurative cholecystitis, pus in gallbladder, and sick patient • emphysematous cholecystitis: bacterial gas present in gallbladder lumen, wall, or pericholecystic space (risk in diabetic patient); organisms involved in secondary infection: E. coli, Klebsiella, Enterococcus • gangrenous gallbladder (20%), perforation (2%): result in abscess formation or peritonitis • cholecystoenteric fistula, from repeated attacks of cholecystitis, can lead to gallstone ileus Ix Lab 1. FBC: leucocytosis (↓Hb = chronic haemolysis→ black pigment stones) 2. LFT: raised ALT, AST & bilirubin (mild) ○ ↑ ALP, GGT→ check for stones with MRCP 3. CRP ↑ 4. Serum amylase: r/o pancreatitis 5. U & E - for pre-op, any AKI Imaging 1. Hepatobiliary US (98% Sensitive) ● Enlarged, thickened gall bladder Mx: Asx→ no action needed Sx ● Triage, ABCDE -Assess pts -resuscitate the patient if needed – IV fluid resuscitation patient’s vitals -Consult surgical review for surgery -Urgent FBC, U&E, LFT, CRP and USS/CT abdomen Conservative (in delayed cholecystectomy) ● IV fluids 2-3L/day Iman, Nisa, Izzaty, Lissa 3/2/2021 Forti