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Welcome to another MedGuide clinical presenation quiz.  This time its jaundice.   One of those medical terms, for once, not derived from Latin or Greek – but French!  Bonne chance! 

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Approach to the Patient with Jaundice

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Question 1

Stem 1 of 5

A 59YOM presents with his concerned partner. She has noticed weight loss over the last six months and the patient appears apathetic with sunken eyes. He states, with flat affect, that he has been unable to sleep recently as he has been constantly scratching his arms and torso.

What is the best matched differential?
A
Ascending cholangitis
B
Cholangiocarcinoma
C
Hepatocellular carcinoma
D
Pancreatic adenocarcinoma
E
Primary sclerosing cholangitis
Question 1 Explanation: 
Ascending cholangitis would more often present with biliary colic pain and constitution signs. Cholangiocarcinoma is a potential, but less likely differential. Hepatocellular carcinoma fits the hepatic signs, but not the demography as much as pancreatic cancer. This is a common presentation of pancreatic cancer.
Question 2

Stem 2 of 5

Which of the following examination findings are least likely in this patient?
A
Courvoisier sign
B
Cullen sign
C
Grey Turner sign
D
Scleral icterus
E
Spherocytosis
Question 2 Explanation: 
Spherocytosis are more likely seen in disfigured RBCs. Cullen and Grey Turner suggest retroperitoneal bleeding, Courvoisier’s sign states that painless jaundice and RUQ mass is not likely to be gallstones, but must be pancreatic cancer until proven otherwise.
Question 3

Stem 3 of 5

Ultrasound scan shows a mass in the tail of the pancreas. When considering resection of this region of parenchyma, which major vessel runs superior to this structure?
A
Left gastric
B
Left gastroepiploic
C
Right gastric
D
Right gastroomental
E
Splenic
Question 3 Explanation: 
The splenic artery runs on the superior surface of the body and tail of the pancreas. The tail actually abuts the hilum of the spleen, where this artery terminates, so this region is exactly near to the splenic artery.
Question 4

Stem 4 of 5

Which is the gold-standard diagnostic test in this patient?
A
Abdominal ultrasound scan
B
Endoscopic retrograde cholangiopancreatography
C
Liver function test
D
Pancreatic protocol CT
E
Prothrombin time
Question 4 Explanation: 
An Abdo-USS would likely be performed first line, alongside FBC, LFTs, clotting screen, albumin, U&E, APP etc, but the diagnostic standard is set by the higher resolution pancreatic protocol CT modality.
Question 5

Stem 5 of 5

Results show a resectable mass, stage II. Which of the following is the most appropriate first line management?
A
Biliary stenting
B
Neoadjuvant radiotherapy
C
Pancreatin administration
D
Stereotactic body insertion
E
Surgical resection
Question 5 Explanation: 
The classic first line is surgical resection and pancreatin replacement therapy. Neoadjuvant radiotherapy is not recommended first line, but trials to its efficacy are ongoing (2020). Biliary stenting can be useful in some cases, but does not improve outcomes and is not a generic first-line pancreatic cancer therapy. Stereotactic body insertion is more likely for unresectable tumour.
Question 6

Stem 1 of 3

A patient presents with worsening tiredness, concerned about early satiety and weight loss. He has a known diagnosis, and family history, of hereditary spherocytosis.

Given the most likely diagnosis, which of the following investigations would be most helpful in the work-up?
A
Conjugated bilirubin
B
Hepatitis A screening antigen test
C
Hepatitis C screening antigen test
D
Urobilinogen
E
White blood cell count
Question 6 Explanation: 
Urobilinogen is uniquely raised in prehepatic causes of jaundice.
Question 7

Stem 2 of 3

According to NICE (2020), when does serum bilirubin become outwardly noticeable?
A
20
B
30
C
40
D
50
E
60
Question 7 Explanation: 
According to nice, the average normal serum bilirubin is 5-19 micromol/L. Clinical jaundice may not become apparent, however, until serum levels reach 51 micromol/L. Source: https://cks.nice.org.uk/topics/jaundice-in-adults/background-information/definition/ [Accessed Sept 2020].
Question 8

Stem 3 of 3

Gilbert’s syndrome has a 3% prevalence in the UK population. Whilst normally benign, it can cause prehepatic jaundice. Which of the following enzymes are deficient in this condition?
A
Acetylcholinesterase
B
Alanine transaminase
C
UDP-glucuronosyltransferase
D
γ-aminobutyric acid
E
γ-Glutamyltransferase
Question 8 Explanation: 
UGT, or UDP-glucuronosyltransferase, is deficient in this syndrome. This results in a decrease in conjugation of bilirubin to its hydrophilic form, affecting excretion and causing prehepatic icterus in some patients depending on the level of deficiency. The absence of UGT, readily fatal as a natural course, is Crigler-Najjar syndrome which can cause bilirubin encephalopathy with death several days postpartum.
Question 9

Stem 1 of 5

A home visit is undertaken at a shelter for a 44YOM who is a known IVDU. He has requested medical assistance because his sclera is getting “more yellow each week!”. He has felt very tired and been vomiting most mornings for the last two weeks. Collateral history from his counselor notes that the patient is becoming increasingly confused and agitated and a new onset resting tremor has developed in his right hand.

The patient has routine screenings ordered with a positive HBsAg. What does this tell you about the disease?
A
The patient has IgM antibodies to the hepatitis B virus.
B
The patient was infected with HBV but it now not contagious
C
The patient was infected within the last six months
D
The patient was likely contaminated via the faeco-oral route
E
The patient was most likely infected in the last two weeks.
Question 9 Explanation: 
IgM antibodies are an acute phase response to the HBV but are confirmed by an assay for that immunoglobulin specifically, not this test. Faeco-oral route is more likely due to HAV. The HBsAg usually is negative after six months and is thus the correct answer.
Question 10

Stem 2 of 5

What does the routine HBcAg test screen for?
A
Mitochondria of HBV
B
Secretions of HBV
C
The cell membrane of HBV
D
The DNA of HBV
E
The flagellum of HBV
Question 10 Explanation: 
HBcAg tests the core of the viral capsid for the circular DNA of the virus.
Question 11

Stem 3 of 5

Which of the following statements is true about the HBV?
A
HBcAg is present throughout the infection of the virus
B
Anti-HBs is when the patient is highly contagious
C
Anti-HBe is when HBeAg is active in the serum
D
HBsAg is an antigen to core cytosolic HBV matter
E
HBeAg is indicative of a difficult phase of HBV transmission
Question 11 Explanation: 
HBcAg is present throughout viral infection. AntiHBs is only present when the virus is no longer contagious. AntiHBe is indicative of when HBeAg is cleared from the body successfully. HBsAg is to the surface of the virus. HBeAg is indicative of a phase where the virus is highly contagious.
Question 12

Stem 4 of 5

Which of the following is best matched to the hepatitis D virus?
A
Commonly an outbreak agent in developing world regions.
B
HDV is usually spread haematogenously.
C
Hepatitis B vaccines confer immunity to HDV.
D
Mostly transmitted through contaminated food supply.
E
Present in the faeces of infective people.
Question 12 Explanation: 
A patient cannot be infected with HDV unless they are already positive of HBV as the virus is defective. Thus if you confer immunity to HBV, you also confer immunity - indirectly - to HDV due to its inherent instability.
Question 13

Stem 5 of 5

Which of the following titres are required to rise before the patient could have non-transmissible, non-barrier protection sex with a partner?
A
AntiHBc
B
AntiHBd
C
AntiHBe
D
AntiHBs
E
AntiHBa
Question 13 Explanation: 
AntiHBs tittre >10IU/L arises after successful vaccination. At this point the HBV is not transmittable. Of course, due to the multiple STIs, and the at risk demography associated with many of the infections - particularly this patient - barrier protection should be counselled.
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References

  • BMJ. (2020). Jaundice. Available: https://bestpractice.bmj.com/topics/en-gb/127/aetiology. Last accessed Sept 2020.
  • Moore’s Clinically Oriented Anatomy – 12th Edition
  • NICE CKS. (2020). Jaundice. Available: https://cks.nice.org.uk/topics/jaundice-in-adults/background-information/causes/#gilberts-syndrome. Last accessed Sept 2020.
  • World Health Organisation. (2020). Hepatitis Information. Available: https://www.who.int/news-room/q-a-detail/what-is-hepatitis. Last accessed Sept 2020.