History

Fact Explanation
Gallstone disease It is the most common cause of biliary obstruction and commonly seen in women than in men. Long standing obstruction of the bile duct due to stones, tumors, strictures can cause secondary biliary cirrhosis. Initially there's inflammation of the liver which later progresses to fibrosis and cirrhosis. . [1] [2] [3] [4]
Yellowish discolouration of skin and sclera [1] [2] [3] [4] bilirubin secretion from liver is blocked therefore it's released into the blood stream and can get deposited in the skin and sclera causing jaundice or yellowish discoloration. [1] [2] [3] [4]
Dark urine [1] [2] [3] [4] Urobilinogen is absent as secretion of bilirubin from the liver is blocked. Instead conjugated bilirubin is passed into the urine which gives the dark (tea) color to urine. [1] [2] [3] [4]
Pale stools [1] [2] [3] [4] As urobilinogen is absent, there's no production of stercobilin in intestines therefore stools appear pale. [1] [2] [3] [4]
itching (Pruritus) [9] Deposition of bile acids in the is thought to cause pruritus. Recently it has been attributed to opioid release in the body as well [9]
Recurrent bouts of right hypochondrial pain [1] [4] When biliary cirrhosis is secondary to gall stone disease, recurrent attacks of right hypochondrial pain may result and the jaundice is painful. [1] [4]
Anorexia, nauea [5] [6] [7] These are symptoms of advanced cirrhosis as well as felt during an episode of acute cholecystitis due to gallstones. [5] [6] [7]
Weight loss [2] This is a feature of malignancy and particularly if there's malignant obstruction of the biliary tree by a cholangiocarcinoma or cancer in the pancreas. [2]
Swelling of the abdomen [5] [6] [7] This is a feature of cirrhosis and liver failure, there's accumulation of fluid in the abdominal cavity. This transudation of fluid could be due to imbalance of Starling forces as there's reduced oncotic pressure due to reduced albumin production from the liver and increased hydrostatic pressure due to portal vein hypertension. [5] [6] [7]
Ankle swelling [5] [6] [7] This is also a feature of liver failure. There's transudation of fluid due to imbalance of Starling forces as there's reduced oncotic pressure due to reduced albumin production from the liver and increased hydrostatic pressure due to portal vein hypertension. [5] [6] [7]
Reversal of sleep patterns and altered level of consciousness [8] This is a feature of hepatic encephalopathy and is seen in advanced cirrhosis. This is thought to be due to accumulation of toxic ammonia and imbalance of neurotransmitters in brain. [8]
References
  1. TAZUMA SUSUMU. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Practice & Research Clinical Gastroenterology [online] 2006 January, 20(6):1075-1083 [viewed 10 August 2014] Available from: doi:10.1016/j.bpg.2006.05.009
  2. BRAHMI SAMI, KHATTAB MOHAMMED, MESBAHI OMAR. Obstructive jaundice secondary to pancreatic head adenocarcinoma in a young teenage boy: a case report. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/1752-1947-5-439
  3. PLUSA S, WEBSTER N, PRIMROSE J. Obstructive jaundice causes reduced expression of polymorphonuclear leucocyte adhesion molecules and a depressed response to bacterial wall products in vitro.. Gut [online] 1996 May, 38(5):784-787 [viewed 10 August 2014] Available from: doi:10.1136/gut.38.5.784
  4. HAYAT J.O., LOEW C.J., ASRRESS K.N., MCINTYRE A.S., GORARD D.A.. Contrasting liver function test patterns in obstructive jaundice due to biliary structures and stones. QJM [online] December, 98(1):35-40 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hci004
  5. FIGUEIREDO ANTONIO, ROMERO-BERMEJO FRANCISCO, PERDIGOTO RUI, MARCELINO PAULO. The End-Organ Impairment in Liver Cirrhosis: Appointments for Critical Care. Critical Care Research and Practice [online] 2012 December, 2012:1-13 [viewed 10 August 2014] Available from: doi:10.1155/2012/539412
  6. HYTIROGLOU P., et al. Beyond "Cirrhosis": A Proposal From the International Liver Pathology Study Group. American Journal of Clinical Pathology [online] December, 137(1):5-9 [viewed 10 August 2014] Available from: doi:10.1309/AJCP2T2OHTAPBTMP
  7. GOTTHARDT D., RIEDIGER C., WEISS K. H., ENCKE J., SCHEMMER P., SCHMIDT J., SAUER P.. Fulminant hepatic failure: etiology and indications for liver transplantation. Nephrology Dialysis Transplantation [online] 2007 September, 22(Supplement 8):viii5-viii8 [viewed 10 August 2014] Available from: doi:10.1093/ndt/gfm650
  8. CIEćKO-MICHALSKA IRENA, SZCZEPANEK MAłGORZATA, SłOWIK AGNIESZKA, MACH TOMASZ. Pathogenesis of Hepatic Encephalopathy. Gastroenterology Research and Practice [online] 2012 December, 2012:1-7 [viewed 10 August 2014] Available from: doi:10.1155/2012/642108
  9. TWYCROSS R.. Itch: scratching more than the surface. [online] 2003 January, 96(1):7-26 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hcg002

Examination

Fact Explanation
Icterus [7] [9] [10] Bilirubin secretion from liver is blocked therefore it's released into the blood stream and can get deposited in the skin and sclera causing jaundice or yellowish discoloration. [7] [9] [10]
Cachexia [9] This is a feature of malignancy and particularly if there's malignant obstruction of the biliary tree by a cholangiocarcinoma or cancer in the pancreas. [9]
Mass in the abdomen [1] [9] Palpable gall bladder in the presence of obstructive jaundice is a feature of malignancy and provides the basis for Courvoisier's law. Mass in the abdomen could also be the malignant mass of the pancreas or cholangiocarcinoma. [1] [9]
Ascitis [7] [9] [10] This is a feature of cirrhosis and liver failure, there's accumulation of fluid in the abdominal cavity. This transudation of fluid could be due to imbalance of Starling forces as there's reduced oncotic pressure due to reduced albumin production from the liver and increased hydrostatic pressure due to portal vein hypertension. [7] [9] [10]
Pitting odema [7] [9] [10] This is also a feature of liver failure. There's transudation of fluid due to imbalance of Starling forces as there's reduced oncotic pressure due to reduced albumin production from the liver and increased hydrostatic pressure due to portal vein hypertension. [7] [9] [10]
Dilated veins in the abdomen (Caput medusae) [2] [3] This is due to opening up of collaterals between portal and systemic circulation in the abdominal wall due to portal hypertension. [2] [3]
Right hypochondrial tenderness [7] [9] [10] When biliary cirrhosis is secondary to gallstone disease, recurrent attacks of right hypochondrial pain may result and the jaundice is painful [7] [9] [10]
Scratch marks [4] Deposition of bile acids in the is thought to cause pruritus and resultant scratch marks. Recently it has been attributed to opioid release in the body as well. [4]
Flapping tremor/ Asterexis [5] [6] This is a feature of hepatic encephalopathy in advanced liver failure and attributed to accumulation of ammonia and imbalance of other neurotransmitters in the brain [5] [6]
References
  1. PARSI M. A.. The Courvoisier sign. Cleveland Clinic Journal of Medicine [online] December, 77(4):265-265 [viewed 10 August 2014] Available from: doi:10.3949/ccjm.77a.09099
  2. HARI KUMAR KVS, RASTOGI SK. Caput medusae in alcoholic liver disease. Niger J Clin Pract [online] 2011 December [viewed 10 August 2014] Available from: doi:10.4103/1119-3077.91769
  3. SATO KAZUHIRO, WATANABE HIROYUKI, SANO MASAAKI, SHIOYA TAKANOBU, ITO HIROSHI. Caput Medusae in the Mediastinum. Am J Respir Crit Care Med [online] 2012 October, 186(8):803-803 [viewed 10 August 2014] Available from: doi:10.1164/rccm.201205-0889IM
  4. TWYCROSS R.. Itch: scratching more than the surface. [online] 2003 January, 96(1):7-26 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hcg002
  5. CIEćKO-MICHALSKA IRENA, SZCZEPANEK MAłGORZATA, SłOWIK AGNIESZKA, MACH TOMASZ. Pathogenesis of Hepatic Encephalopathy. Gastroenterology Research and Practice [online] 2012 December, 2012:1-7 [viewed 10 August 2014] Available from: doi:10.1155/2012/642108
  6. GOTTHARDT D., RIEDIGER C., WEISS K. H., ENCKE J., SCHEMMER P., SCHMIDT J., SAUER P.. Fulminant hepatic failure: etiology and indications for liver transplantation. Nephrology Dialysis Transplantation [online] 2007 September, 22(Supplement 8):viii5-viii8 [viewed 10 August 2014] Available from: doi:10.1093/ndt/gfm650
  7. HYTIROGLOU P., et al. Beyond "Cirrhosis": A Proposal From the International Liver Pathology Study Group. American Journal of Clinical Pathology [online] December, 137(1):5-9 [viewed 10 August 2014] Available from: doi:10.1309/AJCP2T2OHTAPBTMP
  8. FIGUEIREDO ANTONIO, ROMERO-BERMEJO FRANCISCO, PERDIGOTO RUI, MARCELINO PAULO. The End-Organ Impairment in Liver Cirrhosis: Appointments for Critical Care. Critical Care Research and Practice [online] 2012 December, 2012:1-13 [viewed 10 August 2014] Available from: doi:10.1155/2012/539412
  9. BRAHMI SAMI, KHATTAB MOHAMMED, MESBAHI OMAR. Obstructive jaundice secondary to pancreatic head adenocarcinoma in a young teenage boy: a case report. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/1752-1947-5-439
  10. TAZUMA SUSUMU. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Practice & Research Clinical Gastroenterology [online] 2006 January, 20(6):1075-1083 [viewed 10 August 2014] Available from: doi:10.1016/j.bpg.2006.05.009

Differential Diagnoses

Fact Explanation
Gall stones [3] Gallstones in the common bile duct can block the biliary drainage and cause obstructive jaundice. [3]
Bile duct strictures [4] Biliary strictures are most commonly iatrogenic resulting from trauma during surgical procedures and these can cause blockage of the biliary drainage and obstructive jaundice [4]
Tumours [1] [2] Tumours of the bile duct (Cholangiocarcinoma) or pancreatic head (Adenocarcinoma, Ampullary cancers) can cause obstruction of the bile duct and obstructive jaundice. Palpable gall bladder may be found in examination according to Courvoisier's law. [1] [2]
Sclerosing cholangitis [5] This is a chronic liver disease which is due to biliary obstruction and autoimmune aetiology may be the cause. [5]
Primary biliary cirrhosis [6] Primary biliary cirrhosis is an autoimmune disease which later progresses to cirrhosis. This is more common in women. [6]
Alcoholic liver disease [7] There's a wide spectrum of alcoholic liver disease including alcoholic steatosis, hepatitis and later cirrhosis. [7]
Viral hepatitis [8] Infections from Hepatitis B,C,D can cause chronic liver cell disease later. They have jaundice due to intrahepatic cholestasis. [8]
Chronic pancreatitis [9] Chronic pancreatitis can cause blockage of biliary drainage and features of obstructive jaundice. [9]
References
  1. BRAHMI SAMI, KHATTAB MOHAMMED, MESBAHI OMAR. Obstructive jaundice secondary to pancreatic head adenocarcinoma in a young teenage boy: a case report. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/1752-1947-5-439
  2. PARSI M. A.. The Courvoisier sign. Cleveland Clinic Journal of Medicine [online] December, 77(4):265-265 [viewed 10 August 2014] Available from: doi:10.3949/ccjm.77a.09099
  3. TAZUMA SUSUMU. Epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Practice & Research Clinical Gastroenterology [online] 2006 January, 20(6):1075-1083 [viewed 10 August 2014] Available from: doi:10.1016/j.bpg.2006.05.009
  4. DEVIERE J, CREMER M, BAIZE M, LOVE J, SUGAI B, VANDERMEEREN A. Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.. Gut [online] 1994 January, 35(1):122-126 [viewed 10 August 2014] Available from: doi:10.1136/gut.35.1.122
  5. PARHIZKAR BARAN, MOHAMMAD ALIZADEH AMIR HOUSHANG, ASADZADEH AGHDAEE HAMID, MALEKPOUR HABIB, ENTEZARI AMIR HOSSEIN. Primary Sclerosing Cholangitis Associated with Elevated Immunoglobulin-G4: A Preliminary Study. ISRN Gastroenterology [online] 2012 December, 2012:1-4 [viewed 10 August 2014] Available from: doi:10.5402/2012/325743
  6. KUMAGI TERU, HEATHCOTE E JENNY. Primary biliary cirrhosis. Array [online] 2008 December [viewed 10 August 2014] Available from: doi:10.1186/1750-1172-3-1
  7. JACKSON P., GLEESON D.. Alcoholic liver disease. Continuing Education in Anaesthesia, Critical Care & Pain [online] December, 10(3):66-71 [viewed 10 August 2014] Available from: doi:10.1093/bjaceaccp/mkq010
  8. CHWLA YOGESH. . Virol J [online] 2005 December [viewed 10 August 2014] Available from: doi:10.1186/1743-422X-2-82
  9. YAN M, LI Y. Gall stones and chronic pancreatitis: the black box in between Postgrad Med J [online] 2006 Apr, 82(966):254-258 [viewed 10 August 2014] Available from: doi:10.1136/pgmj.2005.037192

Investigations - for Diagnosis

Fact Explanation
Serum bilirubin with indirect and direct fractions [1] [2] Serum bilirubin values (especially direct or the conjugated fraction) are usually elevated. Cholestasis causes elevated conjugated (direct) bilirubin where as liver cell damage causes elevation of unconjugated (Indirect) bilirubin [1] [2]
Alkaline phosphatase (ALP) [1] [2] ALP levels are very high in biliary obstruction. Extrahepatic obstruction: ALP levels are elevated to high levels but in intrahepatic obstruction, ALP levels are elevated, but <3 times the upper limit of the reference range. [1] [2]
Serum Transaminases (ALT, AST) [1] [2] Only moderately high levels are observed in patients with cholestasis [1] [2]
Gamma glutamyl Transferase (GGT) [1] [2] Biliary obstruction elevates GGT. [1] [2]
Prothrombin time (PT) and international normalization ratio (PT-INR) [2] [3] PT can be prolonged as a result of vitamin K malabsorption due to inadequate fat absorption. [2] [3]
Urine full report [4] [5] Urine bilirubin is normally absent but conjugated bilirubin is present. [4] [5]
Antimitochondrial antibody [6] The presence of high levels of antimitochondrial antibodies, is indicative of PBC. [6]
Hepatitis serology [7] Because viral hepatitis maybe difficult to differentiate from extrahepatic obstructive causes, this is done [7]
Plain abdominal x-rays [8] [9] Plain radiographs are not veru helpful as only 10% of gall stones are seen abdominal x-ray. [8] [9]
Ultrasound scan of the abdomen [9] [11] This is the most sensitive technique for visualizing the biliary system, mainly gallbladder. But not helpful to visualize bile ducts. It's safe and cheap as well [9]
CT scan of the abdomen [9] [11] Cause and level of obstruction, with visualization of liver is possible with this [9]
Endoscopic retrograde cholangiopancreatography (ERCP) [9] [11] This is therapeutic as well and more useful to visualize distal bile duct obstruction with proper visualization of the duct system. [9]
Magnetic resonance cholangiopancreatography (MRCP) [9] [11] This is a noninvasive method and the determination of the type of tumor and it's extent is possible. [9]
Percutaneous transhepatic cholangiogram (PTC) [10] This is especially useful for proximal lesions and the liver is punctured via a needle to enter into the duct system inside the liver [10]
Endoscopic ultrasound (EUS) [11] This combines endoscopy and ultrasound to visualize the hepatic-biliary system [11]
CT cholangiography [9] [11] Radiolucent stones may be seen with this technique [9]
References
  1. HAYAT J.O., LOEW C.J., ASRRESS K.N., MCINTYRE A.S., GORARD D.A.. Contrasting liver function test patterns in obstructive jaundice due to biliary structures and stones. QJM [online] December, 98(1):35-40 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hci004
  2. LIMDI J K. Evaluation of abnormal liver function tests. Postgraduate Medical Journal [online] 2003 June, 79(932):307-312 [viewed 10 August 2014] Available from: doi:10.1136/pmj.79.932.307
  3. PANTANO F., SANTINI D., GUIDA F., VINCENZI B., TONINI G.. Potential role of everolimus in inducing cholestasis. Annals of Oncology [online] December, 21(2):433-433 [viewed 10 August 2014] Available from: doi:10.1093/annonc/mdp558
  4. MULLISH BENJAMIN H, FOFARIA RISHI K, SMITH BELINDA C, LLOYD KIRSTY, LLOYD JOSEPHINE, GOLDIN ROBERT D, DHAR AMEET. Severe cholestatic jaundice after a single administration of ajmaline; a case report and review of the literature. Array [online] 2014 December [viewed 10 August 2014] Available from: doi:10.1186/1471-230X-14-60
  5. RATNAYAKE ERANDA C, SHIVANTHAN CHRISHAN, WIJESIRIWARDENA BANDULA C. Cholestatic hepatitis in a patient with typhoid fever - a case report. Array [online] 2011 December [viewed 10 August 2014] Available from: doi:10.1186/1476-0711-10-35
  6. MANTAKA AIKATERINI, et al. Primary Biliary Cirrhosis in a genetically homogeneous population: Disease associations and familial occurrence rates. Array [online] 2012 December [viewed 10 August 2014] Available from: doi:10.1186/1471-230X-12-110
  7. MARUYAMA T, MCLACHLAN A, IINO S, KOIKE K, KUROKAWA K, MILICH D R. The serology of chronic hepatitis B infection revisited.. J. Clin. Invest. [online] 1993 June, 91(6):2586-2595 [viewed 10 August 2014] Available from: doi:10.1172/JCI116497
  8. HAMEED K., AHMAD A., BAGHOMIAN A.. Bouveret's syndrome, an unusual cause of upper gastrointestinal bleeding. QJM [online] December, 103(9):697-698 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hcq015
  9. UPADHYAYA V, UPADHYAYA D N, ANSARI M A, SHUKLA V K.. Comparative assessment of imaging modalities in biliary obstruction. Indian J Radiol Imaging [online] 2006 [cited 2014 Aug 10];16:577-82. Available from: http://www.ijri.org/text.asp?2006/16/4/577/32273
  10. Breathlessness after percutaneous biliary drainage. [online] 2001 December, 77(914):792b-792 [viewed 10 August 2014] Available from: doi:10.1136/pmj.77.914.792b
  11. ADAMEK H E, ALBERT J, WEITZ M, BREER H, SCHILLING D, RIEMANN J F. A prospective evaluation of magnetic resonance cholangiopancreatography in patients with suspected bile duct obstruction. Gut [online] 1998 November, 43(5):680-683 [viewed 10 August 2014] Available from: doi:10.1136/gut.43.5.680

Investigations - Fitness for Management

Fact Explanation
Serum Albumin [1] [2] Low serum albumin indicates chronic liver cell disease and low albumin causes delayed wound healing and anastomotic healing. Therefore this is done prior to any surgeries [1] [2]
Prothrombin time and international normalization ratio [1] [2] Bleeding due to low vitamin K is seen in chronic liver cell disease and this test is done prior to any invasive procedures and correction is done [1] [2]
Renal function tests including estimated glomerular filteration rate, serum creatinine, blood urea nitrogen [3] To assess fitness for anesthesia [3]
Full blood count [3] To exclude anaemia. [3]
References
  1. LIMDI J K. Evaluation of abnormal liver function tests. Postgraduate Medical Journal [online] 2003 June, 79(932):307-312 [viewed 10 August 2014] Available from: doi:10.1136/pmj.79.932.307
  2. PANTANO F., SANTINI D., GUIDA F., VINCENZI B., TONINI G.. Potential role of everolimus in inducing cholestasis. Annals of Oncology [online] December, 21(2):433-433 [viewed 10 August 2014] Available from: doi:10.1093/annonc/mdp558
  3. KUMAR A, SRIVASTAVA U. Role of routine laboratory investigations in preoperative evaluation J Anaesthesiol Clin Pharmacol [online] 2011, 27(2):174-179 [viewed 10 August 2014] Available from: doi:10.4103/0970-9185.81824

Investigations - Followup

Fact Explanation
Serum Bilirubin [1] [2] [3] [4] [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level and also in MELD score. [1] [2] [3] [4] [5]
Serum creatinine [1] [2] [3] This is included in MELD score (Model For End-Stage Liver Disease) for planing liver transplant [1] [2] [3]
Serum electrolytes [6] As the patient is on diuretics in liver failure, monitoring of serum electrolytes is essential. [6]
Serum Albumin [4] [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level. [4] [5]
Prothrombin type-international normalization ratio [4] [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level. [4] [5]
References
  1. BOTTA F. MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study. [online] 2003 January, 52(1):134-139 [viewed 10 August 2014] Available from: doi:10.1136/gut.52.1.134
  2. OBERKOFLER CHRISTIAN E, DUTKOWSKI PHILIPP, STOCKER RETO, SCHUEPBACH RETO A, STOVER JOHN F, CLAVIEN PIERRE-ALAIN, BéCHIR MARKUS. Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients. Array [online] 2010 December [viewed 10 August 2014] Available from: doi:10.1186/cc9068
  3. KLEIN KRISTIN B., STAFINSKI TAENIA D., MENON DEVIDAS, ALICI EVREN. Predicting Survival after Liver Transplantation Based on Pre-Transplant MELD Score: a Systematic Review of the Literature. PLoS ONE [online] 2013 December [viewed 10 August 2014] Available from: doi:10.1371/journal.pone.0080661
  4. ANGERMAYR B. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. [online] 2003 June, 52(6):879-885 [viewed 10 August 2014] Available from: doi:10.1136/gut.52.6.879
  5. BOLUKBAS FUSUN F, BOLUKBAS CENGIZ, HOROZ MEHMET, GUMUS MAHMUT, ERDOGAN MEHMET, ZEYREK FADILE, YAYLA ALI, OVUNC OYA. . BMC Gastroenterol [online] 2004 December [viewed 10 August 2014] Available from: doi:10.1186/1471-230X-4-23
  6. ARAMPATZIS SPYRIDON, FUNK GEORG-CHRISTIAN, LEICHTLE ALEXANDER, FIEDLER GEORG-MARTIN, SCHWARZ CHRISTOPH, ZIMMERMANN HEINZ, EXADAKTYLOS ARISTOMENIS, LINDNER GREGOR. Impact of diuretic therapy-associated electrolyte disorders present on admission to the emergency department: a cross-sectional analysis. Array [online] 2013 December [viewed 10 August 2014] Available from: doi:10.1186/1741-7015-11-83

Investigations - Screening/Staging

Fact Explanation
Antimitochondrial antibody level [1] The presence of high levels of antimitochondrial antibodies, is indicative of PBC. [1]
Hepatitis serology [2] Because viral hepatitis maybe difficult to differentiate from extrahepatic obstructive causes [2]
Serum bilirubin [3] [4] [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level and also in MELD score. [3] [4] [5]
Serum creatinine [3] [4] This is included in MELD score (Model For End-Stage Liver Disease) for planing liver transplant [3] [4]
Serum Albumin [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level. [5]
Prothromin time and international normalization ratio [5] This is included in Child-Pugh score (sometimes the Child-Turcotte-Pugh score) which is used to assess the prognosis of chronic liver disease depending on the level. [5]
References
  1. MANTAKA AIKATERINI, et al. Primary Biliary Cirrhosis in a genetically homogeneous population: Disease associations and familial occurrence rates. Array [online] 2012 December [viewed 10 August 2014] Available from: doi:10.1186/1471-230X-12-110
  2. MARUYAMA T, MCLACHLAN A, IINO S, KOIKE K, KUROKAWA K, MILICH D R. The serology of chronic hepatitis B infection revisited.. J. Clin. Invest. [online] 1993 June, 91(6):2586-2595 [viewed 10 August 2014] Available from: doi:10.1172/JCI116497
  3. BOTTA F. MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study. [online] 2003 January, 52(1):134-139 [viewed 10 August 2014] Available from: doi:10.1136/gut.52.1.134
  4. OBERKOFLER CHRISTIAN E, DUTKOWSKI PHILIPP, STOCKER RETO, SCHUEPBACH RETO A, STOVER JOHN F, CLAVIEN PIERRE-ALAIN, BéCHIR MARKUS. Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients. Array [online] 2010 December [viewed 10 August 2014] Available from: doi:10.1186/cc9068
  5. ANGERMAYR B. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. [online] 2003 June, 52(6):879-885 [viewed 10 August 2014] Available from: doi:10.1136/gut.52.6.879

Management - General Measures

Fact Explanation
Patient education [2] [3] [4] Patient should be educated regarding the aetiology, nature, course and prognosis of the disease, available options of treatment. [2] [3] [4]
Diet [2] Obesity is regarded as a risk factor to develop gall stones therefore weight reduction maybe helpful. [2]
Activity [2] [3] [4] Regular exercise may help to reduce weight and obesity [2] [3] [4]
Liver failure regime [1] When patient develops cirrhosis and liver failure, the liver failure regime including diuretics (Furosemide, ACE inhibitors), vitamin supplements, albumin if indicated, low salt diet is advised. [1]
Bile acid–binding resins [5] [6] [7] Cholestyramine or colestipol reduce the symptoms of pruritus [5] [6] [7]
Antihistamines [5] [6] [7] It also helps to reduce the symptoms of pruritus [5] [6] [7]
Rifampin [5] [6] [7] This is also known to reduce the symptoms of pruritus . [5] [6] [7]
References
  1. MOORE KP, AITHAL GP. Guidelines on the management of ascites in cirrhosis Gut [online] 2006 Oct, 55(Suppl 6):vi1-vi12 [viewed 10 August 2014] Available from: doi:10.1136/gut.2006.099580
  2. PATEK ARTHUR J., POST JOSEPH. TREATMENT OF CIRRHOSIS OF THE LIVER BY A NUTRITIOUS DIET AND SUPPLEMENTS RICH IN VITAMIN B COMPLEX. J. Clin. Invest. [online] 1941 September, 20(5):481-505 [viewed 10 August 2014] Available from: doi:10.1172/JCI101242
  3. AMARAPURKAR DEEPAK N.. Prescribing Medications in Patients with Decompensated Liver Cirrhosis. International Journal of Hepatology [online] 2011 December, 2011:1-5 [viewed 10 August 2014] Available from: doi:10.4061/2011/519526
  4. WAKIM-FLEMING J.. Hepatic encephalopathy: Suspect it early in patients with cirrhosis. Cleveland Clinic Journal of Medicine [online] December, 78(9):597-605 [viewed 10 August 2014] Available from: doi:10.3949/ccjm.78a10117
  5. TWYCROSS R.. Itch: scratching more than the surface. [online] 2003 January, 96(1):7-26 [viewed 10 August 2014] Available from: doi:10.1093/qjmed/hcg002
  6. VINIK A. I.. Barely Scratching the Surface. Diabetes Care [online] December, 33(1):210-212 [viewed 10 August 2014] Available from: doi:10.2337/dc09-2035
  7. HAZIN R., ABU-RAJAB TAMIMI T. I., ABUZETUN J. Y., ZEIN N. N.. Recognizing and treating cutaneous signs of liver disease. Cleveland Clinic Journal of Medicine [online] December, 76(10):599-606 [viewed 10 August 2014] Available from: doi:10.3949/ccjm.76A.08113

Management - Specific Treatments

Fact Explanation
Medical therapy for gall stone disease [1] Ursodeoxycholic acid is helpful for treatment for cholesterol containing stones however it tends to recur after stopping the therapy [1]
Therapetic Endoscopic retrograde cholangiopancreatography (ERCP) for gall stone disease and strictures [1] [2] ERCP is therapeutic as it relieves obstructions after sphincterotomy, removal of stones, , and the placement of stents in strictures. [1] [2]
Extracorporeal shock-wave lithotripsy for gall stone disease [1] [3] This causes dissolution of stones [1] [3]
Surgical care (Cholecystectomy, open bile duct surgery, removal of tumours) [4] [5] [6] When symptoms due to gall stones are seen removal of the gall bladder is done and commonly done laparoscopically. Open bile duct surgery is carried out too but not very commonly. Attempts are also made to resect tumors. [4] [5] [6]
Liver transplanation [7] This is the last option in advanced liver failure. [7]
References
  1. PORTINCASA P, CIAULA AD, BONFRATE L, WANG DQ. Therapy of gallstone disease: What it was, what it is, what it will be World J Gastrointest Pharmacol Ther [online] 2012 Apr 6, 3(2):7-20 [viewed 10 August 2014] Available from: doi:10.4292/wjgpt.v3.i2.7
  2. SIEGEL J. H, KASMIN F. E. Biliary tract diseases in the elderly: management and outcomes. Gut [online] 1997 October, 41(4):433-435 [viewed 10 August 2014] Available from: doi:10.1136/gut.41.4.433
  3. MEISER G, HEINERMAN M, LEXER G, BOECKL O. Aggressive extracorporeal shock wave lithotripsy of gall bladder stones within wider treatment criteria: fragmentation rate and early results. Gut [online] 1992 Feb, 33(2):277-281 [viewed 10 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1373945
  4. KAMAN . Day Care Laparoscopic Cholecystectomy: Next Standard of Care for Gall Stone Disease. Gastroenterol Res [online] 2011 December [viewed 10 August 2014] Available from: doi:10.4021/gr374w
  5. CASCINU S., FALCONI M., VALENTINI V., JELIC S.. Pancreatic cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology [online] December, 21(Supplement 5):v55-v58 [viewed 10 August 2014] Available from: doi:10.1093/annonc/mdq165
  6. HAUGVIK SVEN-PETTER, LABORI KNUT JøRGEN, EDWIN BJøRN, MATHISEN ØYSTEIN, GLADHAUG IVAR PRYDZ. Surgical Treatment of Sporadic Pancreatic Neuroendocrine Tumors: A State of the Art Review. The Scientific World Journal [online] 2012 December, 2012:1-9 [viewed 10 August 2014] Available from: doi:10.1100/2012/357475
  7. VARMA VIBHA, MEHTA NAIMISH, KUMARAN VINAY, NUNDY SAMIRAN. Indications and Contraindications for Liver Transplantation. International Journal of Hepatology [online] 2011 December, 2011:1-9 [viewed 10 August 2014] Available from: doi:10.4061/2011/121862