RACGP KFP 2017.2.6 focusses on a question regarding asymptomatic cholestasis. This subcription article focusses on the answer keys, study sources, references, exam technique.
Betty is a 50 year old female who presents for results after workplace medical examination. The patient has no past medical history of note, and examination was normal at the time performed.
Betty has had no pain, weight loss or stool changes. Her PMHx is unremarkable except for recent cellulitis, treated with Augmentin.
Serum biochemistry is normal except for:
Alk.P 148 U/L (30-115)
GGT 451 U/L (0-70)
FBC is normal.
What are the key features of history to determine the cause of this presentation? (List 8)
This is a difficult question to answer – what are are the causes of asymptomatic cholestasis and you can’t ask any history questions as the vignette states that theres no history. Quite literally all I can think of asking is social history (which is probably wrong).
I believe this is a question regarding drug induced cholestasis, which can be induced by any of the following plus more, as described in Murtaghs Chapter on Jaundice, noting that drug induced patterns can present without the actual jaundice
- Allopurinol
- Antithyroid agents
- Augmentin
- Azathioprine
- Barbiturates
- Captopril
- Carbamezepine
- Chlorpromazine
- Chlorpropamide
- Clindamycin
- Clofibrate
- Diltiazem
- Erythromycin
- Flucloxacillin
- Isoniazid
- Lisinopril
- Methyltestosterone
- Oral contraceptives (containing estrogens)
- Oral hypoglycemics
- Phenytoin
- Trimethoprim-sulfamethoxazole
Having said all that, my answers are along the lines of:
- Previous alcohol intake (asking about AFLD)
- Previous obesity (NAFLD)
- Dosage of antibiotics given (drug induced cholestasis)
- Recent sepsis with cellulitis (sepsis -> cholestasis)
- Previous hepatitis C (Im out of ideas at this point)
- Previous hepatitis
- Recent needle stick exposure
- Recent overseas travel
Theres an AFP Clinical challenge here that is very similar to this question.
The standard questions in history of Murtaghs are as below, with questions disallowed by the college as per their feedback struck through.
any episodes of jaundice- c
hange in colour of faeces and urine anorexia,sore throat,weight loss,pruritusabdominal pain- residence and members of household
- contact with patients with hepatitis or jaundice
- recent overseas travel
- exposure to blood or blood products
- needle-stick injuries or exposure to needles, such as acupuncture, tattooing and intravenous
- drugs
- dietary history—shellfish, drinking water
- sexual history—evidence of promiscuity
- drug history, including alcohol, paracetamol
recent medical history, including surgery- family history—family contacts who have had jaundice, haemolytic disease and other genetic liver diseases
- ethnic history—liable to haemolytic disease, contact with hepatitis B
- occupational history—exposure to hazards
This isn’t very helpful and perhaps focus on history aspects that relate to ALFD and drug induced cholestasis that weren’t covered in the stem.
What are the differentials for this presentation? List 5
Murtaghs lists the significant causes of cholestasis in adults as below, with likely candidates in bold that would present completely asymptomatically
- Intrahepatic
- Alcoholic hepatitis/cirrhosis
- Drugs
- Primary biliary cirrhosis
- Viral hepatitis
- Extrahepatic
- Cancer of bile ducts
- Cancer of pancreas
- Other cancer: primary or secondary spread
- Cholangitis
- Primary sclerosing cholangitis (?autoimmune)
- Common bile duct gallstones
- Pancreatitis
- Post-surgical biliary stricture or oedema
Best guess at answers are
- Flucoxacillin-induced cholestasis
- Cirrhosis
- Alcoholic Fatty Liver Disease
- Cancer of bile ducts
- Pancreatic cancer
- Liver Metastases
What investigations would you perform to determine the diagnosis? (List 5)
- Liver/Transabdominal Ultrasound
- Abdomen CT
- Endoscopic retrograde cholangiopancreatography
- Hepatitis serology
- C-Reactive Protein (exclude inflammation)?
- Carcinoembryonic antigen to detect liver secondaries, especially colorectal
- Alpha-fetoprotein—elevated in hepatocellular carcinoma; mild elevation with acute or chronic liver disease (e.g. cirrhosis)
The focus is on secondary investigations according to the RACGP feedback, though theres an argument for doing the general screens as well, noting they wanted a focus on secondary investigations.
RACGP Feedback
This case focused on a female patient presenting for follow-up of investigations from a workplace medical examination. The patient is asymptomatic, other than recently having had antibiotic treatment for cellulitis. The only abnormal results are liver function tests demonstrating a cholestatic picture.
Candidates were required to provide a focused history relevant for the presentation, as well as the differential diagnosis and secondary investigations.
This case demonstrated the need to ensure that candidates read through the case and questions carefully. The case states the patient had no pain, weight loss or stool changes, and denies her medical history and despite this information, candidates explored aspects of each of these.
The history component of this case focused on aspects of the history that would help establish the diagnosis. When considering a response to this question, enquiring about pruritus, jaundice or rash are not going to assist greatly in establishing a diagnosis, as they are common to many causes of abnormal liver function.
When providing answers for possible differential diagnoses, it is important to ensure they are within the context of the information in the scenario. For example, acute cholecystitis or ascending cholangitis would not present asymptomatically as described in the scenario.
GPCC Feedback
The question on asymptomatic cholestasis would have definitely thrown me in the exam, and I found resources on this hard to come by. When I studied Murtaghs chapter on Jaundice myself, I thought that most or all would have presented with some symptoms, rather that being completely asymptomatic. While Murtaghs does mention this in passing (it always does) there is nothing really of significance in any of the RACGP literature, other than one related clinical case which does talk about it.
Best Study Sources
- Murtaghs – Jaundice – noting the small sentence stating that it can be asymptomatic cholestasis
- AFP Article on Prescribing changes in LFT abnormalities
References
- https://www.ncbi.nlm.nih.gov/pubmed/8963906
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4110573/
- https://www.ncbi.nlm.nih.gov/pubmed/17628332
- https://www.ncbi.nlm.nih.gov/pubmed/7553275
- https://www.aafp.org/afp/1999/0415/p2223.html
- Investigation of Cholestasis – The Liver
- https://www.racgp.org.au/afp/2013/januaryfebruary/prescribing-in-patients-with-alft/
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3089004/
- https://lifeinthefastlane.com/investigations/liver-function-tests/
- http://murtagh.mhmedical.com/content.aspx?bookid=1684§ionid=116081632
