approach to jaundice
TRANSCRIPT
Approach to a Case of Jaundice
Definition …
Yellowish discoloration of sclera, mucosa
& skin due to hyperbilirubinemia
Usually Serum bilirubin > 2-3 mg/dL
Jaundice/ Carotenederma / Mepacrine
Jaundice/ Mepacrine/ carotenederma
Sites to look for Jaundice
Sclera
Under surface of tongue
Skin
Metabolismof Bilirubin
• Haem
• Senescent RBCs
• Ineffective Erythropoesis
• Myoglobin
• Cytochrome oxidase
Bilirubin metabolism …
RBC Breakdown
Unconjugated bilirubin
Hepatic uptake
Conjugation
Hepatocellular excretion
Intrahepatic biliary canaliculi
Extrahepatic biliary pathway
Water insoluble
Alb bound, not in urine
Water soluble
Present in urine
Inside hepatocyte
Causes of Jaundice
Congenital
Acquired
1. Pre -Hepatic
Gilberts, Criggler NajarI & II
Hemolysis,Vit B12 & FA def
2. Hepatocellular
Dubin
Johnson, Rotors synd
Virus, drugs, alcohol
3. Obstructive
Drugs, gall stones, carcinoma
Obstructive Jaundice: Gall stones
Aim of the lecture …
Differentiate
Unconjugated vs Conjugated
hyperbilirubinemia
Medical vs Surgical jaundice
Unconjugated hyperbilirubinemia …
Causes
•Hemolysis•Ineffective erythropoesis
•Gilbert’s syndrome•Criggler Najjar syndrome (I, II)•Sepsis
RBC Breakdown
Unconjugated bilirubin
Hepatic uptake
Conjugation
Hepatocellular excretion
Intrahepatic biliary canaliculi
Extrahepatic biliary pathway
•Sepsis Causes
Clinical features …• Hemolysis –
• lemon tinge sclera, pallor, splenomegaly
• Normal colored urine (cola colored in cases of Intra Venous hemolysis) Acholuric jaundice
• Gilbert’s syndrome:
• mild jaundice
• with fasting
•Criggler Najjar syn (I): Kernicterus
Conjugated hyperbilirubinemia …
RBC Breakdown
Unconjugated bilirubin
Hepatic uptake
Conjugation
Hepatocellular excretion
Intrahepatic biliary canaliculi
Extrahepatic biliary pathway
•DJ/Rotor syndrome
•Hepatocellular damage•Hepatotrophic virus•Alcohol•Drugs/toxins•Autoimmune
•Primary biliary cirrhosis•Perihepatocyte edema•Primary sclerosing cholangitis
•Surgical obstructive jaundice
•Stones, strictures, malignancy
CausesINTRAHEPATIC
Clinical features …
• Hepatocellular damage
•Acute: bleeding manifestation, encephalopathy
•Chronic: edema, parotid enlargement*, gynecomastia*, testicular atrophy, spider angioma*
• Portal htn: varices, splenomegaly (hypersplenism), encephalopathy, ascites
• Underlying diseases: Viral-prodrome, cholangitis
* Features s/o alcoholism
Clinical features …
• Cholestasis: itching, high colored urine, clay
colored stools, fat/fat sol vitamins malabsorption
• Courvoisier's law
• Cholangitis: Fever with chills, jaundice, rt upper abdominal pain
Obstructive Jaundice
URINESTOOL
Lab Investigations LFT
Serum bilirubin > 2- 3 mg/dl ( < 6mg% in hemolytic anaemia)
Van den Bergs reaction Direct: Conjugated > 15 % In direct: UnConjugated: > 85 %
Enzymes ALT & AST raised in Hepatocellular Alk phosphatase & GGT in obstructive jaundice
Prothrombin time: raised in hepatocellular jaundice Serum proteins:
Albumin < globulin in Chronic liver disease
Urine Bilirubin
Present Absent
Conjugated Unconjugated
Urine Urobilinogen
Increased Absent
Hemolysis Cholestasis
Laboratory features of hemolysis …
Increased reticulocyte count (N in ineffective erythropoeisis)
Increased LDHIncreased urinary urobilinogenIV hemolysis:
PBS: schistocytes Hemoglobinemia/hemoglobinuria Hemosiderinuria (Chronic) Decrease haptoglobin
Surgical jaundice … Ultrasound abdomen
CBD/intrahepatic biliary radicals dilatation CBD stones Malignancy
ERCP/MRCP Distal blocks: distal to cystic duct Level, nature & extent of obstruction
Percutaneous transhepatic cholangiography Proximal blocks: proximal to cystic duct
CECT/MRI abdomen
Obstructive Jaundice
Liver ultrasound showing (a) dilated intrahepatic bile ducts (arrow)
Common bile duct (arrow). The normal bile duct measures 6 mm at the porta hepatis.
Obstructive Jaundice:
Oral Cholecystography