jaundice internal medicine presentation

8/7/2019 JAUNDICE Internal Medicine Presentation

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HYPERBILIRUBINEMIAJAUNDICE

(Icterus)

Presenter: Abdul Mushib Ibrahim

MBBS Year 4

UPSM


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Definition

Refers to YELLOWISH pigmentation of:

SKIN

SCLERAEMUCOSA

-Due to increased levels of bilirubin in the blood.


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VALUES

NORMAL PLASMA Bilirubin:

0.5mg/dl

ABNORMAL PLASMA Bilirubin:

> 1.5mg/dl or > 35micromoles/L


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Classification of Jaundice

Jaundice is classified by1-Type of Circulating Bilirubin:

a)Conjugated

b)Unconjugated

2-Site of Problem:

a)Pre-Hepaticb)Hepatic

c)Post Hepatic/Cholestatic/Obstructive


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RBC BREAK DOWNGLOBIN

HEME

biliverdin

(greencolor)

Unconjugated-

bilirubin-yellow

BLOOD STREAM

LIVERConjugated

Bilirubin

UDP-glucuronyl

transferase

Bilary Tree &

Cystic Duct->

BILE

Intestinal Bactria

Urobilinogen

stercobilin urobilin

ALBUMIN

YELLOW

DISCOLOURATION

OF SKIN

1-Gilberts

Syndrome

2-Crigler Najjar

Syndrome


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Uncongugated Bilirubin

-Is water insoluble.

-It does not enter urine.-Bound to plasma Albumin-> travels to Liver->to

form congugated Bilirubin.

-Results in ACHOLURIC Hyperbilirubinaemia.


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Jaundice is classified by1-Type of Circulating Bilirubin:

a)Unconjugated

b)Conjugated

2-Site of Problem:




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Pre-Hepatic-Uncongugated

The pathology is occurring prior to the liver

caused by anything which causes an increasedrate of breakdown of red blood cells

ISOLATED raised Bilirubin levels-(Uncongugated)


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Hemolytic Jaundice:

Genetic diseases, such as:

1-sickle cell anemia2-spherocytosis

3-thalassemia

4 glucose 6-phosphate dehydrogenasedeficiency


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Infective Causes:

5-Malaria-In tropical countries

6-Leptospirosis.

Congenital Causes:

7-Gilberts Syndrome8-Cringler Najjar Syndrome

TYPE I

TYPE II


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1-Type of Circulating Bilirubin:

a)Unconjugated

b)Conjugated

2-Site of Problem:




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Hepatic Jaundice-Congugated

DEFINITION

Results from the inability of the liver totransport bilirubin across the hepatocyte into

the bile duct, occuring as a consequence of

parenchymal liver disease.


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Bilirubin transport is impaired because of:Uptake of Uncongugated Bilirubin into the cells

Transport of Congugated Bilirubin into the Canaliculi.


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In Hepatic Jaundice, concentrations of bothcongugated and Uncongugated Bilirubin

increase.

CARACTERISTICS OF HEPATIC JAUNDICE

Increase in Transaminases AST (Aspartate Transaminase-5-35 iu/L)

ALT (Alanine Aminotransferase-5-35iu/L)

NOTE: Increase in other LFTS suggest other specificaetiologies.


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Acute Jaundice in presence of AST > 1000U/L

is HIGHLY SUGGESTIVE of:

1. An Infectious Cause Hepatitis A, B,C, Alcoholic,

CMV

EBV

2. Hepatic Ischaemia


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3. Drugs

Paracetamol Overdose

Isoniazid, Rifampicin, Pyrazinamide

Monoamine Oxidase Inhibitors

Sodium Valproate

Halothane

Statins


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Other Causes of Hepatic Jaundice

4. Failure to excrete Congugated Bilirubin

Dubin Johnson Syndrome

Rotor Syndrome

5-Sepsis ,hypoperfusion states

6-Toxins

Fungi-Amanita Phalloides

Carbon Tetrachloride


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DIAGNOSING HEPATIC JAUNDICE

Blood Test-LFTS

Imaging-essential to identify features

suggestive of cirrhosis. Irregular liver outline

Splenomegaly

Define Patency of Hepatic Arteries, Veins, Portal

Vein.


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Liver Biopsy-to define the cause of Hepatic

Jaundice.


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1-Type of Circulating Bilirubin:

a)Unconjugated

b)Conjugated

2-Site of Problem:




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POSTHEPATIC-Obstructive

(Cholestatic) JaundiceCaused by:-Failure of hepatocytes to initiate bile flow.

-Obstruction of Bile flow in bile ducts


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Disease States

Obstructive Jaundice extrahepatic cholestasis

Choledocholithiasis (CBD stone)

Cancer (peri-ampullary or cholangio CA)

Strictures after invasive procedures Acute and chronic pancreatitis

Primary sclerosing cholangitis (PSC)

Parasitic infections Ascaris lumbricoides, liver flukes


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Drug induced CholestatsisFlucloxacillin

Augmentin

Nitrofurantonin

Steroids (Pill)

Sulfonylureas

Prochlorperazine

Chlorpromazine.


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Congugated BilirubinDark UrineBut less

Congugated Bilirubin enters the gut thusfeaces is pale.

When severeassociated with pruritis RX-

relief of obstruction.


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Cholestatic Jaundice is CHARACTERISED by:

INCREASED: ALP -Alkaline Phosphatase-30-150

GGT(-g- Glutamyl transpeptidaseU/S is indicated to determine mechnical

obstruction & Dilatation of bilary tree.


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EVALUATION


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Initial Evaluation: History

Jaundice, pale stool, tea-colored urine Fever/chills, RUQ pain (cholangitis)

Could lead to life-threatening septic shock

Reasons to have hepatitis or cirrhosis? Alcohol, Viral, risk factors for viral hepatitis

Exposure to toxins or offending drugs

Inherited disorders or hemolytic conditions Recent blood transfusions or blood loss?

Is patient septic?

Recent gallbladder surgery? (CBD injury)


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Initial Evaluation: Physical Exam

Signs of end stage liver disease (cirrhosis)

Ascites, splenomegaly, spider angiomata, and

gynecomastia

Jaundice evident first underneath the tongue,

also evident in sclerae or skin

Courvoisiers sign = painless, but palpable or

distended gallbladder on exam

Could indicate malignant obstruction (e.g

Pancretic Cancer)

Unlikely to be caused by gallstone obstruction.


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Screening Labs

URINE TEST-Bilirubin is absent in pre-hepatic cause.

-Urobilinogen is absent in obstrcutive cause.

HAEMATOLOGY

-FBC

-Clotting


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BIOCHEMISTRY

-U&E LFT (Bilirubin,ALT,AST, ALK PHOS, GGT,

Total Protein, Albumin)

Alk Phos moreso than AST/ALT implies

cholestasis (intrahepatic vs obstruction)

Alk Phos also seen in sarcoid, TB, bone

In this case, GGT is specific for biliary origin

PredominantAST/ALT implies intrinsic

hepatocellular disease AST/ALT ratio > 2 in alcoholic hepatitis

albumin orINR c/w advanced liver dz


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Imaging for Obstructive Jaundice

RUQ Ultrasound See stones, CBD diameter->6mmobstruction.

ERCP

Direct visualization of biliary tree/panc ducts Procedure of choice for choledocholithiasis

Diagnostic AND- therapeutic

Endoscopic Ultrasound CT scan

Identify both type & level of obstruction

If abdominal malignancy is suspected


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Treatment

If Medical, then treat the etiology If Obstructive Jaundice:

Ascending cholangitis For cholangitis: IVF, IV Antibiotics, Decompression

Stones (remove stones vs stent vs drainage) Done via ERCP or open (surgery)

Benign stricture (stent vs drainage catheter)

Cancer (Stent vs drainage +/- resect the CA)


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THE END

REFERANCE

-DAVIDSONS-PRINCIPLES & PRACTICE OFMEDICINE

-OXFORD HAND BOOK OF CLINICAL MEDICINE

-WIKIPEDIA

jaundice internal medicine presentation

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