Jaundice

• Result of retention of bile

• Functions of bile – Elimination – bilirubin, cholesterol, xenobiotics – Bile salts / phospholipids – emulsification of

dietary fat

• Jaundice – yellowish discoloration of skin and sclera (icterus)

• Serum Bilirubin > 2.0 mg/dl (Normal <1.2)

• Cholestasis – systemic retention of bilirubin and other solutes of bile

Heme containing proteins

Bilirubin uridine diphosphate glucuronosyl transferase

ß- glucuronidases

20% enterohepatic circulation

Bilirubin productionHepatic Uptake

Conjugation Excertion

Normal – rates are equal – no jaundice

Unconjugated bilirubin (indirect)

Conjugated bilirubin(direct)

Increased Bilirubin production

Excess production of bilirubin • Hemolytic anemia • Resorption of blood – alimentary

canal/ hematoma • In-effective erythropoiesis

PRE-HEPATIC JAUNDICE

Reduced hepatic uptake• Drug interference • Diffuse hepatocellular disease –

hepatitis

Reduced uptake

HEPATOCELLULAR JAUNDICE

Impaired conjugation

Impaired bilirubin conjugation • Physiologic jaundice of the new born

HEPATOCELLULAR JAUNDICE

Decreased excretion

Decreased hepatocellular excretion • Deficiency in canalicular membrane

transporters • Drug induced membrane dysfunction • Hepatocellular damage / toxicity

HEPATOCELLULAR JAUNDICE

Impaired flow

Impaired intra- extrahepatic bile flow • Inflammatory destruction of bile ducts • Gall stones • Carcinoma of pancreas

Surgically treatable

OBSTRUCTIVE JAUNDICE

PRELIMINARY TESTS

• Total Serum Bilirubin• Ratio of Conjugated bilirubin total

bilirubin • Urine Bilirubin • Urine Urobilinogen • Stool – color

Test Pre- hepatic

Hepato-cellular

Obstructive

Total Bilirubin ↑ ↑ ↑

Conjugated to Total Bilirubin ratio

<20% 20-40% >50%

Urine bilirubin(Only conjugated is

filtrated)

Absent Present Increased

Urine urobilinogen Increased Present Absent

Stool Polycholic Polycholic Pale/acholic

OTHER MANDATORY TESTS

• Transaminases - AST & ALT • Alkaline phosphatase • 5 Nucleotidase • Gamma Glutamyl Transferase

AST & ALT

ALP, GGT5-Nucleotidase,

Test Hepatocellular Obstructive

AST / ALT ↑↑↑ ↑

ALP/ 5 Nucleotidase/

GGT

↑ ↑↑↑

ADDITIONAL TESTS

• Total Protein • Albumin• Pro-thrombin time • Cholesterol• Liver biopsy

To assess the degree of damage to liver

MISC TESTS

• Antibodies – Anti-mitochondrial • Serum Gamma Globulin