Approach to a patient with JAUNDICE

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Approach to a patient with JAUNDICE

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Approach to a patient with JAUNDICE

  1. 1. Clinical Management of Patient with Jaundice
  2. 2. JAUNDICE Yellow pigmentation of skin, sclera and mucosa due to elevated bilirubin level Visible at 3mg/dL Imbalance between production and clearance of bilirubin. Sclera- high affinity because of elastin content- 3mg/dl
  3. 3. Bilirubin Metabolism:
  4. 4. Classified by: Type of Circulating Bilirubin: 1.Conjugated 2.Unconjugated Site of the Problem: 1.Prehepatic 2.Hepatocellular 3.Cholestatic/ Obstructive
  5. 5. Pre-hepatic Jaundice: - Excess Bilirubin production 1.hemolysis 2.inadequately liver uptake 3.deficient hepatic conjugation - Unconjugated Bilirubin enters the blood - Unconjugated Bilirubin is water insoluble  not excreted in the urine - Resulting in Unconjugated (Indirect) Hyperbilirubinemia
  6. 6. Hepatocellular Jaundice: - With hepatocellular damage +/- cholestasis - Causes: - Viruses: Hep, CMV, EBV - Drugs - Alcoholic Hep, cirrhosis, liver mets/abscess, hemochromatosis - AIH - sepsis, leptospirosis - a1 antitrypsin deficiency - Budd Chiari Syndrome, Wilsons Disease - Failure to Excrete Bilirubin (Dubin – Johnson & Rotor Syndrome) - Right Heart Failure - Toxins( Carbon Tetrachloride) - Fungi (Amanita phaloides)
  7. 7. Cholestatic/Obstructive Jaundice: - Blockage of the Common Bile Duct  Conjugated Hyperbilirubinemia - Conjugated Bilirubin is water soluble  easily excreted in the urine - Pt usually c/o dark, tea-colored urine - Clay-colored stool  due to lack of conjugated bilirubin reaching the GUT - Causes: 1.Choledocholithiasis 2.Pancreatic cancer 3.Porta-hepatis LN 4.Drugs 5.Cholangiocarcinoma 6.Sclerosing Cholangitis 7.PBC 8.Choledochal cyst 9.Biliary atresia
  8. 8. Clinical Manifestations: Ask about: 1.Previous blood transfusion 2.IVDU 3.Body Piercing 4.Tattoos 5.Sexual Activities 6.Travel Hx 7.In Contact with person with Jaundice 8.Family Hx 9.Alcohol Consumption 10.Medications
  9. 9. Physical Exam: 1.Look for signs of chronic liver disease 2.Hepatic Encephalopathy 3.LAD 4.Hepatomegaly 5.Splenomegaly 6.Palpable GB 7.Ascites 8.Pale stools and dark urine
  10. 10. Lab test: Bilirubin (-) in pre-hepatic causes Urobilinogen (-) in Obstructive Jaundice Signs of Hemolysis: Anemia • Elevated LDH • Low Haptoglobin • High Reticulocytes • (+) Coombs test LFT Virology: EBV, CMV, HAV, HBV, HCV Hemochromatosis: elev ferritin & iron:TIBC ratio  high serum iron sat(>50-60) A1-antitrypsin Deficiency – genetic analysis Wilson’s Disease – low serum & high Urine Copper Level, low serum Ceruloplasmin PBC – high anti-mitochondrial ab, AMA AIH – high anti-nuclear & anti-smooth muscle ab US – to check for CBD obstruction MRCP/ERCP – if CBD are dilated Liver Biopsy – if Bile ducts are normal MRI/CT
  11. 11. http://crisbertcualteros.page.tl

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