Published on

this ppt was made by me for my colleagues by the request of Dr. Ahilan (Consultant Physician )

Published in: Health & Medicine
1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  2. 2. Contents • • • • • Bilirubin metabolism. Causes of Jaundice History Examination Special test.
  3. 3. Bilirubin metabolism.
  4. 4. Causes of Jaundice
  5. 5. Causes of Jaundice • Increased bilirubin load (Haemolytic Jaundice) 1. 2. 3. 4. 5. 6. 7. 8. Hereditary spherocytosis Hereditary non spherocytic anaemia Sickle cell disease Thalassemia Acquired haemolytic anaemia Incompatible blood transfusion Severe sepsis Drugs
  6. 6. Causes of Jaundice • Disturbed bilirubin uptake and conjugation of bilirubin 1. 2. 3. 4. 5. 6. Viral hepatitis Hepatotoxins Cirrhosis Gilbert’s familial hyperbilirubinaemai (AD) Familial neonatal hyperbilirubinaemia Crigler-Najjar’s familial jaundice (Type1- AR, Type2AD)
  7. 7. Causes of Jaundice • Disturbed bilirubin excretion Excess of conjugated serum bilirubin known as cholestasis Intra hepatic (without mechanical obstruction) 1. 2. 3. 4. 5. 6. Cirrhosis Viral (chronic active) hepatitis. Drugs- chorpromazine, methyl testosterone Dubin-Johnson’s familial hyperbilirubinaemia(AR) Primary biliary cirrhosis Parenteral or enteral feeding with synthetic nutrition
  8. 8. Causes of Jaundice Extra hepatic cholestasis • Inside the duct 1. Gallstones 2. Foreign body eg- Broken T-tube, parasites (Hydatid,liver fluke, round worms) • In duct wall 1. Congenital atresia 2. Traumatic stricture 3. Sclerosing cholangitis 4. Tumor of the bile duct
  9. 9. Causes of Jaundice • Outside duct 1. Carcinoma of head of the pancreas 2. Carcinoma of the ampulla 3. Pancreatitis 4. Lymph node metastases
  10. 10. History Age: • Young age- Hepatitis is common • Old age- Malignancy (CA) is common
  11. 11. History PC: • Jaundice (Yellowish discoloration of sclera+mucus membrane+Skin) • Exclude other causes for yellow discolouration *Carotenaemia (Only skin, mainly palm and sole are orange color) in eating carrot,mango,papaya and hypothyroidism *Antimalarial drugs *Vit-B12 deficiency
  12. 12. History HPC & Systemic Rvw • Jaundice 1. Sudden onset- Gall stones OR Viral hepatitis 2. Gradual onset- Cirrhosis, Pancreatic CA OR Porta hepatis metastases 3. Progressive- Malignant obstruction 4. Fluctuaing- Stones in the CBD, CA of the duodenal papilla OR repeated hemolytic episodes.
  13. 13. History • Pain: 1. Painless- Viral hepatitis (Dragging subcostal ache due to hepatic enlargement) 2. Pailess+Fluctuating- intermittent obstruction by gallstone OR necrosing ampullary CA 3. Painless+Progressive- Malignant obstruction of CBD 4. Painful- Gallstones OR Pancreatic CA Biliary colic- right subcosatl pain radiating beneath the costal margin to shoulder blade Moderate boring pain passing through to backChronic pancreatitis OR pancreatic tumor
  14. 14. History • Fever: 1. Fever with chills- Extra hepatic cholestasis with cholangitis due to bile duct stone,Liver abscess and leptospirosis 2. Fever without chills- Viral hepatitis, Drug induced hepatitis • Pruritus: Results from the irritation of cutaneous nerves by retained bile salt Cholestatic jaundice
  15. 15. History • Weight lossProgressive weight loss- Malignancy Also in chronic hepatocellular damage. • Anorexia and fatigue Early signs of hepatitis (This is due to production of cachexin and TNF)
  16. 16. History • Colour of the urine and stool Pre hepatic Hepatic Post hepatic Urine colour Normal Dark Dark Stool colour Normal Normal Pale
  17. 17. History Contact history: 1. Contact with jaundice patients from work mates, family- hygienic habits such as toilets, drinking water, taking meals from out side (HepA & HepB) 2. Contact Hx of muddy water in leptospirosis
  18. 18. History  Obstetric Hx: • Ask about LRMP and calculate POA • Benign intra hepatic cholestasis is common in pregnancy period
  19. 19. History PMHx • Viral hepatitis • History of transfusion of blood OR blood products (HepB & HepC) • Recent parenteral injection (HepB & HepC) • Amoebic dysentery • Jaundice following febrile illness- some congenital haemolytic anaemia may be triggered by febrile illness eg- G6PD deficiency
  20. 20. History • Recurrent left hypochondrial pain due to splenomegaly eg- Hereditary spherocytosis • Recurrent foot ulcer eg- some form of chronic haemolytic anaemia such as sickle cell disease • Hx of breast cancer and bowelcancer • SLE and other connective tissue disorders (Hx suggestive of joint pain, skin rash)
  21. 21. History PSHx • Previous difficult biliary surgery suggest – traumatic stricture OR a residual stones in the CBD • Post operative jaundice 1. Resorption of haematomas,haemoperitonium, haemolysis of transfused erythrocyte 2. Impaired hepatocellular function- halogenated anaesthetics, sepsis
  22. 22. History DRUG Hx: • Smilar to pre-hepatic jaundice- rifampicin, methyldopa • Intra-hepati jaundice- ethanol (cirrhosis ), paracetamol, halothane, methyldopa, barbiturates • Post-hepatic jaundice- isoniazid, chlorpromazine • Antileprosy drugs and Antipsychotic drugs • OCP,Saliclate,Sulfonamide , MAOi
  23. 23. History Family Hx: • FHx of jaundice+anaemia+splenectomyHereditary spherocytosis • FHx of jaundice+anaemia- congenital hyperbilirubinaemias • Consanguinity of parents- Inherited congenital haemolytic anaemia eg- G6PD deficiency • Neuropsychiatry llness+jaundice- Wilson’s disease
  24. 24. History  Social Hx: • Hx of Alcohol consumption in Units for yearsChronic alcohol liver disease Hepatocellular CA jaundice Cirrhosis and pancreatic CA • Toddy consumption- Amoebic liver abscess • Sexual promiscuity and unprotected sexual behaviorHepB transmission • Occupational HxSheep farmers OR allied workers- Hydatid infestation Working at chemical enviorment eg-CCl4
  25. 25. Examination  General: • Depth of jaundice: Lemmon yellow- haemolytic jaundice Orange- hepatocellular cause Deep mahogany hue- Prolonged obstructive jaundice
  26. 26. Examination • Anaemia: Suggestive of Haemolytic,malignant OR cirrhotic causes
  27. 27. Examination • Liver failure
  28. 28. Examination • Supraclavicular node enlargementMetastatic CA • SkinScratches and xanthomas in chronic cholestasis
  29. 29. Examination • PyrexiaCholangitis, Viraemia and hepatic involvement eg-Infectious mononucleosis, septicaemia and haemolysis and hepatic abscess
  30. 30. Examination Abdominal Ex: • Scars: previous surgery of biliary tree
  31. 31. Examination • Caput medusae Dilated periumblical vein indicatye portal HT and cirrhosis
  32. 32. Examination • Site of tenderness: Tenderness over the gall bladder indicate biliary inflammation
  33. 33. Examination • Gall bladder A palpable gall bladder in the presence of the jaundice means that janundice is unlikely to be due to a stone (Courvoisier’s sign). CA of head of the pancreas must be suspected
  34. 34. Examination • Liver: 1. Palpable large nodule of large proportionmetastatic malignancy 2. Small nodules- cirrhosis 3. Slightly enlarged smooth live chronic cholestasis 4. Tender liver- viral hepatitis and liver abscess
  35. 35. Examination • Spleen: Splenomegaly may be evident of congenital haemolytic anaemia
  36. 36. Examination • Abdominal mass Hard and irregular abdominal mass suggestive of malignancy. • Ascites Due to abdominal malignancy or liver failure
  37. 37. Examination • Rectal Ex Colour of the stool Presence of a primary malignancy or metastatic deposit in the pouch of douglas