Differential Diagnosis of Icterus/Jaundice

1. Guided by
By
Dr. Ananta. S. Desai
Dr. Madhusudan. B. G
Asst. Professor
PG Scholar
Dept of ROGA NIDANA
Dept of ROGA NIDANA
GAMC, Bangalore
GAMC, Bangalore
Dr. Madhusudan. B. G., DD of Icterus
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2. CONTENTS
• MüÉqÉsÉÉ
•
•
•
•
•
•
•
•
•
•
Introduction
Bilirubin – PHYSIOLOGY
Bilirubin – PATHOLOGY
JAUNDICE – Types
LFT
Case studies
Differential Diagnosis
Treatment
Discussion
Conclusion
Dr. Madhusudan. B. G., DD of Icterus
2

3. MüÉqÉsÉÉ
MüÉqÉÇ ÌmɨÉÇ sÉÉÌiÉ uÉkÉïrÉÌiÉ CÌiÉ
MüÉqÉsÉÉ |
MüÉqÉsÉÉ
As a stage of mÉÉhQÒû
As a synonym of mÉÉhQÒû
As a type of mÉÉhQÒû
As a sɤÉhÉ in different diseases..
MüÉqÉsÉÉ can be seen as a disease and as a
symptom.
Dr. Madhusudan. B. G., DD of Icterus
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4. MüÉqÉsÉÉ
• ÌmɨÉeÉ mÉÉhQÒû
• MüÉå¸zÉÉZÉÉÍ´ÉiÉ MüÉqÉsÉÉ –
oÉWÒûÌmÉ¨É MüÉqÉsÉÉ
• xuÉiÉÇ§É MüÉqÉsÉÉ *** mÉUiÉǧÉ
MüÉqÉsÉÉ
• ®mÉjÉ MüÉqÉsÉÉ
zÉÉZÉÉÍ´ÉiÉ
MüÉqÉsÉÉ
• MüÉqÉsÉÉ
MÑüqpÉ MüÉqÉsÉÉ
Dr. Madhusudan. B. G., DD of Icterus
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5. ICTERUS
• Yellowish pigmentation of Sclera, Skin and
Mucous membranes.
• This condition is also termed as JAUNDICE.
• French word jaune meaning yellow.
• Yellow discolouration will be because of
accumulation of Bile Pigments in the Sclera,
Mucous membranes, Skin, Nails.
• Bile pigments have affinity to tissues containing
ELASTIN.
• More appropriate to be considered as a symptom
rather than a disease.
Dr. Madhusudan. B. G., DD of Icterus
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6. BILIRUBIN METABOLISM-PREHEPATIC
@ the RES
RBC Destruction
Heme+Globulin
Heme
Biliverdin
UNCONJUGATED BILIRUBIN
Bilirubin+Albumin
UCB=UnConjugated Bilirubin
Dr. Madhusudan. B. G., DD of Icterus
INDIRECT BILIRUBIN
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7. BILIRUBIN METABOLISM-HEPATIC
UCB
Protein Y & Z
Albumin + Bilirubin
+
UDP-GT
Glucorunic Acid
@ the RES
RBC Destruction
Hb+Globulin
Heme
Biliverdin
CONJUGATED BILIRUBIN
Unconjugated Bilirubin
DIRECT BILIRUBIN
Dr. Madhusudan. B. G., DD of Icterus
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8. BILIRUBIN METABOLISM-POST HEPATIC
@ the RES
UCB
RBC Destruction
Hb+Globulin
CONJUGATED BILIRUBIN
Heme
Biliverdin
Unconjugated Bilirubin
Fecal
Urobilinogen
Stercobilinogen
Urinary
Urobilinogen
Dr. Madhusudan. B. G., DD of Icterus
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9. HEMOLYTIC OR PRE-HEPATIC JAUNDICE
RBC Destruction RBC DestructionRBC Destructi
RBC Destruction Destruction RBC Destruction
RBC
RBC DestructionRBC Destruction RBC Destructi
RBC Destruction RBC Destruction RBC Destruc
RBC Destruction Destruction RBC Destru
RBC
RBC Destruction
HEME+GLOBULIN
@ the RES
SPLEENOMEGALY
++++++++++
JAUNDICE
ANAEMIA
HEME
++++++++++
++++++++++
+++++++++++++++++++++++++++++++
TO BLOOD
Dr. Madhusudan. B. G., DD of Icterus
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10. HEPATIC JAUNDICE
UCB
Bilirubin
+
Glucorunic Acid
Protein Y & Z
Glucorunyl
transferase
CONJUGATED BILIRUBIN
Dr. Madhusudan. B. G., DD of Icterus
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11. OBSTRUCTIVE JAUNDICE
OBSTRUCION WITHIN THE LIVER
INTRA-HEPATIC
CHOLESTASIS
OR
OUTSIDE
@ COMMON HEPATIC DUCT
@ COMMON BILE DUCT
@ AMPULLA OF VATER
ASCARIS
Dr. Madhusudan. B. G., DD of Icterus
EXTRA-HEPATIC
CHOLESTASIS
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12. WHAT CAUSES JAUNDICE..???
Excess production of Bilirubin
Impaired hepatic uptake of UCB
Impaired conjugation of Bilirubin
Decreased excretion of CB
Dr. Madhusudan. B. G., DD of Icterus
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13. TYPES OF JAUNDICE
UNCONJUGATED
RETENTION
PRE-HEPATIC
CONJUGATED
REGURGITATION
HEPATIC
MIXED
POST-HEPATIC
Dr. Madhusudan. B. G., DD of Icterus
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14. CONJUGATED UNCONJUGATED
CONJ / UNCONJ HYPERBILIRUBINAEMIA
PRE – HEPATIC
HEPATIC
HEPATIC
POST – HEPATIC
Dr. Madhusudan. B. G., DD of Icterus
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15. LFT
 Tests based on EXCRETORY Functions
• Bile salts
• Bilirubin
 Tests based on serum ENZYMES of Liver
• ALT
• AST
• ALP
• GGT
 Tests based on SYNTHETIC activity
• Prothrombin Time
• Albumin
Dr. Madhusudan. B. G., DD of Icterus
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16. ALT=ALAT=SGPT
• Alanine Transaminase = Alanine
Aminotransaminase = Serum Glutamic Pyruvic
Transaminase
• ALT – Viral Hepatitis, Liver damage, Bile duct
pathology, Diabetes, CCF, IM, Myopathies,
NSAIDs, Antibiotics, Anti-convulsants, Antipsychotics.
ALT+ ALP – Bile duct pathology
ALT + CK Enzyme - Myopathies
Dr. Madhusudan. B. G., DD of Icterus
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17. AST=ASAT=SGOT
• Aspartate Transaminase = Aspartate
Aminotransaminase = Serum Glutamic
Oxaloacetic Transaminase
• Found in Liver, Heart, Skeletal muscle, Kidneys,
Brain, Pancreas, Lungs, WBCs and RBCs.
• AST – MI, Hepatitis, Ac. Pancreatitis, Ac.
Hemolytic Anaemia, ARF, Trauma,
Musculoskeletal diseases, Burns.
ALT is more specific indicator of Liver inflammation than AST
Dr. Madhusudan. B. G., DD of Icterus
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18. ALP – ALKALINE PHOSPHATASE
• Present in most tissues, richest being in Bone
osteoblasts, Bile canaliculi, S I Epithelium, PCT
of Kidneys, Placenta, Lactating breasts.
• Adults – mainly derived from Liver.
• In Infancy, Childhood, Rickets, Paget’s disease,
Fractures, Bone cancers – mainly derived from
Bones.
• ALP – Post Menopausal women on HRT,
Pernicious Anaemia, Aplastic Anaemia, CML,
Cretinism, Wilson’s disease.
Dr. Madhusudan. B. G., DD of Icterus
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19. ALP – ALKALINE PHOSPHATASE
• ALP – Primary Hypothyroidism,
Hyperthyroidism, Hodgkin’s Lymphoma,
Polycythemia Vera, IM, DM, CCF, Amyloidosis.
Ca – Liver, Breast, Colon, Lung, Pancreas.
Almost all Liver disorders – such as –
Hepatitis, Cholecystitis, Cholangitis, Cholestasis,
Tumours, Cirrhosis, etc.
LOOK FOR GGT & 5’-NUCLEOTIDASE
Dr. Madhusudan. B. G., DD of Icterus
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20. gGT
• γ-glutamyl transferase
• Present in cell membranes of many tissues –
Liver, Bile duct, Gall bladder, Kidneys, Pancreas,
Spleen, Heart, Brain, Seminal vesicles.
• Isolated or disappropriate elevation – ALD
• GGT – Diseases of Liver, Biliary tract, Pancreas
and also in MI.
GGT has better sensitivity than ALP in biliary tract diseases.
Dr. Madhusudan. B. G., DD of Icterus
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21. SERUM ALBUMIN
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•
•
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Produced in Liver
Half of the serum proteins
Oncotic pressure, Carrier protein
in – Chronic Liver diseases – Cirrhosis, Renal
disorders, Burns, Pregnancy.
• in – Severe or chronic Dehydration, high
protein diet.
• IMP. IN CHRONIC CONDITIONS…
Dr. Madhusudan. B. G., DD of Icterus
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22. PROTHROMBIN TIME
• Except factor VIII all others are synthesized in
the Liver by hepatocytes
• Factors II, VII, IX, X are Vit-K dependant
• Vit-K – Fat soluble vitamin
• Prognostic tool
Dr. Madhusudan. B. G., DD of Icterus
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23. APPROACH TO A CASE OF JAUNDICE
•
•
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•
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Detailed History
Associated complaints
Physical Examination
Laboratory Diagnosis
Radiological Investigations
Dr. Madhusudan. B. G., DD of Icterus
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24. CASE STUDY - HEPATITIS
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•
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• Viral
History-Travel, Contact, Sex, Rx, Alcohol,…
• Toxic
Symptomatology-Fever, fatigue, pain abd,…
• Drugs
Examination-Sick look, Tender liver, icetrus,..
• Auto-immune
Laboratory Investigations- Mixed, AST, ALT
Recovery / Relapse
Chronic Hepatitis-B,C,D
Complications-B,C,D
Dr. Madhusudan. B. G., DD of Icterus
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25. DD – VIRAL HEPATITIS
• HAV – IgM anti-HAV
• HBV – ACUTE – HBsAg, IgM anti-HBc
CHRONIC – IgG anti-HBc, HBeAg
• HCV – anti-HCV, HCV RNA
• HDV – anti-HDV, HDV RNA
• HEV – IgM/IgG anti-HEV
Dr. Madhusudan. B. G., DD of Icterus
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26. CASE STUDY - ALD
• 2 billion alcoholics, 76.3 million diseased.
• 30% Indian adults are alcoholics.
• Risk factors
• Fatty liver
Alcoholic Hepatitis
Cirrhosis
• MADDREY’S Discriminant Function
DF=[4.6X(PT-Control)]+Bilirubin
Dr. Madhusudan. B. G., DD of Icterus
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27. CASE STUDY - CIRRHOSIS
• Causes-Alcohol, Fatty Liver, Ch.Hepatitis-B,C,
Wilson’s Dis, PBC, Auto-immune Hepatitis
• Symptomatology-Chronic Jandice, Weight loss,
Abd pain, Abd distension, Intense nausea
• Signs-Jaundice, Ascites, Palmar erythema,
Spider angioma, Spleenomegaly, Tremor
• Diagnosis-BIOPSY, Alb, Bil, PTT, Globulins
Dr. Madhusudan. B. G., DD of Icterus
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28. CASE STUDY – OBSTRUCTIVE JAUNDICE
• History-Gall stones, Pain abd, Weight loss
• Causes-Impacted Gall stones, Worms, Growth
in the Biliary tract or Head of Pancreas
• Symptomatology-Pain abd, Intolerable itching,
Weight loss, pale stools
• Signs-Greenish yellow sclera, mucous, skin,
• Diagnosis- CB, ALP, GGT.
USG, ERCP
Dr. Madhusudan. B. G., DD of Icterus
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29. CASE STUDY – LIVER CANCER
• 3rd leading cause of death
• Risk factors-Hep-B,C, Cirrhosis, Obesity,
Aflatoxins, Tumors of abdomen and pelvis
• Symptomatology-Weight loss, Pain abdomen,
Abd mass, Vomiting, Fever, Fatigue
• Diagnosis-USG, CT, α-feto protien(AFP)
Dr. Madhusudan. B. G., DD of Icterus
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30. CASE STUDY - LEPTOSPIROSIS
•
•
•
•
•
Weil’s Syndrome, Black jaundice
Spirochete – Leptospira
Commonest ZOONOTIC disease.
Mild febrile illness to MULTIPLE ORGAN FAILURE
Diagnosis-Culture, MAT, IgM ELISA
YELLOW FEVER
Dr. Madhusudan. B. G., DD of Icterus
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31. ΔΔ
WHEN YOU HEAR HOOFBEATS
LOOK FOR HORSES, NOT FOR ZEBRAS
UÉåaÉqÉÉSÉæ mÉUϤÉåiÉ iÉiÉÉå
AlÉliÉUqÉÉæwÉkÉqÉç |
iÉiÉÈ MüqÉï ÍpÉwÉMçü mɶÉÉiÉç
¥ÉÉlÉmÉÔuÉïÇ xÉqÉÉcÉUåiÉç ||
WûÉËUSìuÉhÉïÇ ÂÍkÉUÇ cÉ qÉÔ§ÉÇ ÌuÉlÉÉ
mÉëqÉåWûxrÉ ÌWû mÉÔuÉïÃmÉæÈ |
Dr. Madhusudan. B. G., DD of Icterus
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32. ΔΔ - AGE
• NEONATES – Pathological / Physiological
• CHILDREN – Viral Hepatitis, Drugs, Wilson’s,
Thalassemia, Sickle Cell disease
• ADULTHOOD – Viral Hepatitis, ALD, Cirrhosis,
Drugs,
• OLD – Cirrhosis, Primary or Secondary
tumours, Biliary tree atresia
• PREGNANCY – Obstetric Hepatosis, Acute
fatty liver of Pregnancy
Dr. Madhusudan. B. G., DD of Icterus
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33. NEONATAL JAUNDICE
• Commonest requiring
medical intervention
• Clinically detectable
when bilirubin is above
5mg/dl
• Why does it occur..???
• Breast milk Jaundice
• Breastfeeding Jaundice
Dr. Madhusudan. B. G., DD of Icterus
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34. NEONATAL JAUNDICE
PHYSIOLOGICAL
PATHOLOGICAL
STARTS @
After 4 days
1st or 2nd Day
BILIRUBIN
< 20mg/dl
> 20mg/dl
KERNICTERUS Rare
Common
RESOLVES
Late
Early
Dr. Madhusudan. B. G., DD of Icterus
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35. ΔΔ - SEVERITY
MILD – Hemolytic, Gilbert’s Syndrome, Rotor
Syndrome.
MODERATE – Drugs, Chemotherapy, Hepatitis,
Benign or Malignancy.
SEVERE – Neonatal, CBD Obstruction, Severe
Hepatic Failure, CNS, DJS,
Choledocholithiasis.
Jaundice in Cirrhosis might be Mild, Moderate
and Severe based on the extent and features.
Dr. Madhusudan. B. G., DD of Icterus
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36. ΔΔ - COLOUR
PALE YELLOW
In Hemolytic Jaundice, where Bilirubin doesn’t exceed 5mg/dl.
A symptom of UNCONJUGATED HYPERBILIRUBINAEMIA.
ORANGE YELLOW
In Hepatic and Mild to Moderate Cholestatic Jaundice.
YELLOW GREEN
In COMPLETE Obstruction Jaundice/Chronic Jaundice
Dr. Madhusudan. B. G., DD of Icterus
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37. ΔΔ – LABORATORY INVESTIGATIONS
• SBR, Normal ALT, AST, ALP.
• SBR, Tranaminases, Normal or mild ALP.
• SBR,
ALP, Normal or mild Transaminases.
• S. Albumin abnormalities
Dr. Madhusudan. B. G., DD of Icterus
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38. ΔΔ – ICTERUS
• VERY LIMITED
• CAROTENAEMIA – Yellowish discoloration of
skin, especially on the palms and soles, but not
of the mucous membranes. SCLERA SPARED
• QUINACRINE OVERDOSE
• EXCESSIVE EXPOSURE TO PHENOLS
Dr. Madhusudan. B. G., DD of Icterus
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39. PRINCIPLES OF TREATMENT
• Treat the ÌlÉSÉlÉÉjÉïMüU UÉåaÉ |
• ÌiÉ£ü UxÉ SìurÉÉÈ, qÉëÑSÒ ÌuÉUåcÉlÉ,
MüTüWûUhÉ |
• Where to treat and where not to..
• In Pre-hepatic and Post-hepatic Jaundice,
TREAT THE CAUSE
• Post-hepatic / Obstructive = SURGICAL JAUNDICE
• Hepatic – ÌmÉ¨É UåcÉMüÉÈ, ÌiÉ£ü mÉëkÉÉlÉ
SìurÉÉÈ,
Hepatoprotectives…
Dr. Madhusudan. B. G., DD of Icterus
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40. DISCUSSION
•
•
•
•
•
MEDICAL ERROR / MISDIAGNOSIS
HUMAN ERROR
15,00,000/8,00,000/4,00,000/5,30,000
1,80,000 die of medical error.
Affects 1 in every 10 patients.
• mÉUϤrÉMüÉËUhÉÉå ÌWû MÑüzÉsÉÉ
pÉuÉÎliÉ
Dr. Madhusudan. B. G., DD of Icterus
40

41. CONCLUSION
• Consequences, Dependency, Func reserve…
• UÉåaÉqÉÉSÉæ mÉUϤÉåiÉ iÉiÉÉå
AlÉliÉUÇ AÉæwÉkÉqÉç |
iÉiÉÈ MüqÉï ÍpÉwÉMçü mɶÉÉiÉç
¥ÉÉlÉmÉÔuÉïÇ xÉqÉÉcÉUåiÉç ||
• Proper Diagnosis – Proper treatment
• Improper preparations, Improper dosages
end up in hepatotoxicity
• xÉÉkrÉ AxÉkrÉiÉÉ
• ÌlÉSÉlÉ mÉËUuÉeÉïlÉ, xÉqmÉëÉÎmiÉ
Dr. Madhusudan. B. G., DD of Icterus
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42. SOME INTERESTING FACTS
• Bilirubin on the higher note is beneficial as it
has potent anti-oxidant effects and so person
has reduced risk of Cardio vascular diseases.
• Napoleon-I had Gilbert’s Syndrome
• In ancient Greece it was thought that jaundice
could be cured if the patient gazes at a yellow
bird as the disease would transmigrate from
patient to bird.
• Napoleon army while conquering
Egypt had suffered from Leptospirosis
Dr. Madhusudan. B. G., DD of Icterus
42

43. хвала
THANK U
Dr. Madhusudan. B. G., DD of Icterus
43