What is Jaundice?• Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyperbilirubinemia and deposition of bile pigments .• Equilibrium between bilirubin production and clearance is disturbed .• Serum bilirubin level greater than 2mg/dL• Jaundice is NOT a disease, but rather a sign that can occur in many different diseases.
What is bilirubin?•Bilirubin is a yellowish pigment found inbile, a fluid made by the liver.•The breakdown product of Hgb frominjured RBCs and other heme containingproteins.•Produced by reticuloendothelial system•Released to plasma bound to albumin•Hepatocytes conjugate it and extretethrough bile channels into small intest.
What causes bilirubin?1. Overproduction by reticuloendothelial system2. Failure of hepatocyte uptake3. Failure to conjugate or excrete4. Obstruction of biliary excretion into intestine Normal Range of Bilirubin It is normal to have some bilirubin in your blood. Normal levels are: •Direct (also called conjugated) bilirubin: 0 to 0.3 mg/dL •Total bilirubin: 0.3 to 1.9 mg/dL
TYPES OF JAUNDICEPRE HEPATIC HEPATIC POST HEPATICExcessive amount of Impaired cellular Impaired excretion duebilirubin is presented uptake, defective to mechanicalto the liver due to conjugation or obstruction to bile flowexcessive hemolysis abnormal secretion of bilirubin by the liver cellElevated Both conjugated and Elevated conjugatedunconjugated bilirubin unconjugated bilirubin in serumin serum bilirubin may be elevated in serum
TYPES OF JAUNDICE TYPE PRE HEPATIC POST HEPATIC HEPATICUrine color normal dark darkStool color normal normal acholic Pruritus no No yes
There are other types of Jaundice : Pathologic JaundicePathologic jaundice can occur in children and adults and is diagnosed whenjaundice presents a health risk. Several forms of hepatitis, cirrhosis of theliver and other liver diseases, bile duct blockage, along with infections andmedications, can also cause pathological jaundice. Gilbert Syndrome JaundiceGilberts syndrome is a harmless hereditary condition thatresults in mild jaundice. During times of illness or stress, peoplewith Gilberts syndrome will experience low levels of somebilirubin-processing enzymes in their livers, according toLabTestsOnline.com. Once diagnosed, Gilberts syndrome doesnot require further medical treatment.
Neonatal Jaundice•Jaundice is clinically detectable in the newborn whenthe serum bilirubin levels are greater than 85 μmol/L.This occurs in approximately 60% of term infants and80% of preterm infants.•Neonatal jaundice first becomes visible in the faceand forehead. Blanching reveals the underlyingcolour. Jaundice then gradually becomes visible onthe trunk and extremities.
Signs and Symptoms of Neonatal Jaundice Newborns, as the bilirubin level rises, jaundice will typically progress from the head to the trunk, and then to the hands and feet. Additional signs and symptoms that may be seen in the newborn include: 1. poor feeding 2. lethargy 3. changes in muscle tone 4. high-pitched crying 5. seizures.
Obstructive JaundiceObstructive jaundice is a condition in which there is blockage of the flow ofbile out of the liver INTRAHEPATIC EXTRAHEPATIC
CAUSES OF OBSTRUCTIVE JAUNDICE: EXTRAHEPATIC• Choledocholithiasis• Malignancy : Pancreatic (head of pancreas) carcinoma Choledocholithiasis Malignancy : Pancreatic (head of pancreas) carcinoma
REMOVAL OF OBSTRUCTION JAUNDICE• Non-surgical – Extracorporeal Shockwave Lithotripsy • Non-invasive • successive shock wave pressure pulses – fragment the stones into smaller pieces so they can easily pass through the duct – Endoscopic Retrograde Cholangionpancreatography • insertion of the endoscope up into the ducts in a direction opposite to or against the normal flow of bile down the ducts (retrograde)
• Surgical – Laparoscopic Cholecystectomy • aka minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery • small incisions, usually 0.5-1.5 cm • Laparoscope: a telescopic rod lens system, that is usually connected to a video camera. • fiber optic cable system connected to a light source and cannula or trocar for view of the operative field
Causes of JaundiceJaundice occurs when there is:1. too much bilirubin being produced for the liver to remove from the blood (for example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood)1. a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile; or
3- blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. For example, the bile ducts can be blocked by cancer, gallstones, or inflammation of the bile ducts. The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.
Signs and Symptoms of JaundiceCommon signs and symptoms seen inindividuals with jaundice include:1. yellow discoloration of the skin2. mucous membranes3. the whites of the eyes4. light-colored stools5. dark-colored urine6. itching of the skin.7. nausea and vomiting8. abdominal pain9. fever10.weakness11.loss of appetite12.headache13.confusion14.swelling of the legs and abdomen.
Diagnosis of JaundiceThe health care provider will perform a physical exam. This mayreveal liver swelling.•A bilirubin blood test will be done.Other tests vary, but may include:•Hepatitis virus panel to look for infection of the liver•Liver function tests to determine how well the liver is working•Complete blood count to check for low blood count or anemia•Abdominal ultrasound•Abdominal CT scan•Endoscopic retrograde cholangiopancreatography (ERCP)•Percutaneous transhepatic cholangiogram (PTCA)•Liver biopsy•Cholesterol level•Prothrombin time
Imaging testsIf intra-hepatic jaundice or post-hepatic jaundice is suspected, its oftenpossible to confirm the diagnosis using imaging tests to check for anyabnormalities inside the liver or bile duct systems
Table of diagnostic testsFunction test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic JaundiceTotal bilirubin Normal / Increased IncreasedConjugated bilirubin Normal Increased IncreasedUnconjugated bilirubin Normal / Increased Increased NormalUrobilinogen Normal / Increased Increased Decreased / Negative Dark (urobilinogen + Dark (conjugatedUrine Color Normal conjugated bilirubin) bilirubin)Stool Color Normal Normal/Pale PaleAlkaline phosphatase IncreasedlevelsAlanine transferase and NormalAspartate transferase IncreasedlevelsConjugated Bilirubin in Not Present PresentUrineSplenomegaly Present Present Absent
What about jaundice in pregnancy?Most of the diseases discussed previously can affect women during pregnancy,but there are some additional causes of jaundice that are unique to pregnancy. 1- Cholestasis of pregnancy. Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis often is accompanied by itching but infrequently causes jaundice. The itching can be severe, but can be treated with drugs (ursodeoxycholic acid or ursodiol [Actigall, Urso]). There also is an association between cholestasis of pregnancy and cholestasis caused by oral estrogens, and it has been hypothesized that it is the increased estrogens during pregnancy that are responsible for the cholestasis of pregnancy.
2- Pre-eclampsia.Pre-eclampsia, previously called toxemia of pregnancy, is a disease that occursduring the second half of pregnancy and involves several systems within thebody, including the liver. It may result in high blood pressure, fluid retention, anddamage to the kidneys as well as anemia and reduced numbers of platelets(thrombocytopenia) due to destruction of red blood cells and platelets. It oftencauses problems in the fetus. Although the bilirubin level in the blood is elevatedin pre-eclampsia, it usually is mildly elevated, and jaundice is uncommon. 3- Acute fatty liver of pregnancy. Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy. The cause of AFLP is unclear, but is often associated with pre- eclampsia. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but is not always present in AFLP.
Can we prevent Jaundice?Due to the wide range of potential causes, its not possible to prevent all cases ofjaundice. However, there are four main precautions that you can take tominimise your risk of developing jaundice. They are:1. ensuring that you stick to the recommended daily amount (RDA) for alcohol consumption2. maintaining a healthy weight for your height and build3. if appropriate, ensuring that youre vaccinated against a hepatitis A or B infection, vaccination would usually only be recommended depending on where in the world youre travelling .4. minimizing your risk of exposure to hepatitis C because theres currently no vaccine for the condition .
Jaundice TreatmentTreatment depends on the cause of the underlying condition leading to jaundiceand any potential complications related to it. Once a diagnosis is made, treatmentcan then be directed to address that particular condition, and it may or may notrequire hospitalization.1. Treatment may consist of expectant management (watchful waiting) at home with rest.2. Medical treatment with intravenous fluids, medications, antibiotics, or blood transfusions may be required.3. If a drug/toxin is the cause, these must be discontinued.4. In certain cases of newborn jaundice, exposing the baby to special colored lights (phototherapy) or exchange blood transfusions may be required to decrease elevated bilirubin levels.5. Surgical treatment may be required in case of obstruction jaundice.