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Jaundice (Icterus)

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  • 1. JAUNDICE (ICTERUS)
    • YELLOWISH DISCOLORATION OF SKIN & MUCOUS MEMBRANES
    • EXCESS BILIRUBIN IN PLASMA.
    • NORMAL RANGE 5-17 micromol/L
    • (0.3 – 1.0mg/dl)
    • LEVEL ABOUT 50 micromol/L (3mg/dl)
    • -> CLINICAL JAUNDICE
    • (SCLERA,SKIN,PALATAL MUCOSA)
  • 2. CONTD
    • DIAZO REAGENT(DIAZOTISED
    • SULPHANILIC ACID)->DEMONSTRATES
    • + BILIRUBIN
    • SODIUM NITRITE
    • +
    • HCL ->A RED COMPD. AZOBILIRUBIN
    • CONJUGATED BILIRUBIN ->IMMEDIATE
    • (POLAR MOLECULE) REACTION
    • DIRECT van den Berg reaction
    • UNCONJ.BILIRUBIN ->NO REACTION until alc.is added
    • (NONPOLAR) ->INDIRECT van den Berg reaction
  • 3.  
  • 4. contd
    • UROBILINOGEN-CONSISTS OF
    • UROBILINOGEN,
    • MESOBILINOGEN,
    • & STERCOBILINOGEN.
    • Conj. B. (soluble in water)- excreted in
    • urine.
    • Unconj.B.(bound to albumin)- lipid soluble (does not enter gl.filtrate)
    • DANGER- binding capacity of albumin exhausted--- absorbed by lipid rich areas in Brain.
    • Plasma level 340 micromol/l (20mg/dl)
    • Basal ganglia deeply bile stained- irreparable damage to neurons
    • KERNICTERUS
  • 5. TYPES OF JAUNDICE
    • HAEMOLYTIC.
    • OBSTRUCTIVE.&
    • HEPATOCELLULAR.
  • 6. HAEMOLYTIC JAUNDICE
    • ↑ BILIRUBIN LOAD DUE TO- EXCESSIVE
    • BREAKDOWN OF RBCs.
    • -INEFFECTIVE
    • ERRYTHROPOIESIS (↑IN
    • THALASSEMIA,PERNICIOUS ANAEMIA)
    • CONDITIONS ARE THOSE ASSOC. WITH HAEMOLYTIC ANAEMIA.
    • UNCONJ. HYPERBILIRUBINAEMIA +HEPATIC DYSFUNCTION DUE TO ANAEMIA
  • 7. CONTD.
    • BIOCHEM. MANIFESTATIONS
    • ↑ INDIRECTLY REACTING BILIRUBIN IN PLASMA.
    • ↑ STERCOBILINOGEN IN FAECES
    • ↑ UROBILINOGEN IN URINE.
    • ABSENCE OF BILIRUBIN IN URINE.
    • Jaundice not severe. seldom↑85micromol/l(5mg/dl) except
    • Rh haemolytic disease of newborn.
  • 8. OBSTRUCTIVE JAUNDICE
    • OBSTRUCTION TO PASSAGE OF CONJ. BILIRUBIN FROM LIVER CELLS ->INTESTINE.
    • CHOLESTASIS – EXTRAHEPATIC
    • INTRAHEPATIC
    • EXTRAHEPATIC CHOLESTASIS( surgical jaundice)
    • 1.Blockage of CBD by Gallstones.
    • 2.Occlusion of Duct by Ca head of Pancrease
    • 3.Pressure by enlarged L.nodes in Porta hepatis.
    • 4.Ca. of Duct itself either at Ampulla of Vater or higher
    • up.
  • 9. Contd.
    • INTRAHEPATIC CHOLESTASIS
    • LESS OBVIOUSLY ASSOC. WITH MECH. OBSTRUCTION.
    • 1.Sclerosing cholangitis
    • cholangiography -> multiple areas of stenosis& dilatations of intra & extra hepatic ducts.
    • Pr.– 85% assoc.with U. Colitis.
    • Sec.– in pts.with AIDS &in those with untreated bile duct stenosis
    • All varieties of sec. cholangitis progress to Cirrhosis.
    • 2.Pr. Biliary cirrhosis
  • 10. contd
    • 3.Rare compln.of last trimester of pregnancy
    • (effect of oestrogen),oral contraceptives.
    • 4. Drugs(cholestatic drug jaundice)
    • Chlorpromazine & other phenothiazines.
    • Halothane,Steroids.
    • BIOCHEMICAL MANIFESTATIONS
    • 1. ↑ Conjugated bilirubin in plasma.
    • 2.↓ stercobilinogen in faeces. (pale, bulky, offensive)
    • Bile salts excluded from bowel(absorption of fat)
    • Long standing cases—Malabsorption syndrome,
    • Fat soluble vitamins.↓Vit. K->bleeding
    • Hypovitaminosis D -Osteomalacia
  • 11. Contd
    • 3.Absence of urobilinogen in urine.
    • 4.Presence of bilirubin & bile salts in urine.
    • 5.↑ levels of Pl. alk.PO4ase& ץ glutamyl transferase.
    • -- Pruritis (pl. bile salt concn.&unconj. bile salts in skin)
    • -- Hypercholesterolaemia->cut. Xanthomas.
    • -- ↑ in LDLs & ↓ in HDLs
    • Abn.LDL-LipoproteinX(high proportion of
    • unesterified cholesterol& phospholipid)
    • --Hepatocellular damage
    • --Cirrhosis
  • 12. HEPATOCELLULAR JAUNDICE
    • DIRECT & INDIRECT reacting BILIRUBIN
    • ---Failure of conjugating mechanism
    • ---Obstruction to escape of cong. bilirubin
    • (from cells to canaliculi &from canaliculi)
    • intrahepatic cholestasis
  • 13. contd
    • 1.Enzyme deficiency.
    • 2.Intrahepatic cholestasis complicating liver cell damage.
    • a)Acute fatty liver-obstruction-pr.
    • b)Severe neonatal jaundice –obstruction-
    • inspissated bile in canaliculi.
    • 3.Cirrhosis-ac.exacerbation &terminally.
    • 4.Postop. Jaundice—hepatic necrosis(shock)
    • ----hepatitis(drugs)
    • ----red cell destruction(site, haemolysis of transfused cells)
  • 14.  
  • 15. STEPS IN DIAGNOSIS OF JAUNDICED PATIENT
    • CLINICAL HISTORY &EXAMINATION.
    • URINE,STOOL
    • SERUM BIOCHEMICAL TESTS
    • BILIRUBIN
    • TRANSAMINASE(AST,SGOT)
    • ALKALINE PHOSPHATASE,
    • GAMMA GT.
    • ALBUMIN
    • QUANTITATIVE IMMUNOGLOBULINS.
    • HAEMATOLOGY-Hb,WBC,PLATELETS
    • BLOOD FILM
    • PROTHROMBIN TIME(before & after IM Vit.K)
    • X’RAY CHEST

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