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Approach To A Patient With Jaundice

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  • AST, ALT, Alkaline phosphatase => almost normalSerum protein level => normalAlbumin:globulin ratio => normal
  • Tender hepatomegaly: acute hepatitis
  • Hepatocellular => disproportonate rise in aminotransferases compared to alkaline phosphataseCholestatic => disproportonate rise in alkaline phosphatase compared to aminotransferases
  • Transcript

    • 1. Dr.tanujpaulbhatia
      Approach to a patient with jaundice
    • 2. What is jaundice?
      Yellowish discoloration of skin, sclerae and mucus membranes due to hyperbilirubinemia
      Total bilirubin > 1.5 mg/dl
    • 3. Types of jaundice
    • 4. Hemolytic Jaundice
      Excess production of bilirubin due to excess breakdown of hemoglobin
      Indirect bilirubin (insoluble in water since unconjugated)
      E.g.
      Hemolytic anemia
      Malaria
      Glucose-6-phosphate dehydrogenase deficiency
    • 5. Hepatic Jaundice
      Liver’s ability to conjugate or excrete bilirubin is affected
      Increased level of conjugated and unconjugatedbilirubin
      E.g.:
      Hepatitis, cirrhosis, hepatocellular carcinoma, prolonged use of drugs metabolized by liver
      Genetic disorders:
      Gilbert’s syndrome
      Criggler-Neijer Syndrome
    • 6. Obstructive Jaundice
      Bilirubin formation rate is normal
      Conjugation is normal = direct bilirubin
      Obstruction of bile duct so exit is blocked
      Tumor of the head of the pancreas
      Cholecystitis (gallstones)
    • 7. History
      Pain
      Fever
      Alcohol
      Medications
      Pruritus
      Color of urine
      Type of stools
      Fatigue
    • 8. Physical examination
      BP/HR/Temp.
      Degree of jaundice
      Presence of anemia
      Abdominal tenderness
      Size and character of liver
      Any palpable mass e.g. gall bladder(curvoisier’s law)
      Signs of liver failure
      Mental status
    • 9. Icterus .…………………………………. Ascites
    • 10. Lab investigations
      Complete blood count
      Liver function tests
      BT/CT
      PT/INR
      Serum albumin
      ?blood culture
    • 11. Other investigations
      Ultrasound:
      More sensitive than CT for gallbladder stones
      Equally sensitive for dilated ducts
      Portable, cheap, no radiation, no IV contrast
      CT:
      Better imaging of the pancreas and abdomen
      PTC- percutaneoustranshepaticcholangiogram
      Gives a picture of the intra and extrahepaticbiliary tree
    • 12. MRCP:
      Imaging of biliary tree comparable to ERCP
      Non invasive
      ERCP:
      Therapeutic intervention for stones
      Brushing and biopsy for malignancy
      Invasive, chances of developing pancreatitis post procedure
    • 13. Liver function tests
    • 14. Enzymes
      Alkaline phosphatase
      Bone and liver
      Specific for obstructive jaundice
      Released from biliarycanaliculi in case of bile duct obstruction
      Aspartateaminotransferase (AST/SGOT)
      Reflects damage to hepatic cell
      Less specific
      May be elevated in MI
      Used with ALT to diffrentiate between heart and liver disease
      Alanineaminotransferase (ALT/SGPT)
      Produced withing the cells of the liver
      Most sensitive marker for liver cell damage
    • 15. Patient A
      42 year old female with history of general weakness of 4 months. She was found to have moderate anemia, jaundice and mild splenomegaly.
      Hemolytic Jaundice
    • 16. Clinical Findings—Hemolytic Jaundice
      Decreased hemoglobin
      Explains weakness
      Has moderate anemia
      Splenomegaly
      Increased activity of reticuloendothelial system
      Site of RBC filtration
      Liver Function Tests:
      Increased Serum bilirubin
      Increased load to the liver (increased hemolysis) => increased hemoglobin metabolism
    • 17. Patient B
      30 year old male with history of fever of 2 weeks, nausea and highly colored urine. He had palpable, soft tender liver.
      Hepatic Jaundice
    • 18. Clinical Findings—Hepatic Jaundice
      Highly colored urine
      Increased amount of bilirubin excretion
      Tender hepatomegaly
      Liver function tests
      High serum bilirubin
      AST and ALT highly increased
      Alkaline phosphatase increased moderately
      Seen in both hepatocellular jaundice and cholestatic jaundice
    • 19. Patient C
      35 yr old male with complaints of pain abdomen, jaundice,itching and passing clay colored stools.
      Previously he was diagnosed with gall bladder stones but has not taken treatment.
      Gall bladder is not palpable.
      Obstructive jaundice due to CBD stones.
    • 20. Patient D
      60 yr old male patient with progressive jaundice, itching, loss of weight .
      On palpation gall bladder is palpable.
      Obstructive jaundice due to malignancy
      Periampulary carcinoma
    • 21. Clinical findings in obstructive jaundice
      Deep jaundice
      Scratch marks on body
      High colored urine
      Clay colored stools
      Other features
      ?pain
      ?weight loss
      ?palpable gall bladder
      ?ascites
    • 22. Curvoisier’s law
      “In a case of obstructive jaundice, if the gall bladder is palpable, it is unlikely to be due to stones.”
      Explanation :
    • 23. How to differentiate the types of jaundice?
      Hemolytic:
      Increased unconjugated (indirect) more than direct (conjugated) bilirubin
      Hemoglobin level low
      Anemia
      Hepatic:
      Increased amount of both indirect and direct
      Increase in AST and ALT more than increase in ALP
      Obstructive:
      Increased amount of direct (conjugated)
      Significant increase in ALP more than AST and ALT
    • 24. Treat
    • 25. Obstructive jaundice
    • 26. Obstructive jaundice - etiology
      CHOLEDOCHOLITHIASIS
      NEOPLASMS- periampullary carcinomas
      3. BILIARY ATRESIA
      4. CHOLEDOCHAL CYST
      5. LYMPHADENOPATHY-PORTA HEPATIS
      6. TRAUMATIC- POST CHOLECYSECTOMY
    • 27. Diagnosis
      LFT
      USG abdomen
      CT abdomen
      PTC
      ERCP
      MRCP
    • 28. USG abdomen
    • 29. CT abdomen
    • 30. ERCP
    • 31. Treatment
      Choledocholithiasis
      Open / laparoscopic CBD exploration with stone extraction and T tube placement.
      Endoscopic papillotomy and extraction
      Periampularry carcinoma
      Curative – whipple’s procedure
      Palliative –
      - endoscopic stenting of ampulla
      - bypass prcodures for
      Food e.g. gastrojejunostomy
      Bile e.g. choledochojejunostomy
    • 32. 1. Gall stones removed from CBD2. T-tube cholangiogram
    • 33. Whipple’s operation
      3 structures removed
      C-loop of duodenum
      Head and neck of pancreas
      Pylorus of stomach
      3 anastomosis are made
      Gastro-jejunostomy
      Choledocho-jejunostomy
      Pancreatico-jejunostomy
    • 34. Resectedg.b. and opened C-loop showing periampullary growth
    • 35. Thank you

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