Definition• Is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the
Etiology1.Unconjugated hyperbilirubinaemia• Pre-hepatic- increases the load of bilirubin to be metabolized by the liver2 . Conjugated hyperbilirubinaemia• Hepatocellular-damages or reduces the activity of the transferase enzyme or hepatocyte• Post-hepatic-also called obstructive jaundice, is caused by an interruption to the drainage of bile in the biliary system
Etiology• Pre-hepaticHemolytic anemias;Polycythemia; Shortened red cell life as a result of immaturity or transfused cells ;Drug induced (antimalarias);G- 6PD;etc.• HepatocellularViruses:Hepatitis(A,B,C,D,E);CMV,EBV;Drugs;Autoimmune Hepatitis;Wilsons Disease;Right Heart Failure;Drug induced(Paracetamol, Isoniazid,rifampicin,pyrazinamide); etc.• Post-hepaticExtrinsic obstruction of the bile duct ;Biliary atresia;Common bile duct gallstones;Drugs induced (steroids,flucloxacilin);etc.
Common Causes In Older Children• Infection-eg. Viral (Hepatitis A,B,C,D,E),EB,Malaria,Leptospira• Autoimmune eg. SLE,Kawasaki• Infiltrative eg.Malignancy• Metabolic eg. Wilson,CF• Narrow or obstructed bile ducts• Toxin & drugs eg.AcetaminophanI MET 3
History Taking• ID/CC: Age, sex, symptom• HoPI:-Elaborate the symptoms1. Onset (sudden or progressively)?• sudden (Infection .)• proggressive ( Obstrustion above hepatobiliary duct, chornic hemolysis eg.Thalassaemia ,chronic hepatitis etc.)2. Asso: symptoms- Fever, LOA, Pallor, Stool & urine colour,vomiting,abdo;pain, rash, arthralgia3. if there is any aggravating factor (bloods transfusion, intake of food / drugs).4. Exposures to epidemic areas?
History Taking cont:Sleep—quantity, quality, disturbances (restlessness),
History Taking• PMH:• Pregnancy—gravida/para status, maternal age, duration, exposures (medications,alcohol, tobacco, drugs, infections, radiation); complications (bleeding, gestational diabetes, hypertension, etc.), problems with past pregnancies• Labor and delivery—length of labor, rupture of membranes, fetal movement, medications, presentation/delivery,mode of delivery, assistance (forceps, vacuum), complications, Apgars• Neonatal—birth height/weight, abnormalities/injuries, length of hospital stay, complications (respiratory distress,cyanosis, anemia, jaundice, seizures, anomalies, infections), behavior• Infancy—temperament, feeding, family reactions to infant• Illnesses/hospitalizations/surgeries/accidents/injuries —dates, medications/interventions, impact on child/family• Past medical illness• Medicatioion/Drug H/O—past (antibiotics, especially), present, reactions• Allergies—include reaction• Immunizations—up to date, reactions• Family history—relatives, ages, health problems, deaths (age/cause), miscarriages/stillbirths/deaths of infantsor children• Social history—parents’ education and occupation, living arrangements, pets, water (city or well), lead exposure(old house, paint), smoke exposure, , risk-taking behaviors,school/daycare
Investigation• Full blood count (RBC,Retic )• Liver function tests(ALT, AST,GGT, AKP,T&DP,TB,UCB,CB)1. TB+UCB = pre-hepatic2. TB+UCB+CB =hepatic3. TB+CB = post-hepatcic• Coagulation profile –PT,INR• Ultrasound (In adavanced MRCP,ERCP)• Urine FEME,• Urine for leptospiral Ag• Renal function test• Stool test• Genetic Test (G-6PD ,Thalasseamia)• Serology Test for viruses(Hepatitis A,B,C,D,E)• Serology Test for Autoimmune• Coombs test• Liver biopsy
Table of Diagnosis TestFunction test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic JaundiceTotal bilirubin Normal / Increased Increased IncreasedConjugated bilirubin Normal Increased IncreasedUnconjugated Normal / Increased Increased NormalbilirubinUrobilinogen Normal / Increased Increased Decreased / NegativeUrine Color Normal Dark (urobilinogen + Dark (conjugated conjugated bilirubin) bilirubin)Stool Color Normal Normal/Pale PaleAlkaline phosphatase Normal Increased IncreasedlevelsAlanine transferase Normal Increased Increasedand Aspartatetransferase levelsConjugated Bilirubin Not Present Present Presentin Urine
References• Goljan, Edward F., Rapid Review Pathology 2nd edition. Pg. 368–369. 2007.• First Aid For The Pediatric Clerkship Pg.9-10• Oxford Handbook Of Clinical Medicine Pg.250-251• Nelsons Pediatrics 18th edition• Essential Nelson• Current Paed: