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Approach to a patient with
jaundice
Pr epar ed by:
Saj ad Al-Ramahy
Hawler Medical Univer sit y
Outlines
•
•
•
•

Introductoin
Bilirubine Metabolism
Types of jaundice
Management
What is jaundice?
• Yellowish discoloration of skin, mucous
membrane and the sclerae due to
hyperbilirubinemia
• Jaundice is usually detecta...
• Bilirubin
Metabolism
Jaundice can occur in four different ways:
• 1- Increased bilirubin load as in haemolysis.
2- Disturbance in the hepatic u...
Types of jaundice
Hemolytic Jaundice
• Excess production of
bilirubin due to excess
breakdown of hemoglobin
• Indirect bilirubin
(insoluble ...
Hepatic Jaundice
• Inability of the liver to
transport bilirubin across the
hepatocyte into bile, due to
parenchymal liver...
Acute or subacute hepatocellular injury

Viral hepatitis, alcohol, drugs, ischemic hepatitis, Wilson's disease,
acute fatt...
Obstructive Jaundice
• Caused by:
• Failure of hepatocyte to
initiates bile flow.
• Obstruction of bile flow in the
bile d...
•
•
•
•
•
•

Ex:
Tumor of the head of the pancrease
Choledocolithiasis
Parasitic infection
Traumatic biliary stricture
Pan...
History
•
•
•
•
•
•
•
•

Pain
Fever
Alcohol
Medications
Pruritus
Color of urine
Type of stools
Fatigue
Physical examination
•
•
•
•
•
•

BP/HR/Temp.
Degree of jaundice
Presence of anemia
Abdominal tenderness
Size and characte...
Icterus .…………………………………. Ascites
Lab investigations
•
•
•
•
•

Complete blood count
Liver function tests
BT/CT
PT/INR
Serum albumin
Other investigations
• Ultrasound:

– More sensitive than CT for gallbladder stones
– Equally sensitive for dilated ducts
...
• MRCP:
– Imaging of biliary tree comparable to ERCP
– Non invasive

• ERCP:
– Therapeutic intervention for stones
– Brush...
Liver function tests
Ser.Billirubin
Indirect

0.1 – 0.3 mg/dl

Direct

0.2 – 0.7 mg/dl

SGOT (AST)
LFT

0.2-0.8 mg/dl

0-3...
Enzymes

• Alkaline phosphatase

– Bone and liver
– Specific for obstructive jaundice
– Released from biliary canaliculi i...
Clinical Findings—Hemolytic Jaundice
• Decreased hemoglobin
– Explains weakness
– Has moderate anemia

• Splenomegaly
– In...
Clinical Findings—Hepatic Jaundice
• Highly colored urine
– Increased amount of bilirubin

• Tender hepatomegaly
• Liver f...
Clinical findings in obstructive jaundice
•
•
•
•

Deep jaundice
Scratch marks on body?
High colored urine
Clay colored st...
How to differentiate the types of
jaundice?
• Hemolytic:
– Increased unconjugated (indirect) more than direct
(conjugated)...
Treatment
• Treatment of pre hepatic and hepatic Jaundice
is by treating the underlying cause
• Choledocholithiasis
– Open...
Whipple’s operation
• 3 structures removed
– C-loop of duodenum
– Head and neck of pancreas
– Pylorus of stomach

• 3 anas...
References
• Davidson’s Principle and Practice of Medicine
• http://www.onhealth.com/jaundice/article.htm
• http://www.eme...
Thank you
Jaundice
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Jaundice

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Jaundice

  1. 1. Approach to a patient with jaundice Pr epar ed by: Saj ad Al-Ramahy Hawler Medical Univer sit y
  2. 2. Outlines • • • • Introductoin Bilirubine Metabolism Types of jaundice Management
  3. 3. What is jaundice?
  4. 4. • Yellowish discoloration of skin, mucous membrane and the sclerae due to hyperbilirubinemia • Jaundice is usually detectable when the plasma bilirubin exceeds 3 mg/dl (normally <1mg/dl)
  5. 5. • Bilirubin Metabolism
  6. 6. Jaundice can occur in four different ways: • 1- Increased bilirubin load as in haemolysis. 2- Disturbance in the hepatic uptake & transport of bilirubin within the hepatocytes 3- Defects in conjugation. 4- Defects in the excretion of conjugated bilirubin across the canalicular cell membrane or an obstruction of the large biliary channels.
  7. 7. Types of jaundice
  8. 8. 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
  9. 9. Hepatic Jaundice • Inability of the liver to transport bilirubin across the hepatocyte into bile, due to parenchymal liver disease. • Increased level of conjugated and unconjugated bilirubin • E.g.: – Hepatitis, cirrhosis, hepatocellular carcinoma, prolonged use of drugs metabolized by liver
  10. 10. Acute or subacute hepatocellular injury Viral hepatitis, alcohol, drugs, ischemic hepatitis, Wilson's disease, acute fatty liver of pregnancy Chronic hepatocellular Disease: Viral hepatitis, alcoholic, autoimmune hepatitis, Wilson dis., Haemochromatosis, NASH, alpha 1 antitrypsin deficiency. Hepatic disorders with prominent cholestasis. * Diffuse infiltrative disorders (e.g. granulomat dise. as TB, sarcoidosis, lymphoma, drugs) Amyloidosis, malignancy. * Inflammation of intrahepatic bile ductules (PBC), GVHD, Drugs (chloropromazine) • Miscellaneous e.g. use of oestrogen & steroids, TPN, bact. Infection. Genetic disorders: Gilbert’s syndrome Criggler-Neijer Syndrome
  11. 11. Obstructive Jaundice • Caused by: • Failure of hepatocyte to initiates bile flow. • Obstruction of bile flow in the bile duct or portal tracts. • Obstruction of bile flow in the extrahepatic bile duct • Bilirubin formation rate is normal • Conjugation is normal = direct bilirubin
  12. 12. • • • • • • Ex: Tumor of the head of the pancrease Choledocolithiasis Parasitic infection Traumatic biliary stricture Pancreatitis
  13. 13. History • • • • • • • • Pain Fever Alcohol Medications Pruritus Color of urine Type of stools Fatigue
  14. 14. 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 • Scratch marks?
  15. 15. Icterus .…………………………………. Ascites
  16. 16. Lab investigations • • • • • Complete blood count Liver function tests BT/CT PT/INR Serum albumin
  17. 17. 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- percutaneous transhepatic cholangiogram – Gives a picture of the intra and extrahepatic biliary tree
  18. 18. • 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
  19. 19. Liver function tests Ser.Billirubin Indirect 0.1 – 0.3 mg/dl Direct 0.2 – 0.7 mg/dl SGOT (AST) LFT 0.2-0.8 mg/dl 0-35 IU SGPT (ALT) 0-35 IU Alk. Phosph. 30-120 IU Ser. Protein 5.5 – 8.5 G/dl Alb 3.5 – 5.5 G/dl Glob 2.0 – 3.0 G/dl
  20. 20. Enzymes • Alkaline phosphatase – Bone and liver – Specific for obstructive jaundice – Released from biliary canaliculi in case of bile duct obstruction • Aspartate aminotransferase (AST/SGOT) – – – – Reflects damage to hepatic cell Less specific May be elevated in MI Used with ALT to diffrentiate between heart and liver disease • Alanine aminotransferase (ALT/SGPT) – Produced withing the cells of the liver – Most sensitive marker for liver cell damage
  21. 21. 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
  22. 22. Clinical Findings—Hepatic Jaundice • Highly colored urine – Increased amount of bilirubin • Tender hepatomegaly • Liver function tests Seen in both hepatocellular jaundice and excretioncholestatic jaundice – High serum bilirubin – AST and ALT highly increased – Alkaline phosphatase increased moderately
  23. 23. Clinical findings in obstructive jaundice • • • • Deep jaundice Scratch marks on body? High colored urine Clay colored stools
  24. 24. 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
  25. 25. Treatment • Treatment of pre hepatic and hepatic Jaundice is by treating the underlying cause • 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
  26. 26. 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
  27. 27. References • Davidson’s Principle and Practice of Medicine • http://www.onhealth.com/jaundice/article.htm • http://www.emedicinehealth.com/jaundice/article_ em.htm • http://www.nlm.nih.gov/medlineplus/jaundice.html
  28. 28. Thank you

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