Successfully reported this slideshow.
We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime.
JAUNDICE

Vineela Nekkanti
V Pharm.D
Contents of the topic
 Definition
 Classification
 Signs and symptoms
 Diagnosis

 Pathophysiology
 Prevention

 Tr...
Definition :
Jaundice, as in the French jaune, refers to the yellow
discoloration of the skin.

Also known as Icterus
Jaun...
 Introduction to Bilirubin :
Bilirubin is a orange-yellow pigment formed in the liver
by the breakdown of hemoglobin and ...
Conjugated Bilirubin

Unconjugated Bilirubin

Water soluble

Water Insoluble

It reacts quickly to produce
azobilirubin

I...
Metabolism of Bilirubin
Types of Jaundice
 Prehepatic Jaundice
 Intrahepatic jaundice
 Post hepatic Jaundice
Type of Jaundice

Pre-Hepatic

Intra-hepatic

Post-Hepatic

Other Name

Hemolytic
jaundice

Hepatocellular
Jaundice

Obstr...
Type of
Jaundice

Pre-Hepatic

Intra-hepatic

Post-Hepatic

Biochemical
characteristics

serum
unconjugated
bilirubin

ser...
Etiology/Causes
Common Drugs Associated With
Hyperbilirubinemia
HEPATOCELLULAR CAUSES
•
•
•
•
•
•
•
•
•
•
•

Acetominophen
Alcohol
Amiodar...
Common Drugs Associated With
Hyperbilirubinemia
CHOLESTATIC CAUSES





















Amitriptyline
...
Etiopathogenesis
1.
2.
3.
4.

5.

Increased bilirubin
production
Reduced bilirubin uptake
by hepatic cells
Disrupted intra...
1. INCREASED BILIRUBIN PRODUCTION
(unconj. Hyperbilirubinemia)


Hemolysis


Increased destruction of RBCs
eg sickle cel...
2. DECREASED HEPATIC UPTAKE
(unconj. Hyperbilirubinemia)
 Several drugs have been reported to inhibit
bilirubin uptake by...
3) DISRUPTED INTRACELLULAR
CONJUGATION
(unconj. Hyperbilirubinemia)

Neonatal jaundice
occurs in 50% of newborns
fetal bi...
Crigler-Najjar Syndrome, Type I (CN-I)

recessive allele; mutation-induced loss of
conjugating ability in the critical en...
4) DISRUPTED SECRETION OF BILIRUBIN INTO BILE
CANALICULI
(conj. Hyperbilirubinemia)


Dubin–Johnson Syndrome


mild conj...
5) Intra/extra-hepatic bile duct obstruction



Intra-hepatic
Obstruction of bile canaliculi, bile ductules or hepatic du...
Signs and Symptoms
 Skin and sclerae - yellow
 Stool - light colour, clay coloured
 Dark urine

 Pain in abdomen
 Itc...
Diagnosis
 Medical history and examination

 Urine test
 Liver function and blood tests
 Imaging tests
 Liver biopsy
 Medical history and physical examination
Patient interview for
-

abdominal pain, itchy skin or weight loss
malaria or h...
 Urine test :
- to measure levels of a substance called urobilinogen
- more than normal urobilinogen levels : Pre and Int...
 Imaging tests
- CT Scan
- MRI Scan

- Ultrasound Scan
- Endoscopic retrograde cholangiopancreatography (ERCP)
Used to ch...
Jaundice treatment
The treatment given to someone with jaundice will depend on what
type they have, how serious it is and ...
Treatment & Therapeutic Considerations
PHOTOTHERAPY
 Through absorption of the wavelengths at the blue end of the spectru...
PHENOBARBITAL
 This drug is not approved by FDA for use in neither adult nor
pediatric hyperbilirubinemia patients, due t...
CLOFIBRATE (ATROMID-S)
 This drug has been shown to reduce bilirubin levels via an unknown
mechanism.
 Clofibrate is als...
Prevention of Jaundice :
• Limit alcohol intake to not more than two drinks a day for
men or one drink a day for women.

•...
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Jaundice V PharmD by Vineela.N
Upcoming SlideShare
Loading in …5
×

Jaundice V PharmD by Vineela.N

2,241 views

Published on

Published in: Education
  • Be the first to comment

Jaundice V PharmD by Vineela.N

  1. 1. JAUNDICE Vineela Nekkanti V Pharm.D
  2. 2. Contents of the topic  Definition  Classification  Signs and symptoms  Diagnosis  Pathophysiology  Prevention  Treatment
  3. 3. Definition : Jaundice, as in the French jaune, refers to the yellow discoloration of the skin. Also known as Icterus Jaundice is a liver disease characterized by elevated levels of bilirubin in the blood termed as hyperbilirubinaemia. Normal range of serum bilirubin concentration is 0.31.3mg/dl Jaundice occurs when bilirubin levels exceeds 2mg/dl
  4. 4.  Introduction to Bilirubin : Bilirubin is a orange-yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile.  Two types of bilirubin : Conjugated and Unconjugated bilirubin  Sources of Bilirubin : • Catabolism of heme of hemoglobin (80-85%) • Non-hemoglobin heme containing pigments such as myoglobin, catalase and cytochromes
  5. 5. Conjugated Bilirubin Unconjugated Bilirubin Water soluble Water Insoluble It reacts quickly to produce azobilirubin It reacts slowly to produce azobilirubin It produces azobilirubin only in the presence of dye It produces azobilirubin in the absence of dye Known by Direct bilirubin Known by Indirect bilirubin
  6. 6. Metabolism of Bilirubin
  7. 7. Types of Jaundice  Prehepatic Jaundice  Intrahepatic jaundice  Post hepatic Jaundice
  8. 8. Type of Jaundice Pre-Hepatic Intra-hepatic Post-Hepatic Other Name Hemolytic jaundice Hepatocellular Jaundice Obstructive/ Regurgitation Jaundice Cause Increased hemolysis of erythrocytes Examples Malaria, sickle cell anemia, incompatible blood transfusion Dysfunction of liver Obstruction of bile due to damage to duct – prevents the parenchymal cells passage of bile into intestine Viral infection(hepatitis), poisons and toxins(chloroform, carbon tetrachloride, phosphorus), cirrhosis Gallstones, cancer of pancreas, gall bladder and bile duct
  9. 9. Type of Jaundice Pre-Hepatic Intra-hepatic Post-Hepatic Biochemical characteristics serum unconjugated bilirubin serum conjugated and unconjugated bilirubin, SGPT and SGOT Serum conjugated bilirubin and ALP Clinical manifestations Dark brown color stools Nausea and anorexia Nausea; GI pain and clay colored feces Absent Absent Increased Increased Stercobilinogen Increased content Urobilinogen content Increased
  10. 10. Etiology/Causes
  11. 11. Common Drugs Associated With Hyperbilirubinemia HEPATOCELLULAR CAUSES • • • • • • • • • • • Acetominophen Alcohol Amiodarone Azulfidine Carbenicillin Clindamycin Colchicine Cyclophosphamide Diltiazem Ketoconazole Methyldopa • • • • • • • • • • Niacin Nifedipine NSAIDs Propylthiouracil Pyridium Pyrazinamide Quinidine Rifampicin Salicylates Verapamil
  12. 12. Common Drugs Associated With Hyperbilirubinemia CHOLESTATIC CAUSES                     Amitriptyline Androgenic steroids (B) Atenolol Augmentin Azathioprine Bactrim (D) Benzodiazeprines Captopril Carbamazole Chlordiazepoxide (D)) Clofibrate Coumadin Cyclosporine Danazol (B) Dapsone Disopyramide Erythromycin Estrogens (B) Ethambutol Floxuridine                     5-Flucytosine Fluoroquinolones Griseofulvin Haloperidol (D) Labetolol Nicotinic acid NSAIDs Penicillins Phenobarbital Phenothiazines (D) Phenytoin Tamoxifen Tegretol Thiabendazole (D) Thiazides Thiouracil Tolbutamide (D) Tricyclics (D) Verapamil Zidovudine
  13. 13. Etiopathogenesis 1. 2. 3. 4. 5. Increased bilirubin production Reduced bilirubin uptake by hepatic cells Disrupted intracellular conjugation Disrupted secretion of bilirubin into bile canaliculi Intra/extra-hepatic bile duct obstruction Lead to increases in free (unconj.) bilirubin Result in rise in conj. bilirubin levels
  14. 14. 1. INCREASED BILIRUBIN PRODUCTION (unconj. Hyperbilirubinemia)  Hemolysis  Increased destruction of RBCs eg sickle cell anemia, thalassemia    Drastic increase in the amount of bilirubin produced Unconj. bilirubin levels rise due to liver’s inability to catch up to the increased rate of RBC destruction Prolonged hemolysis may lead to precipitation of bilirubin salts in the gall bladder and biliary network - result in formation of gallstones and conditions such as cholecystitis and biliary obstruction  Other   Degradation of Hb originating from areas of tissue infarctions and hematomas Ineffective erythropoiesis
  15. 15. 2. DECREASED HEPATIC UPTAKE (unconj. Hyperbilirubinemia)  Several drugs have been reported to inhibit bilirubin uptake by the liver e.g. novobiocin, flavopiridol Hepatic cell Plasma Alb Bile B B + GST Alb B :GST B + UDPGA CB UGT1A1 sER MRP2
  16. 16. 3) DISRUPTED INTRACELLULAR CONJUGATION (unconj. Hyperbilirubinemia) Neonatal jaundice occurs in 50% of newborns fetal bilirubin is eliminated by mother’s liver causes: hepatic mechanisms are not fully developed resulting in decreased ability to conjugate bilirubin rate of bilirubin production is increased due to shorter lifespan of RBCs Acquired disorders hepatitis, cirrhosis impaired liver function
  17. 17. Crigler-Najjar Syndrome, Type I (CN-I) recessive allele; mutation-induced loss of conjugating ability in the critical enzyme glucuronosyltransferase CN-II greatly reduced but detectable glucuronosyltransferase activity due to mutation (predominantly recessive); enzymatic activity can be induced by drugs  Gilbert’s Syndrome glucuronosyl transferase activity reduced to 1030% of normal; also accompanied by defective bilirubin uptake mechanism
  18. 18. 4) DISRUPTED SECRETION OF BILIRUBIN INTO BILE CANALICULI (conj. Hyperbilirubinemia)  Dubin–Johnson Syndrome  mild conj. hyperbilirubinemia, but can increase with concurrent illness, pregnancy, and use of oral contraceptives; otherwise asymptomatic    Inability of hepatocytes to secrete CB after it has formed Due to mutation in the MRP2 gene (autosomal recessive trait) Rotor Syndrome  Autosomal recessive condition characterized by increased total bilirubin levels due to a rise in CB  Caused by a defect in transport of bilirubin into bile
  19. 19. 5) Intra/extra-hepatic bile duct obstruction  Intra-hepatic Obstruction of bile canaliculi, bile ductules or hepatic ducts  Extra-hepatic Obstruction of cystic duct or common bile duct Cholecystitis  Obstruction causes backup and reabsorption of CB which results in increased blood levels of CB
  20. 20. Signs and Symptoms  Skin and sclerae - yellow  Stool - light colour, clay coloured  Dark urine  Pain in abdomen  Itching  Trouble with sleeping  Fatigue  Swelling  Ascites  Mental confusion  Coma  Bleeding
  21. 21. Diagnosis  Medical history and examination  Urine test  Liver function and blood tests  Imaging tests  Liver biopsy
  22. 22.  Medical history and physical examination Patient interview for - abdominal pain, itchy skin or weight loss malaria or hepatitis A change of colour in your urine and stools history of prolonged alcohol misuse Flu like symptoms Medications Occupation Physical examination : - Yellowish discoloration of eye and skin Swelling of legs, ankle and feet Hepatomegaly
  23. 23.  Urine test : - to measure levels of a substance called urobilinogen - more than normal urobilinogen levels : Pre and Intra hepatic jaundice - Less than normal urobilinogen level : Post hepatic jaundice  Liver function and blood tests : Damage to liver releases liver enzymes like SGPT, SGOT and ALP and proteins, this indicates - Hepatitis - Alcoholic liver disease - cirrhosis
  24. 24.  Imaging tests - CT Scan - MRI Scan - Ultrasound Scan - Endoscopic retrograde cholangiopancreatography (ERCP) Used to check for abnormalities inside the liver or bile duct systems.  Liver biopsy Used to diagnosis Cirrhosis and liver cancer.
  25. 25. Jaundice treatment The treatment given to someone with jaundice will depend on what type they have, how serious it is and what caused it. It may include tackling an underlying condition such as malaria and bothersome symptoms, such as itching. For genetic conditions that don't get better, like sickle cell anaemia, a blood transfusion may be given to replenish red blood cells in the body. If the bile duct system is blocked, an operation may be needed to unblock it. During these procedures measures may be taken to help prevent further problems, such as removal of the gallbladder. If the liver is found to be seriously damaged, a transplant may be an option
  26. 26. Treatment & Therapeutic Considerations PHOTOTHERAPY  Through absorption of the wavelengths at the blue end of the spectrum (blue, green and white light), bilirubin is converted into water-soluble photoisomers. This transformation enhances the molecule’s excretion into bile without conjugation.
  27. 27. PHENOBARBITAL  This drug is not approved by FDA for use in neither adult nor pediatric hyperbilirubinemia patients, due to possibility of significant systemic side-effects.  Exact pathway is not known, but it is believed to act as an inducing agent on UDP-glucuronosyl transferase, thereby improving conjugation of bilirubin and its excretion. ALBUMIN  A 25% infusion can be used in treating hyperbilirubinemia (esp. due to hemolytic disease).  It is used in conjunction with exchange transfusion to bind bilirubin, enhancing its removal.
  28. 28. CLOFIBRATE (ATROMID-S)  This drug has been shown to reduce bilirubin levels via an unknown mechanism.  Clofibrate is also associated with increased risk of developing cholelithiasis, cholecystitis, as well as functional liver abnormalities, which can worsen hyperbilirubinemia. PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY  Allows extraction of stones and thus removal of the source of obstruction when present.
  29. 29. Prevention of Jaundice : • Limit alcohol intake to not more than two drinks a day for men or one drink a day for women. • Avoid exposure to industrial chemicals. • Do not use illegal drugs. • Do not share needles or nasal snorting equipment. • Vaccination : Hepatitis A and Hepatitis B • Maintain healthy body weight.

×