I am Student of B.Tech(CSE) Mewar University

1. Jaundice
Maj.Gen.Dr. Saud Omani, MBBS, FIMC RCSEd, FRCSEd.
Consultant GS/ Trauma and Immediate Medical Care,
Prince Sultan Military Medical City.

2. Introduction
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Bile physiology.
Pathophysiology of Jaundice.
Gallbladder stones formation and
complications.
Etiology of obstructive jaundice.
Investigating Jaundiced patient .
Liver Function Tests interpretation.

3. Intestinal Juice
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• Process and storage of nutrients.
• Protection and clearance.
• Synthetic.
• Immunity.
• Formation and secretion of bile.

5. Composition of Bile
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• Grigler Najar Syndrome
• Gilber’s syndrome
• Dubin Johnson
• Rotor’s syndrome

7. Hyperbilirubinemia
Jaundice.
Types:
Pre-hepatic.
• Hemolysis.
• Genetic.
Hepatic.
• Hepatocytes.
• Obstruction.
Post-hepatic.
• Obstruction (Stone).
• Obstruction (Pressure).
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Cholestatic

8. Bile
• Bile is alkaline, 250 – 1000 ml /day.
• Secreted continuously by liver and Stored in
GB, (30-60mls) and concentrated 5 – 20
folds.
• Secretion is controlled by:
• Secretin.
• CCK.
• Vagal nerve.
• Composition:
• Water 84%.
• Bile Salts 12%.
• Cholesterol 0.7%.
• Phospholipids (Lecithin).
• Others.
• Functions:
• Emulsification.
• Absorption of Fat.
• Prevents metabolic deficiency.
• Laxative.
• Bactericidal.
• Neutralize acidity.
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9. Cholelithiasis
• Cholesterol, 75%, (most of GB).
• Pigmented:
• Black, 20% .
• Brown (predominantly
intrahepatic).
• Bile duct stones are
predominantly mixed.
• Prevalence 10-15%.
• 80% asymptomatic, only about
15% will become symptomatic.
• 1-2 complications with about
0.12% mortality.
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10. Cholelithiasis
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12. Risk and Protective Factors
Risk factors:
Obesity, weight loss and diet..
Diseases (DM, ilium, …etc.).
Systemic diseases.
Drugs: estrogen, octreotide,
antibiotics and TPN.
Spinal cord disease.
Age and gender and pregnancy.
Protective factors:
Statins.
Coffee.
Ascorbic acids.
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13. Complications of gallstones
Choledocolithiasis,
Obstructive Jaundice.
Biliary colic.
Chronic Cholecystitis.
Acute cholecystitis.
Acute Cholangitis.
Acute pancreatitis.
Porcelaine gallbladder.
Mucocele of gallbladder.
Mirizzi’s syndrome.
Cholecystoenteric
Fistula:
Colon.
Duodenum.
• Gallstone ileus (small bowel
obstruction.
• Bouveret’s syndrome (gastric outlet
obstruction).
Emphysematous
cholecystitis.
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14. Jaundice work up
Urine.
Blood tests.
Radiological
Investigations.
Endoscopy.
Interventional radiology.
Nuclear medicine.
Operative
cholangiogram.
Liver Biopsy.
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• Process and storage of nutrients.
• Protection and clearance.
• Synthetic.
• Immunity.
• Formation and secretion of bile.

16. Clinical assessment
Alcohol consumption.
Risk factors for viral hepatitis.
Medications.
Occupational exposure to toxins.
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17. Normal Values
Test Normal Values
Total Bilirubin 2 – 21 mol/l
Direct Bilirubin 0 – 6 mol/l
ALP 35 – 104 u/l
ALT 0 – 33 u/l
AST 8 – 48 u/l
INR 0.9 – 1.3
GGT 9 – 48 u/l
Albumin 25 – 52 g/l
5’Nuleotidase 0 – 11 u/l
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18. Pitfalls about LFT’s
Nonspecific.
Insensitive.
Rarely diagnostic.
Most informative if used as a group.
Diagnosis of liver disease depends on
combination of patient’s history, clinical
examination …..etc.
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19. Bed side tests
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Test Normal Post-hepatic Hepatic Pre-hepatic
Bilirubin Negative Positive Positive Negative
Urobilinogen Positive Negative /Decreased Increased Increased
Urine color Normal Dark Norma/Dark Normal
Stool color Normal Pale Normal Normal

20. Liver Function Tests
Excretion and
detoxification:
Bilirubin.
Ammonia.
Biosynthesis:
Total Protein and
albumin.
Clotting factors, (PT
and INR).
Enzymes:
Cell: ALT, AST
(aminotransferases).
Duct: ALP, GGT,
5’Nucleotidase and.
Immunologic:
Immunoglobulins,
Autoantibodies.
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21. Bilirubin
Test Pre-hepatic Hepatic Post-hepatic
Total Bilirubin + ++ +++
Conjugated Normal Increased Increased
Unconjugated Increased Increased Normal
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22. Ammonia
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23. Synthesis
Protein: Albumin
Half life  20 days.
Made exclusively in the
liver.
10 gram/day.
Usually normal in acute and
low in chronic liver disease.
Albumin level is dependent
on other factors.
Clotting Factors:
Made exclusively in the liver
except factor VIII.
Short half life.
Vit K dependent factors (II,
VII, IX, X).
Evaluated by INR and PT.
For Acute liver disease.
Hepatocellular disease vs
cholestasis with fat
malabsorption.
The first and most sensitive.
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24. Liver Enzymes (ALT and AST)
ALT (SGPT).
AST (SGOT).
ALP.
GGT.
5’Neucleotidase.
AST and ALT are transaminases which
catalyze the reaction between ketoacid and
AA.
AST is found in liver, heart, muscle, kidney
and RBCs while ALT is predominantly in the
liver.
AST and ALT increased in any form of HCD
& biliary disease.(Leak from liver cells).
AST is increased in Rhabdomyolysis,
hemolysis and Acute MI.
Have no correlation with clinical outcome.
ALT is more specific than AST.
ALT varies with BMI, Lipid, glucose level and
higher in male.
AST/ALT ratio is high in alcoholic insult.
AST/ALT ratio. (2 alcoholic liver and 5
suggest extrahepatic).
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25. Liver Enzymes (ALP and GGT)
ALP is a collection of isoenzymes present throughout the
body.
ALP (bile duct, placenta, intestine, bone, tumors), check
GGT and or 5’Neucleotidase. Chronic cholestasis.
ALP varies with age and gender. ALP is elevated in normal
pregnancy and high bone turnover.
GGT is found in hepatobiliary disease with similar
sensitivity and specificity ALP. Elevated in alcohole upuse,
diabetes, phenytoin and renal failure.
Both elevated in HCD and biliary system disease.
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26. Liver Enzymes and
Hyperbilirubinemia
Test Pre-hepatic Hepatic Post-hepatic
ALT/AST Normal +++ +
ALP
GGT
5’Nucleotidase
Normal + +++
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27. Acute Liver Diseases
ALT AST Hx Dx
Hep A   Oral Igm anti Hep A virus
Hep B   IV, Body fluid
Igm for s and c antigen is
positive
Hep C   IV, Drugs,
Igm Anti HCV antibodies
HCV RNA
ETOH   ETOH
Hx
Liver Ischemia Low Pressure
Hx
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28. Chronic Liver Diseases
ALT AST Hx Dx
NASH   Young, obese female By exclusion
THOH   ETHO By exclusion
Autoimmune Hepatitis
 
Autoimmune disease, alcohl,
female
Anti smooth muscle cell
antibodies
Haemochromatosis
 
Male,Fe/TIBC50%
Feritin 1000, chromosome
6
Bronz diabetes, iron
infiltrating other organs
Wilson disease
 
Kayser Fleischer ring in the
eye
Low ceruloplasmin, low
Alk. Phophatase
-antitripsin
 
COPD, Asthma
Autosomal recessive
PAS +ve granules
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30. Cholestatic Liver Diseases
ALP TB Hx Dx
Primary Biliary Cirrhosis  
Mid age,
female, itching
Portal
granuloma,intrahepatic
duct destruction, +ve
antimitochondrial
antibodies,
chlasterol,asymptomatic
for years
Primary Sclerosing Cholangitis  
Intra and extra hepatic
ducts, Ulcerative colitis,
peeds in string in
cholangiography
Biliary Duct Obstruction   Gallstones, pain
US, Cholangiogram, ERCP,
MRCP etc
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33. Others
FBC and platelet.
Urea and electrolytes (hepatorenal
syndrome).
Quantitative tests of liver function:
14C- aminopyrine breath test.
Indocyanine grean clearance.
Antipyrine clearance.
Galactose elemination capacity.
13C-caffeine breath test.
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34. Summary
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Abnormal liver tests may present as asymptomatic
patient.
A good clinical history and physical examination are
invaluable.
LFTs often become abnormal in non-hepatic disease.
If a systematic approach is adopted the cause is often
apparent.
When face with abnormality:
Assess the degree.
Evaluate and confirm.
A specialized opinion should be sought when appropriate.

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PSMMC