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JAUNDICE
BY
Dr
HAYDER M. ABDULNABI
CABS
Jaundice – Classification
Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg%
Jaundice is increased levels of SB > 1.0 mg%
Over production of Bilirubin (Hemolytic)
From hemolysis of RBC
Impaired hepatic function (Hepatitic)
Hepatocellular dysfunction in handling bilirubin
 Uptake, Metabolism and Excretion of bilirubin
Obstruction to bile flow (Obstructive)
Intrahepatic cholestasis
Extrahepatic Obstruction (Surgical Jaundice)
2www.drsarma.in
Clinical Aspects of
Jaundice
Clinically detectable if SB is >3 mg%
With edema and dark skin – Jaundice is masked
What is special about the sclera ? – Rich Elastin
Darkening of the urine – Differential Diagnosis
Skin discoloration – Yellowish, - Carotinemia – Eyes N
Mucosa – hard palate (in dark skinned)
Greenish hue of skin and sclera - due Biliverdin – indicates
long standing jaundice ( CA head pancreas )
Generalized Pruritus – Obstructive Jaundice – Why ?
3www.drsarma.in
Clinical History – Imp clues
Duration of jaundice – Acute / Chronic
Abdominal pain v/s painless jaundice
Fever – Viral / bacteria /sepsis
Scraches-Pruritus - obstructive
Appetite – Hepatocellular / Malignancy
Weight loss – Malignancy
Colour of stools –chalky white –obstructive
Family history – Hemolytic – Inherited dis.
H/o transfusion
Alcohol abuse, Medications – INH, EM, Largactil
www.drsarma.in 4
Coloured Urine – Differ.
Diagnosis
Bilirubin in urine due to Jaundice (CB)
Concentrated urine in dehydration
Sulfasalazine use – for Ulcerative colitis
Rifampicin, Pyridium and Thiamine use
Red urine – Porphyria,
Hemoglobin & Myoglobinuria, Hematuria
Melanin excretion from Melanoma-black
food
www.drsarma.in 5
Fate of RBC
6
• RBC life span in blood stream is 90-120 days
• Old RBCs are phagocytosed and/or lysed
• Lysis occurs extravascularly in the RE system
subsequent to RBC phagocytosis
• Intravascular Hemolysis of young RBC
• This is due to hemolytic diseases of RBC
www.drsarma.in
E V Pathway for RBC
Scavanging
Liver, Spleen &
Bone marrow
Hemoglobin
Globin
Amino acids
Amino acid pool
Heme Bilirubin
Fe2+
Excreted
Phagocytosis & Lysis
Through Liver
7www.drsarma.in
Bilirubin Metabolism - Summary
8www.drsarma.in
Bilirubin handling in
Kidney
www.drsarma.in 9
How to clinically evaluate the patient ?
What tests will help us in D.D ?
What imaging modalities will be useful ?
How to monitor the progress ?
10
ALGORITHMIC APPROACH FOR
JAUNDICE
www.drsarma.in
First Step
11www.drsarma.in
Second Step : If SB > 1.0
mg
12www.drsarma.in
Third Step : If CSB is
increased
13www.drsarma.in
Fourth Step :
Hepatocellular
14www.drsarma.in
What imaging we need
• Ultrasonography – 98% Sp, 90% Sen.
• For GB stones USG better than CT
• For duct stones –only 40% seen in USG
• PTC – Extrahepatic obstr. – drainage
• ERCP – Distal biliary obstruction Dx.Rx.
• MRCP – Most useful for duct stones
www.drsarma.in 15
Post hepatic Obstructive Jaundice
• Painful v/s painless
• Obstruction can be
– Intra Luminal -(stone), hydatit cysts worms
– Luminal- Stricture (benign v/s
cholangiocarcinoma), periampulary ca
– Klatskin tumor
– Extra luminal pancreatic cancer,. lymph nodes,
choledocal cyst
• Investigate & treat with
– Radiology (US, CT, MRCP)
– ERCP / PTC
16www.drsarma.in
• A Klatskin tumor (or hilar
cholangiocarcinoma) is a
cholangiocarcinoma (cancer of the
biliary tree) occurring at the
confluence of the right and left
hepatic bile ducts. It is named after
Dr. Gerald Klatskin, an American
physician working at Yale.
Acute Cholecystitis
17
GB wall is thickened and striated.
Courtesy of Udo Schmiedl, M.D.www.drsarma.in
Magnetic Resonance
Cholangio-Pancreatography
(MRCP)
Two stones in the common bile ductTwo stones in the common bile duct
Courtesy of Udo Schmiedl, M.D.Courtesy of Udo Schmiedl, M.D.
Retrograde Cholangiogram -
ERCP
Bile leak from the cystic duct after
cholecystectomy Courtesy of Michael
Primary sclerosing cholangitis (PSC) with stricture
due to cholangiocarcinoma. Courtesy of Robert L.
Carithers, Jr., M.D.
Retrograde Cholangiogram -
ERCP
Irregular dilation of intrahepatic and extrahepatic ducts.
Courtesy of Charles Rohrmann, M.D.
Retrograde Cholangiogram -
ERCP
Primary Sclerosing
Cholangitis
Normal Extra
hepatic BD
Narrowed
abnormal intra-
heptic bile ducts.
23
PRE-OPERATIVE MANAGEMENT
OF OBSTRUCTIVE JAUNDICE
1. HIGH INTAKE OF GLUCOSE (BUILD
UP LIVER GLYCOGEN STORE)
2. VITAMIN K (FAT SOLUBLE), 10mg IV
OR IM
3. ANTIBIOTICS (BROAD SPECTURUM)
4. HYDRATION (PREVENT RENAL
FAILURE) (5% DEXTROSE TO ENSURE
30 ml/HOUR URINE FLOW)
5. DIURESIS – MANNITOL- 200ML
REGIMEN
24
SURGICAL PROCDURES
1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET,
BALLOON CATHETER)(STENT TO RELIEVE
SYMPTOMS)
2. PERCUTANEOUS REMOVAL OF STONES BY
BURHENNE METHOD (T- TUBE LEFT FOR SIX
WEEKS AND THEN REMOVED, DILATION OF THE
MATURE TRACT, STEERABLE CATHETER, AND
THEN STONE BASKET)
3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN
THE VERY ILL
4. SUPRADUODENAL CHOLEDOCHOTOMY WITH
OR WITH OUT TRANSDUODENAL
SPHINCTEROTOMY OR
CHOLEDOCHODUODENOSTOMY
5. STENTING
25
EXPLORATION OF THE CBD
26
DORMIA BASKET
ERCP
DILATED CBD
Ascending
cholangitis
• Physical examination findings typically
include jaundice and right upper
quadrant tenderness.
• Charcot's triad is a set of three common
findings in cholangitis: abdominal pain,
jaundice, and fever.
Causes
•OBSTRUCTION
•GALL STONES
10-30% of cases
•CA
•TRAUMATIC--
ERCP
• TESTS
• MANAGEMEN
T

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Obstructive jaundice (1)

  • 2. Jaundice – Classification Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg% Jaundice is increased levels of SB > 1.0 mg% Over production of Bilirubin (Hemolytic) From hemolysis of RBC Impaired hepatic function (Hepatitic) Hepatocellular dysfunction in handling bilirubin  Uptake, Metabolism and Excretion of bilirubin Obstruction to bile flow (Obstructive) Intrahepatic cholestasis Extrahepatic Obstruction (Surgical Jaundice) 2www.drsarma.in
  • 3. Clinical Aspects of Jaundice Clinically detectable if SB is >3 mg% With edema and dark skin – Jaundice is masked What is special about the sclera ? – Rich Elastin Darkening of the urine – Differential Diagnosis Skin discoloration – Yellowish, - Carotinemia – Eyes N Mucosa – hard palate (in dark skinned) Greenish hue of skin and sclera - due Biliverdin – indicates long standing jaundice ( CA head pancreas ) Generalized Pruritus – Obstructive Jaundice – Why ? 3www.drsarma.in
  • 4. Clinical History – Imp clues Duration of jaundice – Acute / Chronic Abdominal pain v/s painless jaundice Fever – Viral / bacteria /sepsis Scraches-Pruritus - obstructive Appetite – Hepatocellular / Malignancy Weight loss – Malignancy Colour of stools –chalky white –obstructive Family history – Hemolytic – Inherited dis. H/o transfusion Alcohol abuse, Medications – INH, EM, Largactil www.drsarma.in 4
  • 5. Coloured Urine – Differ. Diagnosis Bilirubin in urine due to Jaundice (CB) Concentrated urine in dehydration Sulfasalazine use – for Ulcerative colitis Rifampicin, Pyridium and Thiamine use Red urine – Porphyria, Hemoglobin & Myoglobinuria, Hematuria Melanin excretion from Melanoma-black food www.drsarma.in 5
  • 6. Fate of RBC 6 • RBC life span in blood stream is 90-120 days • Old RBCs are phagocytosed and/or lysed • Lysis occurs extravascularly in the RE system subsequent to RBC phagocytosis • Intravascular Hemolysis of young RBC • This is due to hemolytic diseases of RBC www.drsarma.in
  • 7. E V Pathway for RBC Scavanging Liver, Spleen & Bone marrow Hemoglobin Globin Amino acids Amino acid pool Heme Bilirubin Fe2+ Excreted Phagocytosis & Lysis Through Liver 7www.drsarma.in
  • 8. Bilirubin Metabolism - Summary 8www.drsarma.in
  • 10. How to clinically evaluate the patient ? What tests will help us in D.D ? What imaging modalities will be useful ? How to monitor the progress ? 10 ALGORITHMIC APPROACH FOR JAUNDICE www.drsarma.in
  • 12. Second Step : If SB > 1.0 mg 12www.drsarma.in
  • 13. Third Step : If CSB is increased 13www.drsarma.in
  • 15. What imaging we need • Ultrasonography – 98% Sp, 90% Sen. • For GB stones USG better than CT • For duct stones –only 40% seen in USG • PTC – Extrahepatic obstr. – drainage • ERCP – Distal biliary obstruction Dx.Rx. • MRCP – Most useful for duct stones www.drsarma.in 15
  • 16. Post hepatic Obstructive Jaundice • Painful v/s painless • Obstruction can be – Intra Luminal -(stone), hydatit cysts worms – Luminal- Stricture (benign v/s cholangiocarcinoma), periampulary ca – Klatskin tumor – Extra luminal pancreatic cancer,. lymph nodes, choledocal cyst • Investigate & treat with – Radiology (US, CT, MRCP) – ERCP / PTC 16www.drsarma.in
  • 17. • A Klatskin tumor (or hilar cholangiocarcinoma) is a cholangiocarcinoma (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts. It is named after Dr. Gerald Klatskin, an American physician working at Yale.
  • 18. Acute Cholecystitis 17 GB wall is thickened and striated. Courtesy of Udo Schmiedl, M.D.www.drsarma.in
  • 19. Magnetic Resonance Cholangio-Pancreatography (MRCP) Two stones in the common bile ductTwo stones in the common bile duct Courtesy of Udo Schmiedl, M.D.Courtesy of Udo Schmiedl, M.D.
  • 20. Retrograde Cholangiogram - ERCP Bile leak from the cystic duct after cholecystectomy Courtesy of Michael
  • 21. Primary sclerosing cholangitis (PSC) with stricture due to cholangiocarcinoma. Courtesy of Robert L. Carithers, Jr., M.D. Retrograde Cholangiogram - ERCP
  • 22. Irregular dilation of intrahepatic and extrahepatic ducts. Courtesy of Charles Rohrmann, M.D. Retrograde Cholangiogram - ERCP
  • 23. Primary Sclerosing Cholangitis Normal Extra hepatic BD Narrowed abnormal intra- heptic bile ducts.
  • 24. 23 PRE-OPERATIVE MANAGEMENT OF OBSTRUCTIVE JAUNDICE 1. HIGH INTAKE OF GLUCOSE (BUILD UP LIVER GLYCOGEN STORE) 2. VITAMIN K (FAT SOLUBLE), 10mg IV OR IM 3. ANTIBIOTICS (BROAD SPECTURUM) 4. HYDRATION (PREVENT RENAL FAILURE) (5% DEXTROSE TO ENSURE 30 ml/HOUR URINE FLOW) 5. DIURESIS – MANNITOL- 200ML REGIMEN
  • 25. 24 SURGICAL PROCDURES 1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET, BALLOON CATHETER)(STENT TO RELIEVE SYMPTOMS) 2. PERCUTANEOUS REMOVAL OF STONES BY BURHENNE METHOD (T- TUBE LEFT FOR SIX WEEKS AND THEN REMOVED, DILATION OF THE MATURE TRACT, STEERABLE CATHETER, AND THEN STONE BASKET) 3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE VERY ILL 4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR WITH OUT TRANSDUODENAL SPHINCTEROTOMY OR CHOLEDOCHODUODENOSTOMY 5. STENTING
  • 26.
  • 27.
  • 28.
  • 32. • Physical examination findings typically include jaundice and right upper quadrant tenderness. • Charcot's triad is a set of three common findings in cholangitis: abdominal pain, jaundice, and fever.
  • 33. Causes •OBSTRUCTION •GALL STONES 10-30% of cases •CA •TRAUMATIC-- ERCP