♦ Accumulation of bilirubin.
♦ Yellowish pigmentation of plasma.
♦ Discolouration of heavily perfused tissues
likeskin,sclera and mucous membranes.
♦ Clinically hyperbilrubinemia manifests as
icterus or jaundice.
♦ Serum bilrubin > 34-43 micro mol/l
♦ Jaundice manifestes even at lower levels in people
with fair skin and anemia
♦ Obscured in dark skin individuals or with edema.
♦ Need to be observed in sun light.
♦ Needs to be differentiated from Carotenemia
charecterised by yellow brown pigmentation of
palms ,soles and nasolabial folds with normal
sclera ,mucosal membrane and urine color.
Production and metabolism
♦ Normal serum Bilirubin Conc.
5-17 micro mol/l
♦ More than 90% is unconjugated circulating
as albumin bound complex.
♦ Remainder conjugated(primarily
glucuronide) to polar group which is water
soluble and excreted in urine.
♦ 80% of Bilirubin –RBCs break down.
♦ 15-20%-Ineffective erythropoises and
metabolism of other heme containing
Evalution of jaundice.
♦ Hemolysis—In direct Bilirubin.
♦ Hepatobiliary –Direct Bilirubin.
♦ Resorbtion of large hematoma.
♦ Bil. Rarely above 5mg%.
♦ Gilbert syndrone is an exception.
♦ Reticulocyte count is high.
♦ Hb is low.
♦ LDH is high.
Extra hepatic obstruction.
Approach to patient with
♦ Duration of symptoms.
♦ Abdominal pain.
♦ Fever and other symptoms of active
♦ Appitite change,weight loss or altered
♦ Transfusion.(hepatitis B&C).
♦ Use of intravenous drugs.
♦ Sexual contact.
♦ Travel and immunization.
Cholestsis.Anabolic steroids and chlorpromazine.
♦ Past history of jaundice, hepatitis,arthralgias
♦ Previous surgery:Biliary procedures.
♦ Pre existing IBD.
♦ Right heart failure.
♦ Skin tatooing.
♦ History of GI bleeding.
♦ Family history.Congenital spherocytosis.
Increased frequency with normal
IBS ,Proctitis and
Involuntary release of rectal contents.
Acute and choronic.
♦ Acute: 7---14 days.
occasionally less than 6 week.
♦ Chronic: More than 4 weeks.
Occasionally more than 6
♦ Persistent:2—4 weeks.
♦ Acute infectious causes are commonest.
♦ Acute GI diseases are second only to URTI.
♦ In less than 5 years of age.
2—3 illnesses per child per
18 illnesses per child per year in developing
Billion cases world wide.
4—6 million deaths.
Acute infectious diarrhea.
♦ Non bloody.
♦ Periumblical cramps.
♦ Nausea and vomitting .
♦ Single or in combition.
♦ Small in volume.
♦ Left lower quadrant cramps.
♦ Urgency and tenesmus.
♦ Viral:Norwalk,Nor walk like and Rota virus
♦ Protozoal: Giardia,cryptosporidium.
aures, bacellius cereus and clostridium
perfringens 2.Enterotoxin production:Ecoli,vibrio cholera.
♦ Staphylococcus aureus.
♦ Shortest incubation period.1—6 hours.
for less than 12 houres.
♦ Infected human carriers are the source.
♦ If food is left to cool slowly and remains at room
temperature organisms have opportunity to form
♦ Out breaks after picnics.
♦ Potatos,salads,mayonnise,cream pastries.
♦ Short incubation period.
1—6 hours emetic form.
hours diarrheal form.
♦ If cooked rice is not refrigerated,heat
resistant spores which have escaped boiling
germinate and produce toxin.Frying before
serving may not destroy these preformed
heat stable toxins.
Etiology for infllammatory
♦ Protozoal:Entamoeba histolytica.
r jejuni,entero invasive E-coli and vibrio
Approach to patient.
2.Fever.Infections out side
the gut like malaria.
Pain with yersina.
-Bloating with Giardiasis.
♦ Results from lack of absorption of orally
ingested solutes (food).Osmotic effect.
♦ Relieved with fasting.
♦ Clinical symptoms are usually becauses of
malabsorption of fat or carbohyderates.
♦ Osmotic causes include lactase deficiency,
drugs like laxatives etc.
♦ Excreation of large ammount more than
♦ No effect with fasting.
♦ Abnormal fluid and electrolyte transport.
♦ Harmones mediated.
♦ Causes may include Carcinoid, Zollinger
ellison syndrome, Medullary carcinoma of
thyroid and extensive gut recsection.
♦ Abdominal pain and tenderness.
♦ Patients may have toxic looks.
♦ Extra intestinal manefestation may be
♦ Causes include IBD,malignancy,radiation
♦ Systemic disorders like diabetes and
♦ Previous gut surgery.
♦ Irritable bowel.
♦ Fecal impaction.
♦ Neurological disorders.
♦ FECTITIOUS DIARRHEA:Laxative abuse
Approach to patients.
♦ Symptoms and signs of inflammation.
♦ Extra intestinal manefestations.
♦ Perepheral edema or ascitis.
♦ Type of stools-intestinal malabsoption.
♦ Weight loss.
♦ Systemic manifestations like flushing.
♦ Autonomic dysfunctions like postural drop
and disordered sweating in diabetes.
♦ Diarrhea alternating with constipation-IBS.
♦ Effects of malabsorption like anemia,
and infertility should be looked for.