Approach to jaundice.pptx
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An Approach to a patient presenting with Jaundice
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Approach to jaundice.pptx
- 2. BILIRUBIN : METABOLISM • Tetrapyrrole compound Heme degradation • 4mg/kg formed each day • Heme Biliverdin Bilirubin; HO and BR • Bilirubin uptake OATPB1 • Bilirubin conjugation Bilirubin UDP- glucuronyl tranferase • Bilirubin glucuronide transport MRP-2 (bile canaliculi) • Conjugated bilirubin to plasma MRP-3
- 3. BILIRUBIN- PHYSIOLOGY • 80% conjugated bilirubin is in diglucuronide form • Gut microbiota in terminal ileum and colon converts conjugated bilirubin to unconjugated urobilinogens • Normal serum Bilirubin is 1to 1.5 mg/dl, 95% unconjugated. • Diazo reaction; Direct and Indirect • Automated reflectance spectroscopic assays
- 4. DISORDERS OF BILIRUBIN METABOLISM • Isolated unconjugated hyperbilirubinaemia • Increased production • Decreased hepatocellular uptake • Decreased conjugation • Isolated conjugated hyperbillirubinaemia • Dubin-Johnson and Rotor
- 5. LIVER DISEASE • Hepatocellular dysfunction • Acute or subacute hepatocellular injury • Chronic hepatocellular disease • Hepatic disease with prominent cholestasis • Infiltrative diseases • Cholangiocyte injury • Miscellaneous
- 6. BILE DUCT DISEASES • Bile duct obstruction • Choledocholithiasis • Bile duct diseases • Inflammation, infection • Neoplasm • Extrinsic compression • Neoplasm , pancreatitis, vascular enlargement
- 7. HEREDITARY DISORDERS OF BILE METABOLISM • Gilbert syndrome • MC; incidence 6-12% • activity of UGT1A1 - bilirubin conjugation • Bilirubin < 3mg/dl, increased in stress • Liver histology normal • Excellent prognosis; no treatment
- 8. TYPE 1 CRIGLER-NAJJAR SYNDROME • Very rare • Near total deficiency of UGT1A1 • Bilirubin >20, all unconjugated ; liver histology Normal • Kernicterus • Death in infancy • Phototherapy, exchange transfusion, LT
- 9. TYPE 11 CRIGLER-NAJJAR • Uncommon • Mod deficiency of UGT1A1 • Bilirubin < 20 • Risk of kernicterus • Phenobarbital response
- 10. DIRECT HYPERBILIRUBINAEMIA • Dubin – johnson • MRP-2 mutation • Bilirubin < 7 mg/dl • Coarse pigment of hepatocytes • Good prognosis • Avoid estrogens
- 11. ROTOR SYNDROME • Deficiency of OAT1b1 and b3 • Usually <7mg/dl • Normal liver histology • No long term sequelae • No treatment
- 12. ACUTE HEPATOCELLULAR INJURY • Usually associated with increased liver enzymes • Acute viral hepatitis • Toxic hepatitis • DILI • Alcohol • Ischemic hepatitis • Wilson disease
- 13. CHRONIC HEPATOCELLULAR DISEASE • Chronic viral hepatitis • NAFLD • Hemochromatosis • Wilson disease • Alpha 1 anti-trypsin deficiency • Auto-immune hepatitis • Celiac disease
- 14. HEPATIC DISORDERS WITH PROMINENT CHOLESTASIS (INTRAHEPATIC CHOLESTASIS) • Infiltrative diseases • Granulomatous diseases • Amyloidosis • Malignancies
- 15. INTRAHEPATIC CHOLESTASIS • Cholangiocyte injury • Immune mediated – PBC • GVD • DRUGS – Erythromycin, Amoxy-clav, co-trimoxazole • CF
- 16. CHOLESTASIS WITH MINIMAL HISTOLOGIC ABNORMALITIES • Benign recurrent cholestasis FIC1 and BSEP mutation • Estrogens - downregulation NTCP, competitive inhibition of BSEP, interference with MRP2 • Anabolic steroids • Parenteral nutrition • Stauffer syndrome • Atypical presentations Viral hepatitis, Alcoholic hepatitis
- 17. JAUNDICE IN PREGNANCY • Hyperemesis gravidarum • Intrahepatic cholestasis of pregnancy • Acute fatty liver of pregnancy • Pre-eclampsia and HELLP
- 18. BILE DUCT OBSTRUCTION • Choledocholithiasis • Bile duct diseases • Congenital – cysts and Atresia • PSC • AIDS cholangiopathy • Biliary strictures • Neoplasms of biliary tract
- 19. EXTRINSIC COMPRESSION • Vascular malformation : arterial aneurysm, portal cavernoma • HCC /periportal lymphoma • Pancreatitis • Mirizzi syndrome
- 20. DIAGNOSTIC APPROACH • 1. History, physical examination and screening tests • 2. Formulation of a working DD • 3. Selection of special tests • 4. Development of a strategy for treatment
- 21. FEATURE BILIARY OBSTRUCTION LIVER DISEASE HISTORY Abdominal pain, fever rigors, older age, prior biliary surgery Viral prodrome, exposure to toxin, family history of liver disease, history of blood transfusion, injection drug use Laboratory studies Elevated amylase or lipase Leukocytosis Predominant elevation of ALP relative to AT PT INR normal or normalizes with Vit K administration Predominant elevation of AT>ALP Prolonged PT-INR that doesn’t normalize with Vit K admin Serologies indicative of specific liver disease Thrombocytopenia Physical examination Surgical scar Abdominal tenderness Fever Palpable mass Asterixis Spider telangiectasis Stigmata of portal hypertension
- 22. History, examination,routin e investigations ALP or Aminotransferase elevated ? Evaluate for hemolysis, hereditary hyperbilirubinaemia Biliary tract obstruction ? No No Abdominal US or CT Yes Yes Biochemical studies for specific causes of liver diseases Spe cific ther apy pos itiv e Liver biopsy Clinical likelihood of biliary obstruction Non dilated bile ducts ERCP or THC Therapeuti c interventio n MRCP or EUS Intermediate Non dilated bile ducts Dilated bile ducts High
- 23. IMAGING STUDIES • USG sensitivity 51-91% specificity 82-95% • CT sensitivity 63-96% specificity 93-100% • MRCP 82-100 % 94-98% • ERCP 89-98% 89-100% • THC 98-100% 89-100% • EUS 89-97% 67-98% • Nuclear imaging
- 24. LIVER BIOPSY • Provides precise information regarding lobular architecture and pattern of hepatic inflammation and fibrosis • Useful for diagnosis of NAFLD, hemochromatosis, Wilson disease, autoimmune hepatitis, PBC, granulomatous hepatitis, and neoplasm