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Jaundice

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Jaundice

  1. 1. JAUNDICE By Dr. Osman Bukhari
  2. 3. <ul><li>Definition </li></ul><ul><li>Yellow discoloration of the sclera, mucus membranes & skin from increased serum bilirubin concentration in the body fluids, detectable when serum level is above 3mg/100ml </li></ul><ul><li>Mechanism </li></ul><ul><li>1-Increased production in haemolysis </li></ul><ul><li>2-Imparied excretion </li></ul><ul><li>a) Congenital non-haemolytic hyper bilirubinaemia </li></ul>
  3. 4. <ul><li>b) Hepatocellular jaundice : acute or chronic parenchymal liver disease </li></ul><ul><li>c) Cholestasis </li></ul><ul><li>Haemolytic jaundice </li></ul><ul><li>1-Due to increased RBC destruction </li></ul><ul><li>2-Jaundice is mild & urine is dark. </li></ul><ul><li>3-Anaemia </li></ul><ul><li>4-Spleenomegaly +_ </li></ul><ul><li>5-Increased uncongugated bilirubin in the blood </li></ul>
  4. 5. <ul><li>6-Increased urobilinogen in urine in the absence of bile pigments </li></ul><ul><li>7-Reticulocytosis </li></ul><ul><li>8-Decreased haptoglobin </li></ul><ul><li>9-Peripheral blood macrocytosis , polychromasia & red cells abnormality (spherocytosis & sickles ) </li></ul><ul><li>10-Bone marrow erythrocytosis with megaloblastic changes from folate deficiency </li></ul><ul><li>11-Decreased RBC survival </li></ul>
  5. 6. <ul><li>. 12-Increased serum L.D.H </li></ul><ul><li>13-Normal L.F.T </li></ul><ul><li>Congenital non haemolytic hyper bilirubinaemia </li></ul><ul><li>Inherited disorders due to either defective bilirubin uptake, conjugation or excretion </li></ul><ul><li>1-Gilberts (unconjugated hyper bilirubinaemia) </li></ul><ul><li>-Autosomal dominant </li></ul><ul><li>-Deficient glucuronyl transferase & defective bilirubin uptake from plasma leading to Unconjugated hyper bilirubinaemia </li></ul>
  6. 7. <ul><li>-Commonest variety affecting youngs </li></ul><ul><li>-Mild jaundice which may follow recovery from viral hepatitis or precipitated by infection, fatigue or fasting </li></ul><ul><li>-May be asymptomatic or dyspeptic symptoms </li></ul><ul><li>-Normal life spam </li></ul><ul><li>-No evidence of haemolysis </li></ul><ul><li>-No treatment but occasionally Phenobarbitone </li></ul>
  7. 8. <ul><li>2- Crigler – Najjar (unconjugated) </li></ul><ul><li>-Rare </li></ul><ul><li>-Type I is A.R in neonates with absent glucuronyl transferase with rapid death from kernictorus </li></ul><ul><li>-Type 2 is A D in neonates with reduce glucuronyl transferase activity leading to severe jaundice & patient can survive to adult life with Phenobarbitone, photothearapy & liver transplantation </li></ul>
  8. 9. <ul><li>3- Dubin – Johnson (conjugated) </li></ul><ul><li>-A.R </li></ul><ul><li>-Defective canalicular excretion of bilirubin </li></ul><ul><li>-Any age </li></ul><ul><li>-Jaundice is mild </li></ul><ul><li>-Liver histology shows black pigmentation </li></ul><ul><li>-Normal life span </li></ul>
  9. 10. <ul><li>4- Rotors (conjugated) </li></ul><ul><li>-AD </li></ul><ul><li>-Similar to Dubin – Johnson but no pigmentation in Liver histology </li></ul>
  10. 11. <ul><li>- Hepatocellular jaundice </li></ul><ul><li>1-Impaired bilirubin transport to the bile at any point between uptake of unconjugated bilirubin into hepatocytes & transport of conjugated bilirubin into the canaliculae </li></ul><ul><li>2-Cholestasis may occur from inflammatory aedema </li></ul><ul><li>3-Both conjugated & unconjugated hyper bilirubinanemia </li></ul><ul><li>4-Jaundice is variable </li></ul>
  11. 12. <ul><li>5-Urine is dark </li></ul><ul><li>6-Increased Amino transferases </li></ul><ul><li>Cholestatic jaundice (obstruction) </li></ul><ul><li>1-Intra hepatic : due to failure of hepatocytes to generate bile flow or obstruction of bile flow in the bile ducts within the liver e.g. PBC, Drugs, Viral hepatitis, pregnancy, primary Sclerosing cholengitis, idiopathic </li></ul><ul><li>2-Extra hepatic : due obstruction of bile flow in extra hepatic bile ducts </li></ul><ul><li>-Choledocholithiasis </li></ul>
  12. 15. <ul><li>-Carcinoma (Ampullary, Pancreatic, Cholangio carcinoma & secondaries in the porta hepatis </li></ul><ul><li>-Benign tumours </li></ul><ul><li>-Cystic fibrosis </li></ul><ul><li>-parasitic infections </li></ul><ul><li>-Traumatic biliary stricture </li></ul><ul><li>-Choledocal cyst </li></ul><ul><li>-Pancreatitis </li></ul><ul><li>3-Clinical features due to Cholestasis include: </li></ul>
  13. 16. <ul><li>-Early features: jaundice, dark urine, pale stool & pruritis </li></ul><ul><li>-Late features: Xanthama & Xanthelasma, malabsorption (steatorhoea, weight loss, bleeding tendency & Osteomalacia) </li></ul><ul><li>4-Clinical features due to cholangitis include fever, Rigors, pain & hepatic abscess </li></ul><ul><li>5-Investigations: </li></ul><ul><li>-High ALP, G.GT, & prolong P.T </li></ul><ul><li>-Mainly conjugated bilirubin </li></ul>
  14. 17. <ul><li>-U/S, ERCP, CT & P.T.C, Serology & liver biopsy </li></ul><ul><li>Underlying cause of Cholestatic jaundice related to clinical features </li></ul><ul><li>1-Static or progressive jaundice = Carcinoma </li></ul><ul><li>2-Fluccuating jaundice = stone, stricture, Pancreatitis or Choledocal cyst </li></ul><ul><li>3-Abdominal pain = stone, Pancreatitis or Choledocal cyst </li></ul><ul><li>4-Cholangitis = stone, stricture or choledocal cyst </li></ul>
  15. 18. <ul><li>5-Abdominal scar = stone , stricture </li></ul><ul><li>6-Irregular hard Hepatomegly = hepatic carcinoma </li></ul><ul><li>7-Palpable G.B =Carcinoma below cystic duct e.g. Ca head of pancreas </li></ul><ul><li>8-Abdominal mass = Ca, Pancreatitis (cyst) or Choledochal cyst </li></ul><ul><li>9-Occult blood in stools = Ampullary tumour </li></ul>
  16. 19. <ul><li>Work out a case of jaundice </li></ul><ul><li>Or </li></ul><ul><li>Abnormal liver function tests </li></ul><ul><li>1-Young patient : likely to have viral hepatitis. Ask about history of drugs, alcohol & sexual behaviour </li></ul><ul><li>2-Elderly patient with weight loss :- Ca </li></ul><ul><li>3-Country of origin (HBV) + travel (HAV) </li></ul><ul><li>4-Abdomial pain: biliary obstruction orhepatitis </li></ul><ul><li>5-Duration of illness: short history with prodrome suggest HAV as a recent outbreak of jaundice </li></ul>
  17. 20. <ul><li>6-I.V. drugs abuse, tattooing, blood transfusion or plasma products (HBV,HCV) </li></ul><ul><li>7-Male homosexuality or female prostitution: HBV </li></ul><ul><li>8-Alcohol consumption </li></ul><ul><li>9-History of drug ingestion in the previous three months </li></ul><ul><li>10-Recent anaesth: Halothane </li></ul><ul><li>11-Recent history of biliary surgery or Ca </li></ul><ul><li>12-F.H: Gilbert, Wilson's </li></ul><ul><li>13-Pruritus: Cholestasis </li></ul>
  18. 21. <ul><li>14-Fever & chills: Cholangitis or liver abscess </li></ul><ul><li>15-Smooth tender Hepatomegaly: hepatitis & extra hepatic obstruction </li></ul><ul><li>16-Nodular hepatomegaly: malignancy </li></ul><ul><li>17-Spleenomegaly: PHT </li></ul><ul><li>18-Acitis: Cirrhosis or PHT or Ca </li></ul><ul><li>19-Palpable G.B: Ca head of pancreas </li></ul><ul><li>20-Generalised L.N: Lymphoma </li></ul><ul><li>21-Viral marker for high risk groups </li></ul>
  19. 22. <ul><li>22-U/S to exclude extra hepatic Cholestasis </li></ul><ul><li>ـــــ dilated ducts </li></ul><ul><li>ـــــ level of obstruction </li></ul><ul><li>ـــــ cause of obstruction </li></ul><ul><li>23-Liver biochemistry </li></ul><ul><li>24-CBC & Retics count </li></ul><ul><li>25-Low serum alb. & prolonged PT: chronic liver disease </li></ul><ul><li>26-Leucocytosis suggest bacterial infection e.g. Cholangitis or hepatic abscess </li></ul>
  20. 23. <ul><li>27-lucopenia with viral hepatitis </li></ul><ul><li>28-Abnormal lymphocyte: inf. Mono. </li></ul><ul><li>29-Serolgy & alphafoetoprotien </li></ul><ul><li>30-ERCP & PTC </li></ul><ul><li>31-FNAC </li></ul><ul><li>32-Fine needle biopsy: more sensitive </li></ul><ul><li>33-Generally </li></ul><ul><li>-Young patient ـــــ viral markers </li></ul><ul><li>-If negative ـــــ U/S </li></ul><ul><li>-If both U/S & viral markers are negative ــــ serology </li></ul>
  21. 24. <ul><li>-U/S ـــــ obstruction ـــــ ERCP & PTC </li></ul><ul><li>-U/S ـــــ Focal lesion ـــــ FNAC or biopsy </li></ul><ul><li>-U/S ـــــ abnormal liver parenchyma ـــــ liver biopsy </li></ul><ul><li>-U/S ـــــ normal ـــــ viral markers </li></ul><ul><li>-U/S ـــــ portal or venous obstruction ـــــ Angiography </li></ul>

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