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An approach to jaundice
1.
2. Jaundice a.k.a icterus
› Jaune,jaunesse-french- yellow
› Ikterus -greek-yellow bird, oriole(
genus- icterus)
Jaundice could be cured if pt
looked at the bird- people
thought so!!!!
3. Yellowish discolouration of tissues resulting
from deposition of bilirubin.
Normal - < 1 mg/dl ( 17 µmol/l)
0.2 – 0.9 mg/dl– 95% of normal popn.
Jaundice seen if values exceeds 3 mg/dl
4. High affinity to elastin rich tissues.
Sclera, skin, frenulum of tongue, ear drum
etc…
Best seen at upper sclera, palate,
undersurface of tongue
Clearly seen in daylight; difficult to see if
room has fluorescent lighting.
5. Long standing jaundice: yellow to greenish
hue– due to biliverdin, oxidation product of
bilirubin
Shades of jaundice:
› Rubin jaundice - reddish shade ( hepatitis)
› Flavin jaundice - lemon yellow with red hue ( hemolysis)
› Verdin jaundice - greenish yellow( obstruction)
› Melas jaundice - grayish or brackish green ( prolonged obstn)
6. 1. Carotenemia – carrots and mangoes –mainly
seen in palms, soles, forehead, nasolabial
folds- sclera sparing
2. Lycopaenemia – excessive tomatoes
3. Acriflavin,Fluorescine,Picric acid staining
4. Quinacrine, busulfan
7. Next sensitive indicator- darkening of urine
Tea or cola colored urine
d/d:
› dehydration, fluid deprivation
› sulfasalazine use ( orange- yellow colored urine)
› other colored urines( rifampicin-orange, porphyria-
red, melanuria- dark, ochranosis- black)
8. Total bilirubin – 250-300 mg/day
70-80% -- senescent RBCs, remaining from
premature destruction of RBCs, myoglobin,
cytochromes
Reticulo-endothelial cells of spleen and liver
10. 1
• Hepatocyte (HC) uptake of UCB
• Alb+UCB dissociates and UCB enters HC
2
• Intracellular binding
• Several of Glutathione-s-transferases-LIGANDINS
3
• Conjugation in ER of Hepatocyte (HC)
• Formation of mono and di glucuronides BMG, BDG
• UDP Glucuronosyl transferase is energy dependent
4
• Excretion in into biliary canaliculi (MRP-2,MRP-3)
• Rate limiting step in metabolism
11. 1
• CB enters to duodenum; not taken up by int. mucosa
• Distal ileum, colon- hydrolysed by β- glucuronidases to UCB
• UCB- acted on by gut bact to urobilinogens( UBG)
2
• 80-90% UBG– unchanged/ reduced(stercobilin)– excreted in faeces
• 10-20% Enters EHC- liver
3
• UBG in liver– enters circulation– oxidised to urobilin
• Excreted in kidneys
12. *
• Urobilinogen/ urobilin– normally present– in traces
• If increased---hepatocellular injury
*
• UCB– not filtered or secreted in kidneys
• Always nil in urine
*
• CB– filtered and re-absorbed by proximal tubules
• Not normally present– if present, abnormal
13. Van der bergh reaction
Bilirubin exposed to diazotised sulfanilic acid
Dipyrrylmethene azopigments- absorbs light at 540 nm
› Direct fraction - measured directly,
› Total fraction - measured after adding alcohol,
› Indirect - difference between two
Normal 1 mg/dl. Upto 15% maybe direct
Delta fraction/ Bili-protein-- CB with albumin. T1/2 is 14
days( normal is 4 hrs)
14. Properties Unconjugated Conjugated
Normal serum fraction 85% 15%
Water solubility (polarity) 0 (non polar) + (polar)
Affinity to lipids (Kernicterus) +++
Renal excretion Nil +
Vanden Berg Reaction Indirect Direct
Temporary Albumin Binding +++ 0
Irreversible Delta Bilirubin 0 ++
14
15.
16. Is it isolated elevation of serum bilirubin ?
If so, is the↑unconjugated or conjugated fraction?
If not,is it accompanied by other liver test abnormalities ?
Is the disorder hepatocellular or cholestatic?
If cholestatic, is it intra- or extrahepatic?
Answers can be sought by careful history, physical
examination, lab tests and radiological procedures
17.
18. Duration of jaundice – Acute / Chronic
Painful/painless jaundice
Accompanying symptoms- fever,
dyspepsia,arthralgia, myalgia, rash, weight
loss,loss of appetite,back pain,
Exposure to medications- OTC/ prescribed/
alternative
Parenteral exposures- transfusions, iv abuse
19. Tatoos, alcohol history, sexual promiscuity
Family history- hemolytic anemias,
congenital hyperbilirubinemias, wilson
disease
Recent travel history
Occupational history- rats
20. G/E:
› Anemia- hemolysis/ca/cirrhosis
› Gross wgt loss- ca/severe malabsorption
› Hunched up position- pancreatic ca
› Primary sites- breast,colon,stomach, thyroid, lung
› Lymph node- virchow/ sister mary joseph nodules
Fetor hepaticus, flapping tremor-impending hepatic coma
Skin changes: scratch marks, melanin pigmentation,
xanthoma of eyelids- chronic cholestasis
21. Stigmata of chronic liver disease –spider nevi, palmar
erythema, gynecomastia, caput medusa, dupuytrens
contractures, parotid enlargement or testicular atrophy.-
advanced alcoholic cirrhosis
Bruising, purpuric spots- clotting defects-
thrombocytopenia of cirrhosis
Ankle edema- cirrhosis, IVC obstn due to hepatic,
pancreatic malignancy
22. Abdominal examination- Size and consistency of liver and
spleen
A grossly enlarged nodular liver or an obvious abdominal mass
suggests malignancy
Small liver- severe hepatitis/cirrhosis
An enlarged tender liver could signify
› viral or alcoholic hepatitis;
› an infiltrative process such as amyloidosis; or, less often,
› an acutely congested liver secondary to right-sided heart failure.
23. Choledocholithiasis- GB area may be tender;
murphy sign +
Palpable, visibly enlarged GB- pancreatic ca
Splenomegaly- hemolytic states, hodgkin’s,
portal HT
Ascites- cirrhosis/ abd malignancy
24.
25. Look for serum bilirubin
› If < 1 mg%--- normal,
› if > 2.5 mg %--- elevated.
If isolated elevation of bilirubin, check for
direct fraction
› direct < 15% -- indirect ( Pre-hepatic)
› direct > 15% -- direct ( hepatocellular and obst)
26. Hemolysis- inherited or acquired
SB rarely > 5 mg%
If above, check for c0-existent renal,
hepatic dysfunction or r/o sickle cell
crisis
Chronic hemolysis- high incidence of
gallstones-- obstruction
Rifampicin, probenecid,
ribavirin,flavaspidic acid– decreases
hepatic uptake of bilirubin for
conjugation
27. Criggler-najjar type 1:- AR pattern
Complete absence of UDPGT activity
Mutation in 3’ domain of the gene
No conjugation at all
Severe jaundice ( UCB > 20 mg/dl)
Kernicterus, leading to death in infancy
No response to phenobarbital
28. Criggler- najjar type 2 (arias syndrome):
More common than type 1
Mutations in gene cause activity reduction(< 10 %)
SB values in range of 6-25 mg/dl
Survive to adulthood: kernicterus in stress
Enzyme activity induced by phenobarbital
Inheritance not clear; both AD with variable
penetrance and AR
Responds to phenobarbital- ↓ in bilirubin conc by >
25%
29. Gilbert syndrome:
3-7 % of popn; M:F = 2-7:1
enzyme activity upto 30 %
SB always < 6 mg/dl
mutation in promoter region of gene, not coding
jaundice precipitated by fasting, fever, alcohol
AR pattern
Also called constitutional hepatic dysfunction/ familial
nonhemolytic jaundice
Phenobarbital- normalizes serum bilirubin
Fasting test, nicotinic acid test, phenobarbital test, thin
layered chromatography- diagnostic tests
30.
31. Dubin-johnson syndrome:
AR; MRP-2 gene mutation
Liver, macroscpically is greenish-black; (black
liver jaundice), in section, liver cells contain
brown pigment
Chronic, intermittent jaundice with conj.
Hyperbilirubinemia and bilirubinuria
32. Rotor syndrome:
probable autosomal recessive inheritance
similar to dubin-johnson in presentation, but no
brown pigment
deficiency of the major hepatic drug re-uptake
transporters OATP1B1 and OATP1B3
33. Dubin-johnson Rotor
Liver cells contain brown pigment No such pigment
Non-visualisation of GB in OCG GB visualised
BSP clearance delayed; reflux of
conjugated BSP in 90 mins
BSP clearance delayed; no reflux of
conjugated BSP
Total urinary coproporphyrin N Total urinary coproporphyrin elevated
Fraction of isomer 1 > 80% Fraction of isomer 1 < 70%
36. Tissues of high metabolic activity
Heart, liver, s.m, kidney, brain
Though cytosolic, 80% in liver-
mitochondrial
AST:ALT > 2 in ALD(mitochondrial damage)
37. Cytosolic, more specific for liver
30-50 times in infectious/toxic hepatitis
Mod. Increase in hepatocellular disease
Synthesis more sensitive to pyridoxal-5-
phosphate; def. in alcoholics--- lower ALT
levels
38. ALP-
› non-specific, in placenta, ileal mucosa, kidney,
bone and liver
› rises in obst. Jaundice, SOL liver, cholestasis
› Isolated elevation– bone lesion; elevation along
with 5’-nucleotidase—liver lesion
› Isolated elevation in preg– N in 3rd trimester
39. GGT
› Increased in cholestasis, hepatocellular disease
› Confirms raised ALP of hepato-biliary origin
› Isolated rise in alcohol abuse; monitor cessation of alcohol
consumption in chronic alcoholic
LDH
› Cytosolic enzyme
› ALT:LDH > 1.5– acute viral hepatitis
› ALT:LDH < 1.5– ischemic hepatitis, para toxicity
40. Liver enzymes Normal Range Value
Alkaline phosphatase 25-100 u/L Dx of Obstructive Jaundice
Aspartate transaminase
(AST/SGOT)
14-20 u/l(m)
10-36 u/l(f)
Early Dx and follow up
Alanine transaminase
(ALT/SGPT)
10-40 u/l(m)
7-35 u/I(f)
AST/ALT > 2 in ALD
Gamma glutamyl
transpeptidase (GGT)
7-47 u/L (m)
5-25 u/l(f)
Very sensitive in ALD
Albumin 3.5-5.0 g/dL Assess severity of disease
Prothrombin time (PT) 12-16 s Assess severity of disease
40
41. Abnormal LFT Non hepatic causes
Albumin
Nephrotic syndrome
Malnutrition, CHF
ALP
Bone disease, Pregnancy,
Malignancy , Adv age
AST MI, Myositis, I.M.injections
Bilirubin
Hemolysis, Sepsis,
Ineffective erythropoiesis
42.
43. Wilson’s disease occurs primarily in young adults; severe liver d in
childhood+f/h of liver d+ neuropsyciatric disturbances -
ceruloplasmin assay(↓d); ↑ hepatic cu and urinary cu
Autoimmune hepatitis is typically seen in young to middle-aged
women- ANA assay, SMA assay
alcoholic hepatitis –AST:ALT atleast 2:1, and the AST level rarely
exceeds 300 U/L
viral hepatitis and toxin --aminotransferase levels >500 U/L, with the
ALT greater than or equal to the AST
44. Hep A IgM antibody
assay
HbsAg &
anti- Hbc assay
HCV RNA load
Anti- HEV IgM assay
CMV,EBV assay
46. AMA + VE
USG
Dilated ducts
Extra-hepatic
cholestasis
Normal ducts
Intra-hepatic
cholestasis
CT/MRCP
Serology,
AMA, drugs
MRCP/liver
biopsy
Liver
biopsy
negative
47. USG – valuable but operator dependant
sensitivity of 55-91% & specificity of 82-95% for biliary obstruction
Besides it can differentiate intrahepatic from extrahepatic cholestasis,
US can also detect the associated abnormalities such as portal
hypertension, focal lesions & fatty liver.
48. sensitivity of 63-96% & a specificity of 93-
100% to detect biliary obstruction
Non-calcified cholestrol gall stones can be
easily missed on CT
49. not only permits direct visualization of the
biliary tree but also allows therapeutic
intervention
gold standard test for the evaluation of
extrahepatic biliary disease causing jaundice.
50. direct contrast visualization of the biliary tree is obtained
via a percutaneous needle puncture of the liver
useful if there is high biliary obstruction e.g. a tumour at
the bifurcation of the hepatic ducts
also permits therapeutic intervention such as stent
insertion to bypass a ductal malignancy
51. MRCP is superior to US & CT in detecting
biliary obstruction.
It has a sensitivity of 82-100% & a specificity of
92-98% to detect biliary obstruction
52. Relatively low risk, it is needed in only a minority of cases
with hepatic dysfunction
Major indications include
› chronic hepatitis,
› cirrhosis,
› unexplained liver enzyme abnormalities,
› hepatosplenomegaly of unknown aetiology,
› suspected infiltrative disorder,
› suspected granulomatous disease
53.
54. Choledocholithiasis- m.c.c
P.S.C and IgG4 cholangitis- stricturing of biliary tree– later
responds to glucocorticoids
AIDS cholangiopathy- infection of bile duct epithelium by
CMV, cryptosporidia
Mirrizi syndrome- gall stone impacted in cystic duct/GB
neck---compression of CBD
Pancreatic, GB, ampullary ca, cholangio carcinoma;
ampullary-highest surgical cure rate; others poor prognosis
58. Primary biliary cirrhosis
› Auto-immune, middle aged women
› Destruction of interlobular bile ducts
› Diag by AMA.
Primary sclerosing cholangitis
› Destruction of larger bile ducts
› Diag by p-ANCA; MRCP/ERCP- segmental strictures
59. Vanishing bile duct/ adult bile ductopenia
› ↓d no. of bile ducts in liver specimen
› Seen in patients
Chronic rejection after liver transplant
GVH disease after bone marrow transplant
Sarcoidosis, chlorpromazine
60. Progressive familial intra-hepatic cholestasis (PFIC)
› PFIC1- AR-ATP8B1-childhood
› PFIC2- ABCB11
› PFIC3- MRP-3
Benign recurrent intra-hepatic cholestasis(BRIC)
› BRIC1-ATP8B1
› BRIC2-ABCB11
› AR pattern; in adulthood; considered benign because
does’nt lead to cirrhosis or ESLD
63. Jaundice is a hallmark of liver disease.
Through clinical examination and history
becomes vital in all cases.
Classified as pre hepatic, hepatocellular and
cholestatis although overlaps do occur.
Biochemical and radiological evaluation helps in
making a diagnosis.
64. 1. Harrison’s principles of Internal Medicine-19th edition
2. Sherlock’s diseases of Biliary system- 12th edition
3. A manual of Lab. and Diagnostic tests – 9th edition- Frances
fischbach, Marshall.B.Dunning
4. Medscape articles –www.medscape.com