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Child with jaundice
- 2. Learning Objectives 2 Definition of Jaundice Mechanism of Bilirubin metabolism Types of jaundice and its clinical characteristics Obstructive jaundice Approach to jaundice.
- 3. What Is Jaundice?? Condition which is characterized by yellowish discoloration of the skin, sclera and mucous membrane due to increase concentration of bilirubin above normal level. 3
- 4. • Normal Value:- 0.2 to 0.8 mg/dl • Latent Jaundice :1 mg to 1.9 mg/dl • Clinical Jaundice : more than 2 mg / dl 4
- 6. Pathway For Bile Flow 6
- 8. Classification 8 Neonatal Jaundice ConjugatedUnconjugated Physiological Pathological Hemolytic Non-Hemolytic • Heriditary Spherocytosis • Sickle Cell Disease • Thalassemia • Breast Milk Jaundice • Sepsis • Hypothyroidism Hepatic Post Hepatic • Torch Infection • Galactosemia • Biliary Atresia • Cholodocal Cyst
- 9. Physiological Jaundice In neonates, jaundice tends to develop because of • More RBC mass • Life span of RBC is less (90 days) • Breakdown of fetal hemoglobin as it is replaced with adult hemoglobin • Increased intrahepatic circulation 9
- 10. • Relatively immature hepatic metabolic pathways of liver, which are unable to conjugate and excrete bilirubin as quickly as an adult • Resulting in accumulation of bilirubin in the blood (hyperbilirubinemia), leading to the symptoms of jaundice 10
- 11. Pathological Jaundice Jaundice that is visible during the first 24 hours and after 2 weeks of life is likely to be non physiological Neonates who present with jaundice after 3-4 days of life may also require closer monitoring 11
- 12. Breast Milk Jaundice 12 Indirect hyperbilirubinemia in a breast feed new born that develop after 4-7 days of life. Progesterone Present in breast milk inhibit UDP- glucuronyl transferase Decrease UDP-glucuronyl activity in new born Increase concentration of nonesterified free fatty acids that inhibit hepatic glucuronyl transferase.
- 13. Where To Look For….... Sclera Ventral surface of Tongue Palmar Crease Sole of foot Whole body 13
- 15. Causes Of Jaundice In neonatal period Surgical cause Biliary atresia Choledochal cyst Medical Cause Breast feeding jaundice Hemolytic disease Hypothyroidism
- 16. In infantile period Surgical causes • Biliary atresia • Choledocal cyst • Choledocholithiasis • Sclerosing cholangitis • Pyogenic cholangitis • Traumatic stricture • Benign or malignant tumor of CBD • Extramural compression. • Worm In CBD
- 17. Medical Liver disease – hepatitis Metabolic liver diseases Hemolytic jaundice 17
- 18. When To Concern…... Jaundice is progressive Medical management fail It lasts for more than two weeks It is associated with Hepatosplenomegaly History suggestive of obstructive cause – Dark urine, pale stool
- 19. Clinical Features Yellowish discoloration of skin, sclera & mucous membrane Pale or clay colored stools Dark colored urine May have high grade fever with or without chills and rigor Itching all over body Loss of appetite Nausea and vomiting 19
- 20. How To Proceed ? History taking Age Jaundice Onset Fluctuation Progression Association with other symptoms like pain , fever & itching
- 21. Cont. Colour of Urine Colour of Stool Weight loss Drug History Ante-natal History ( TORCH of Mother ) Family history of jaundice 21
- 22. Examination ON GENERAL EXAMINATION Jaundice Anemia Nutritional Status Body build Temperature Hydration Status
- 23. ON SYSTEMIC EXAMINATION Gastrointestinal System: Inspection: Yellowish coloration of skin, Abdomen Distended, Engorged vein , Position of Umbilicus ,Scar marks Palpation: Hepatosplenomegaly 23
- 24. Percussion: Upper Border Of liver Dullness Ascites 05-Apr-16 24
- 25. Investigation Blood : CBC,ESR, Hb % ,Peripheral Blood Film : LFT ( Serum Bilirubin, ALT, AST, Alk Phos,PT, ) : Viral Marker Imaging: Usg of hepatobiliary system : CT of hepatobiliary system : MRCP : HIDA Urine : Urine RE, Urobilinogen
- 26. Table Of Diagnostic Tests Function test Pre-hepatic jaundice Hepatic jaundice Post-hepatic jaundice Total bilirubin Normal / increased Increased Conjugated bilirubin Normal Increased Increased Unconjugated bilirubin Normal / increased Increased Normal Urobilinogen Normal / increased Decreased Decreased / negative Urine color Normal Dark (urobilinogen + conjugated bilirubin) Dark (conjugated bilirubin) Stool color Normal Normal/pale Pale Alkaline phosphatase levels Normal Increased Alanine transferase and aspartate transferase levels Increased Conjugated bilirubin in urine Not present Present Splenomegaly Present Present Absent 26
- 27. MANAGEMENT 27
- 28. GENERAL MANAGEMENT 28 PRINCIPLES OF GENERAL MANAGEMENT • Correction of dehydration and electrolyte • Correction of coagulation profile • To prevent hepatic failure • Control/prevention of infection • To prevent translocation of gut organism
- 29. Correction Of Dehydration & Electrolyte Adequate hydration by intravenous fluid infusion Correction of electrolyte imbalance 29
- 30. Correction of coagulation profile Inj. Vitamin-K IM/IV once daily for 3 days. Then check the prothrombin time; if not corrected then repeat this treatment and again check for prothrombin time. If not corrected then arrange Fresh Frozen Plasma (FFP) before operation and perform operation. 30
- 31. To prevent hepatic failure Avoid hepatotoxic drugs. Encourage glucose containing diet. 31
- 32. Control/prevention of infection 3rd generation cephalosporin+ Metronidazole 2nd generation cephalosporin (Cefuroxime). 32
- 33. To prevent translocation of gut organism Lactulose to decrease gut organism. 33
- 34. Surgical Management According to Cause 34
- 35. 35