......

1. DR TOQEER HUSSAIN
RESIDENT PHYSICIAN
SKBZ CMH MZD AJK
APPROACH TO A
PATIENT WITH
JAUNDICE

2. What is jaundice?
⚫Yellowish discoloration of skin, sclerae and mucus
membranes due to hyperbilirubinemia
⚫Total bilirubin > 1.5 mg/dl

3. Types of jaundice
Prehepatic /
Hemolytic
jaundice
Hepatic
jaundice
Posthepatic /
Obstructive/
Surgical jaundice

4. Family history of liver disease
Alcohol and drug history
Sexual history
Transfusion history
Nutrition history
Exposure to
n Environmental toxins,Persons with
jaundice , Drugs
n Outbreaks or epidemics in the community
n
History of biliary or pancreatic disease.
History

5.  Shaking chills or fevers point toward cholangitis or bacterial
infection
 Abdominal pain may indicate pancreatic disease, especially if it
radiates to the back
 Right upper quadrant ache point toward Viral hepatitis
 Weight loss, anorexia, nausea, and vomiting are not helpful signs
because most patients with hepatobiliary disease or obstruction have
anorexia and some weight
 Pruritus can be associated with both intrahepatic cholestasis as well
as biliary obstruction.
Cont.....

6. Age:
• Children and young adults ——› congenital,viral
hepatitis
• < 30 years ——› acute parenchymal disease
• > 65 years ——› stones or malignancies
• 30 - 50 years ——› chronic liver disease
•
Cont.....

7.  Men are more likely to develop
• Cirrhosis secondary to alcohol
• Pancreatic cancer
• Hepatocellular carcinoma,
• Hemochromatosis
 Women are more likely to have
• Primary biliary cirrhosis
• Gallstones
• Chronic active hepatitis
Cont....

8.  Shrunken, nodular liver may ——› cirrhosis
 Palpable mass ——› abscess or malignancy
 A liver span >15 cm ——› fatty infiltration, congestion
other infiltrative diseases, or malignancy
 Liver tenderness ——› acute disease but is generally not
helpful
Cont....

9. 
Physical Examinition
 Spider angioma
 palmar erythema
 distended abdominal
veins
 jaundice
 Ascites
 jaundice...........>
 Ascites.............>
Indicate
cirrhosis
Acute
hepatitis
Cirrhosis
Malignancy

10.  Splenomegaly................>
 A palpable, distended
gallbladder ——›
malignant biliary
obstruction
 Asterixis.......................>
 Fever...........................>
Cont....
Infections
Infiltrative diseases
Fulminant hepatic
failure End-stage liver
diseas
Billiary colic
Infection

11. 1. Is the elevated bilirubin conjugated or unconjugated?
2. If the hyperbilirubinemia is unconjugated, is it caused by
n increased production
n decreased uptake
n impaired conjugation
3. If the hyperbilirubinemia is conjugated, is the problem
n intrahepatic or
n extrahepatic?
4. Is the process acute or chronic?
Several questions must be
answered initially

12. Pre Hepatic/Hemolytic
Jaundice
⚫Excess production of
bilirubin due to excess
breakdown of hemoglobin
⚫Indirect bilirubin
(insoluble in water since
unconjugated)
⚫E.g.
 Hemolytic anemia
 Malaria
 Glucose-6-phosphate
dehydrogenase deficiency

13. Icterus .………………. Ascites

14. Hepatic Jaundice
⚫Liver’s ability to conjugate or
excrete bilirubin is affected
⚫Increased level of conjugated
and unconjugated bilirubin
⚫E.g.:
 Hepatitis, cirrhosis,
hepatocellular carcinoma,
prolonged use of drugs
metabolized by liver
 Genetic disorders:

15.  Usually acquired disease
 Intrahepatic or Extrahepatic (obstructive) cause.
 Acute disease usually can be differentiated from chronic disease
by the patient's history, physical examination, and laboratory tests
 clinical evaluation
n xanthelasma,
n spider angioma,
n ascites,
n hepatosplenomegaly.
 Laboratory evidence of chronic disease
n Hypoalbuminemia,
n Thrombocytopenia,
• uncorrectable prolongation of the prothrombin time.
Conjugated Hyperbilirubinemia

16. Obstructive Jaundice
⚫Bilirubin formation rate is
normal
⚫Conjugation is normal =
direct bilirubin
⚫Obstruction of bile duct so
exit is blocked
⚫Tumor of the head of the
pancreas
⚫Cholecystitis
(gallstones)

17.  Chronic cholestasis may arise from
n Cirrhosis,
n Primary sclerosing cholangitis,
n Primary biliary cirrhosis,
n Secondary biliary cirrhosis,
n Carcinoma
n Drugs.
 Acute disease.
n New-onset bilirubinuria
n Fever
n Right upper quadrant pain,
n Tenderness,
n Hepatomegaly,
CONT......

18. ⚫ Complete blood count
⚫ Liver function tests
⚫ BT/CT
⚫ PT/INR
⚫ Serum albumin
⚫ ?blood culture
Lab investigations

19.  ALT in hepatocyctes
n Indicator of hepatocellular injury
n High ALT↑↑↑, ALP ↑ suggests hepatocellular
 ALP liver/ bile duct/ bone
n Raised in cholestasis
n ALP ↑↑, ALT↑ suggests cholestasis
Help from LFTs

20.  GGT
n Raised in biliary epithelium/ bile duct obstn
n Raised in alcohol and phenytoin
 ALP and GGT raised →cholestasis
 ALP isolated = not hepatobiliary
Cont....

21.  Causes
n Prehepatic
• Haemolysis
n Gilberts syndrome (most common)
Jaundiced ALT/ALP normal

22. Enzymes
⚫ Alkaline phosphatase
 Bone and liver
 Specific for obstructive jaundice
 Released from biliary canaliculi in case of bile duct obstruction
⚫ Aspartate aminotransferase (AST/SGOT)
 Reflects damage to hepatic cell
 Less specific
 May be elevated in MI
 Used with ALT to diffrentiate between heart and liver disease
⚫ Alanine aminotransferase (ALT/SGPT)
 Produced withing the cells of the liver
 Most sensitive marker for liver cell damage

23. Liver function tests
LFT
Ser.Billirubin 0.2-0.8 mg/dl
Indirect 0.1 – 0.3 mg/dl
Direct 0.2 – 0.7 mg/dl
SGOT (AST) 0-35 IU
SGPT (ALT) 0-35 IU
Alk. Phosph. 30-120 IU
Ser. Protein 5.5 – 8.5 G/dl
Alb 3.5 – 5.5 G/dl
Glob 2.0 – 3.0 G/dl

24.  Colour of urine and stools
n Normal urine + normal stools = pre-hepatic cause
n Dark urine + normal stools = hepatic cause
n Dark urine + pale stools = post-hepatic cause
(obstructive)
Urine - Jaundice

25. ⚫ Ultrasound:
 More sensitive than CT for gallbladder stones
 Equally sensitive for dilated ducts
 Portable, cheap, no radiation, no IV contrast
⚫ CT:
 Better imaging of the pancreas and abdomen
⚫ PTC- percutaneous transhepatic cholangiogram
 Gives a picture of the intra and extrahepatic biliary
tree
Radiological investigations

26.  Anti-nuclear antibody
 Anti-smooth muscle antibody
 Immunoglobulins
 Anti-mitochondrial antibody
 hepatitis serologies
 a1-antitrypsin
 iron levels
 Ceruloplasmin
• a-fetoprotein
Second-line tests for jaundice
“focused” or “screen”

27. ⚫ MRCP:
 Imaging of biliary tree comparable to ERCP
 Non invasive
⚫ ERCP:
 Therapeutic intervention for stones
 Brushing and biopsy for malignancy
• Invasive, chances of developing pancreatitis post
procedure
cont.....

28. How to differentiate the types of
jaundice?
⚫Hemolytic:
 Increased unconjugated (indirect) more than direct
(conjugated) bilirubin
 Hemoglobin level low
 Anemia
⚫Hepatic:
 Increased amount of both indirect and direct
 Increase in AST and ALT more than increase in
ALP
⚫Obstructive:
 Increased amount of direct (conjugated)
 Significant increase in ALP more than AST and
ALT

29. Patient A
⚫42 year old female with history of general
weakness of 4 months. She was found to
have moderate anemia,
jaundice and mild splenomegaly.
⚫Hemolytic Jaundice

30. Clinical Findings—Hemolytic
Jaundice
⚫Decreased hemoglobin
 Explains weakness
 Has moderate anemia
⚫Splenomegaly
 Increased activity of reticuloendothelial system
 Site of RBC filtration
⚫Liver Function Tests:
 Increased Serum bilirubin
 Increased load to the liver (increased hemolysis) =>
increased hemoglobin metabolism

31.  Hemolysis
n Glucose-6-phosphate deficiency
n Pyruvate kinase deficiency
n Drugs
 Ineffective erythropoiesis
 Uridine diphosphate glucuronosyltransferase deficiencies
n Gilbert syndrome
n Crigler-najjar syndromes (i and ii)
 Miscellaneous causes
n Drugs
n Hypothyroidism
n Thyrotoxicosis
n Pulmonary infarct
n Fasting
UnConjugated Hyperbilirubinemia
Etiology

32.  Acetominophen
 Alcohol
 Amiodarone
 Azulfidine
 Carbenicillin
 Clindamycin
 Colchicine
 Cyclophosphamide
 Diltiazem
 Ketoconazole
• Methyldopa
Common Drugs Associated With Hyperbilirubinemia
(hepatocellular cause)

33. Patient B
⚫30 year old male with history of fever of 2
weeks, nausea and highly colored urine.
He
had palpable, soft tender liver.
⚫Hepatic Jaundice

34. Clinical Findings—Hepatic
Jaundice
⚫ Highly colored urine
 Increased amount of bilirubin excretion
⚫ Tender hepatomegaly
⚫ Liver function tests
 High serum bilirubin
 AST and ALT highly increased
 Alkaline phosphatase increased moderately
Seen in both
hepatocellular
jaundice and
cholestatic
jaundice

35.  Congenital causes
Rotor syndrome
n Dubin-Johnson syndrome
n Choledochal cysts
 Familial disorders
n Benign recurrent
intrahepatic cholestasis
n Cholestasis of pregnancy
 Hepatocellular defects
n Alcohol abuse
n Viral infection
 Sepsis
Conjugated Hyperbilirubinemia
Etiology
 Cholestatic
n
Primary biliary
cirrhosis
n
Primary
sclerosing
cholangitis
n
Biliary
obstruction
n
Pancreatic
disease
 Systemic disease
 Infiltrative
disorders
 Postoperative
complications
 Renal disease
 Drugs

36. Patient C
⚫35 yr old male with complaints of pain abdomen,
jaundice,itching and passing clay colored
stools.
⚫Previously he was diagnosed with gall bladder stones
but has not taken treatment.
⚫Gall bladder is not palpable.
⚫Obstructive jaundice due to CBD stones.

37. Patient D
⚫60 yr old male patient with progressive jaundice,
itching, loss of weight .
⚫On palpation gall bladder is palpable.
⚫Obstructive jaundice due to malignancy
⯍ Periampulary carcinoma

38. Clinical findings in obstructive
jaundice
⚫Deep jaundice
⚫Scratch marks on body
⚫High colored urine
⚫Clay colored stools
⚫Other features
 ?pain
 ?weight loss
 ?palpable gall bladder
 ?ascites

39. 1. CHOLEDOCHOLITHIASIS
2. NEOPLASMS- periampullary carcinomas
3. BILIARY ATRESIA
4.CHOLEDOCHAL CYST
5. LYMPHADENOPATHY-PORTA HEPATIS
• TRAUMATIC- POST CHOLECYSECTOMY
Obstructive jaundice - etiology

40.  Amitriptyline
 Androgenic steroids (B)
 Atenolol
 Augmentin
 Azathioprine
 Bactrim (D)
 Benzodiazeprines
 Captopril
 Carbamazole
 Cyclosporine
 Danazol (B)
 Dapsone
 Disopyramide
 Erythromycin
 Estrogens (B)
 Ethambutol
• Floxuridine
Drugs Associated With Hyperbilirubinemia
cholestatic cause

41. Curvoisier’s law
⚫―In a case of obstructive jaundice, if the gall
bladder is palpable, it is unlikely to be due to
stones.‖
⚫Explanation :

42. Treatment
⚫Choledocholithiasis
 Open / laparoscopic CBD exploration with stone extraction
and T tube placement.
 Endoscopic papillotomy and extraction
⚫Periampularry carcinoma
 Curative – whipple’s procedure
 Palliative –
- endoscopic stenting of ampulla
- bypass prcodures for
a. Food e.g. gastrojejunostomy
b. Bile e.g. choledochojejunostomy

43. Whipple’s operation
⚫3 structures removed
 C-loop of duodenum
 Head and neck of pancreas
 Pylorus of stomach
⚫3 anastomosis are made
 Gastro-jejunostomy
 Choledocho-jejunostomy
 Pancreatico-jejunostomy

44. THANK YOU