This document discusses jaundice, including its signs, stages, causes, differential diagnosis, and approach. Jaundice is a yellowish discoloration of the skin and eyes caused by high bilirubin levels. It is often a sign of liver disease or hemolytic disorders. The document outlines the sequential sites of jaundice, metabolism of bilirubin, measurement of bilirubin levels, differential diagnosis between liver diseases and bile duct disorders, and three patient cases presenting with different causes of jaundice.

1. APPROACH TO JAUNDICE

2. JAUNDICE
• Yellowish discoloration of skin, sclera
and mucous membrane resulting from
deposition of bilirubin .
• It is a sign of liver disease or less often a
hemolytic disorder or disorder of
bilirubin metabolism

3. SEQUENTIAL SITES OF JAUNDICE
1st STAGE
Frenulum of tongue(>1.5mgdl)
2nd STAGE
Sclera of eye (>2.5mgdl)
3rd stage
Skin(>3.5 mg/dl)

4. Differential diagnosis of Yellowing of
skin
• Carotenoderma-yellow color imparted to the
skin because of carotenes prsent in Carrots,
green leafy vegetable, squash, peaches and
oranges.
• Palms, soles, forehead and nasolabial folds.
• Spares the sclera(differentiated from
jaundice)
• Quinacrine an ANTIMALARIAL DRUG- 4-37%
yellowish discoloration of skin, also sclera.

5. METABOLISM OF BILIRUBIN
1 . Production of bilirubin
2. Excretion of bilirubin

6. Production of bilirubin
• Tetrapyrrole pigment
• Break down product of Heme
• 80-85%- Breadown of Old RBCS
• Rest- Premature destruction of erythroid
cells in the bone marrow and from turnover
of hemoproteins myoglobin and
cytochromes.
• Formation- RE Cells in liver and spleen

8. MEASUREMENT OF SERUM BILIRUBIN
• BASED ON VAN DE BERG REACTION

10. MEASUREMENT OF URINE BILIRUBIN
• Unconjuated bilirubin always bound to
albumin - not found in urine
• Conjugated bilirubin filtered by the
glomerulus and majority is reabsorbed by the
prox tubules.
• Urine dipstick test- ICTOTEST
• False negative in prolonged cholestasis due to
conjugated BR bound to albumin.

12. HOW TO APPROACH

15. DIFFERENTIAL DIAGNOSIS OF
JAUNDICE
1. Inherited disorders of bilirubin metabolism
a----Unconjugated hyperbilirubinemia
b----Conjugated hyperbilirubinemia
2.Liver Diseases
a----Hepatocellular dysfunction
b----Hepatic disorders with prominent cholestasis
3.Bile duct disorders
a----Choledocholithiasis
b----Bile dut diseases

16. ISOLATED DISORDER OF BILIRUBIN
METABOLISM

17. A-Unconjugated hyperbilirubinemia
• Increased bilirubin production-Due to
hemolysis and ineffective erythropoeisis
• Decreased hepatocellular uptake-Drugs like
Rifampicin
• Decreased conjugation- Gilberts syndrome
,Criggler –Najjar syndrome

18. B. Conjugated or mixed hyperbilirubinemia
• Dubin johnson syndrome
• Rotors syndrome

20. LIVER DISEASE
A. Hepatocellular dysfunction
• Acute or subacute hepatocellular injury seen
in viral hepatitis , hepatotoxins,, ischaemia
• Chronic hepatocellular disease autoimmune
hepatitis, celiac disease, wilsons disease

21. B-Hepatic disorders with prominent cholestasis
• Infiltrative disease such as sarcoidosis,
mycobacterial infections
• Cholangiocyte injury due to primary biliary
Cirrhosis

22. BILE DUCT OBSTRUCTION
A.Choledocholithiasis
B.Bile duct diseases
• Inflammation- primary sclerosing cholangitis
• Pancreatitis
• Neoplasms-Pancreatic carcinoma
• Vascular enlargement-portal cavernoma

23. TAKE HOME MESSAGE
• 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.
• This is just a overview.

24. PATIENT A
42YEAR OLD FEMALE WITH HISTORY OF GENERAL
WEAKNESS OF4 MONTHS . SHE WAS FOUND TO
HAVE MODERATE ANEMIA , JAUNDICE AND
MILDSPLENOMEGALY .

25. Ans. HEMOLYTIC JAUNDICE

26. Patient B
• 30 YEAR OLD MALE WITH HISTORY OF FEVER
OF 2 WEEKS , NAUSEA AND dark COLORED
URINE . HE HAD PALPABLE , SOFT TENDER
LIVER .

27. Ans. Hepatic Jaundice

28. PatientC
• 35YR 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 .

29. Ans.OBSTRUCTIVE JAUNDICE