JAUNDICE

DR NILESH KATE
MBBS,MD
ASSOCIATE PROF
DEPT. OF PHYSIOLOGY
JAUNDICE

OBJECTIVES.
 Definition
 Mechanism of production
 Types
 Characteristic features
 Physiological Jaundice
 Prevention
 Treatment .
Thursday, November 3, 2016

DEFINITION
 JAUNDICE is defined
as Yellowish
discoloration of skin,
sclera & mucous
membrane

CAUSE
 Increase bilirubin concentration
( Hyperbilirubinemia) in the body fluids.
 Normal range of serum bilirubin – 2-3 mg/100ml.
 Jaundice when plasma bilirubin > 2-3 gm/dl.

EXCEPTION
 All internal tissue & body fluids are yellow coloured
except BRAIN
 d/t – BLOOD BRAIN BARRIER which not allow
bilirubin to pass except in neonatal period.

KERNICTERUS
 Deposition of excess
bilirubin to brain mainly
Basal Ganglia –
Kernicterus.
 C/f – 3 phases
 Decreased alertness,
Hypotonia, poor feeding,
 Hypertonia, Opisthotonus
 Hypotonia.

BILIRUBIN & JAUNDICE
BILIRUBIN FORMATION.
Tetra pyrrole straight chain with
Globin & Iron

BILIRUBIN & JAUNDICE
UPTAKE OF BILIRUBIN.
 After degradation of Hb
bilirubin is released into
circulation. Its free of Un-
conjugated Bilirubin.
 Its lipid soluble in plasma
& bound to albumin
 This binding prevents its
excretion by the kidneys.

CONJUGATION OF BILIRUBIN
 This un-conjugated taken
up by liver, albumin
removed & enters hepatic
cells
 Conjugate with UDP-
Glucoronic acid to form
conjugated bilirubin
 Enzyme – UDP-
Glucoronyl transferase.

EXCRETION OF BILIRUBIN
 Conjugated Bilirubin
from liver is excreted
into Bile Canaliculi
against conc gradient.
 Enters Intestine

FORMATION & EXCRETION OF
UROBILINOGEN.
 In intestine Conjugated bilirubin is degraded by
intestinal bacteria
 β Glucoronidase convert Bilirubin to Urobilinogen
& Stercobilinogen.
 20% of Urobilinogen reabsorbed into portal system
to liver & escape into general circulation & re-
excreted into bile
 From General Circulation some filtered by kidney &
excreted in Urine.

BILIRUBIN CIRCULATION IN
THE BODY

MECHANISM OF PRODUCTION
 Excessive breakdown
( Hemolysis) of RBC so
called Hemolytic Jaundice
or Prehepatic Jaundice.
 Damage to liver cells –
Hepatic or Hepatocellular
Jaundice.
 Obstruction to bile duct –
Post hepatic or Cholestatic
Jaundice.

TYPES
 Hemolytic Jaundice
( Pre-Hepatic)
 Hepatocellular
Jaundice (Hepatic
Jaundice)
 Cholestatic or
Obstructive
Jaundice.(Post-
Hepatic)

HEMOLYTIC JAUNDICE ( PRE-
HEPATIC)
 Types of serum bilirubin
accumulated.
 Van den Bergh test
 Urine bilirubin
 Urine urobilinogen.
 Faecal stercobilinogen.
 Faecal fat level.
 Specific blood tests

 Excessive Breakdown
of RBC –
 Produces Un-
more than healthy
liver can conjugate &
excrete.

TYPES OF SERUM BILIRUBIN
ACCUMULATED.
Unconjugated
Hyperbilirubinaemia.

VAN DEN BERGH TEST
 Reagent used – Diazo
reagent ( Mixture of
Sulphanilic acid,
Hydrochloric acid &
sodium Nitrite)
 Test – 2 types
 Direct
 Indirect.

VAN DEN BERGH TEST
 Direct – when Diazo reagent added to serum
containing Conjugated Bilirubin Reddish Brown
colour developed in 30 sec.
 Indirect - when Diazo reagent added to serum
containing Un-Conjugated Bilirubin No colour
developed but when some alcohol added which
dissolves Unconjugated Bilirubin – reddish Brown
colour is obtained.

VAN DEN BERGH TEST
 Indirect Positive
Reaction – Due to Un-
Conjugated Bilirubin.

URINE BILIRUBIN
 Unconjugated
Bilirubin is insoluble in
water & transported n
plasma with albumin.
 Since albumin is not
Filtered it is not appear
in Urine.

URINE UROBILINOGEN.
 Liver excrete lots of conjugated bilirubin in
intestine in bile & more Urobilinogen is formed
 So Urine Urobilinogen is increased.

FAECAL STERCOBILINOGEN.
 Normal 25-250 mg/day.
 Same as more Urobilinogen & stercobilinogen
is formed
 Faeces is Dark Brown in colour.

FAECAL FAT LEVEL.
 Normal
 5-6% of total intake /day

SPECIFIC BLOOD TESTS
 Peripheral blood film – Haemolysis, Anaemia,
Reticylocytosis.
 Normal Plasma Albumin: Globulin ratio.
 Serum alkaline phosphatase Normal
 Liver function tests – Normal ( As liver is normal)

HEPATOCELLULAR JAUNDICE
(HEPATIC JAUNDICE)
accumulated.
 Urine bilirubin

 Inability of liver to conjugate & transport
bilirubin into bile duct due to Liver damage.

ACCUMULATED.
 Both conjugated & Unconjugated bilirubin
increased.

VAN DEN BERGH TEST
 Biphasic Reaction as
both Conjugated & Un-
present.

URINE BILIRUBIN
 Present
 As conjugated
bilirubin is water
soluble is dissolved,
filtered & appear in
urine
 Also called Choluric
Jaundice.

URINE UROBILINOGEN.
 Decreases
 As damaged liver cells are producing & excreting
less of conjugated Bilirubin & thus less
Urobilinogen.

 Less
 As less formation of Stercobilinogen
 So Faeces are Pale Coloured.

FAECAL FAT LEVEL.
 Increased up to 40-50%.
 As less bile in intestine – less emulsification &
absorption of fat
 So bulky, pale, greasy & foul smelling faeces-
steatorrhoea.

 Peripheral blood film – Normal
 Albumin decreased, so albumin: globulin ratio
Decreased
 Serum alkaline phosphatase – Increased.
 Liver function test – impaired.

CHOLESTATIC OR OBSTRUCTIVE
JAUNDICE.(POST-HEPATIC)
accumulated.
 Urine bilirubin

 Obstruction to the
bile flow from
Hepatocytes to
duodenum.

ACCUMULATED.
 Conjugated Hyperbilirubinaemia due to
impaired flow of bile.

VAN DEN BERGH TEST
 Direct Positive
reaction.
 As only conjugated
bilirubin present.

URINE BILIRUBIN
 Present.
 As conjugated
bilirubin filtered in
urine.

URINE UROBILINOGEN.
 Markedly decreased or absent.
 As due to obstruction conjugated bilirubin is not
released in intestine
 No Urobilinogen is formed.

 Absent – when obstruction is complete.
 Stools are clay coloured.

FAECAL FAT LEVEL.
 Increased.

 Peripheral blood film – normal.
 Plasma albumin, globulin & ratio – Normal
 Serum Alkaline phosphatase – markedly
increased.
 Liver function tests - normal

PHYSIOLOGICAL JAUNDICE
 NEONATAL JAUNDICE.
 Mechanism of
production
 Appears 2-5 days after
birth & disappears in 2
weeks.
 Excessive destruction of
RBC & hepatic Immaturity
in first 7-10 days.

SIGNS & SYMPTOMS

PREVENTION
 By giving Hepatic Microsomal enzyme inducers
(Phenobarbital) to pregnant mother or
newborn-
 Increases activity of Glucoronyl Transferase.

TREATMENT .
 PHOTOTHERAPY
 Exposure of skin to
white light – PHOTO-
ISOMERIZATION of
Bilirubin to water
soluble Lumirubin
which is excreted in
Bile without
conjugation

TREATMENT OF PATHOLOGICAL
JAUNDICE IN ADULT

JAUNDICE

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