This document provides an overview of jaundice and hyperbilirubinemia. It begins with the etymology and brief history of jaundice. It then discusses the anatomy of the liver and bilirubin metabolism. Various types and causes of hyperbilirubinemia are explained, including pre-hepatic, hepatic and post-hepatic jaundice. Specific conditions like Gilbert's syndrome and viral hepatitis are described. Liver histology findings in different liver diseases and drug induced liver injuries are also summarized.

1. Dr. Swarnendu Pal

2.  Introduction
 Etymology & Brief History
 Anatomy of liver & Bilirubin metabolism
 Clinical examination
 Direct vs Indirect bilirubin
 Normal values
 Causes of Hyperbilirubinemia
 Individual entities
 Workup
 Treatment
 Take home message

3. Jaundice
It is a yellowish discoloration of skin & mucus
membrane resulting from the deposition of
bilirubin in the tissue with serum
hyperbilirubinemia.

4. Etymology
Jaune ”yellow”
Jaunice
Jaunes “Yellowness”
Jaundice
Old French, (12c.)
Middle English, (14c.)

6. History
 Jaundice one of the earliest diseases known to
mankind.
 The Babylonian scripts describes Jaundice as a
sign of causeless hatred
 Hippocrates (460BC-370BC)

7. History contd...
 1836 Effects of alcohol were first described by
Addison in
 1849 Virchow discovered ‘hematoidin’
 1864 Bilirubin term coined by Stadeler
 1935 Concept of obstructive jaundice by Whipple.

8. History contd...
 1947 “Infectious hepatitis” renamed hepatitis A,
“serum hepatitis” renamed hepatitis B.
 1965 - “Australia antigen” detected in serum of an
Australian aborigine and some American leukemia
patients.
 1983 - Hepatitis E identified

10. Infamous Infectious Hepatitis
experiments

11. Infamous Infectious Hepatitis
experiments
Five Australian prisoners of war were intentionally
infected with hepatitis when they were held captive
by Nazi doctors during World War II (1941)
Nazi doctor Friedrich Meythaler, carried out the
experiments

12. Infamous Infectious Hepatitis
experiments
Nazi doctor Friedrich Meythaler, studied human-to-
human infection of hepatitis, monitored the men,
finding after a few days - they had enlarged livers,
increasing temperatures, among other symptoms.

13. Willowbrook School experiment
 At Staten Island, (1963 -1966), a study was
conducted by Saul Krugman at the
Willowbrook State School for children with
mental retardation.
 The children were intentionally given
hepatitis orally and by injection to see if
they could then be cured with gamma
globulin.
 Children were infected with viral
hepatitis by feeding them an extract made
from the feces of patients infected with the
disease

15. Liver Anatomy
 C- Sinusoids
 T- Portal tract
 V- Central vein

17. Bilirubin Metabolism

18. Bilirubin
metabolism  Bilirubin is Selectively
transported into the
hepatocyte.
 The conjugates are
secreted into bile via the
Multidrug resistance protein
2 (MRP-2).
 Some unconjugated and
conjugated bilirubin also
refluxes into the plasma.
Alb- Albumin
B- Bilirubin
UDP-G- Uridine DiPhospho
Glucuronic acid
BG- Conjugated Bilirubin
OATP- organic anion transporting
polypeptide
OATP
BiT
BiT-Bilirubin transporter

19. Bilirubin Metabolism
 70-80% of the bilirubin – breakdown of hemoglobin in
senescent red blood cells.
 Remainder –
 prematurely destroyed erythroid cells in bone
marrow and
 Turnover of hemoproteins such as myoglobin and
cytochromes

20. When does Jaundice occur?
Normally serum contains small amount of bilirubin
and balance is maintain by production and
clearance
Any factor that can disturb equilibrium between
bilirubin production & clearance, causes jaundice.

21. Clinical examination of
Jaundice
 Examining the sclerae, soft
palate, undersurface of
tongue, skin, palms and
sole
 The presence of scleral
icterus indicates a serum
bilirubin level of at least
51 μlmol/L(3 mg/dL)

22. D/D of Jaundice
 Carotenoderma，
 Use of drug quinacrine
 Excessive exposure to phenols

24. Direct vs Indirect Bilirubin
 Terms direct(conjugated) and
indirect(unconjugated) bilirubin respectively-are
based on the original Van den Bergh reaction.
 When diazotised sulfanilic acid reacts with
bilirubin, ‘azobilirubin’, a purple coloured
product (540 nm).
Reaction is known as Van den Bergh reaction.

25. Direct vs Indirect Bilirubin
 The direct fraction –
 Conjugated bilirubin  gives colour immediately
(<1min).
 Reacts with diazotized sulfanilic acid in absence of
an accelerator substance such as alcohol.
 Provides an approximation of the conjugated
bilirubin level in serum.
 The total serum bilirubin is the amount that reacts after
the addition of alcohol and reacts immediately
 Unconjugated bilirubin = Total bilirubin – Conjugated(Direct) bilirubin

26. Direct vs Indirect Bilirubin
 Conjugated bilirubin : blirubin glucuronide +
bilirubin diglucuronide + delta (δ) bilirubin.
 Delta bilirubin represents bilirubin covalently bound
to albumin in circulation.
In cholestasis, proportion of δ-bilirubin increases

27. Normal value and
Hyperbilirubinemia
Normal value-
Bilirubin Serum
Total --------- 0.3–1.3 mg/dL
Direct ----- 0.1–0.4 mg/dL
Indirect ------- 0.2–0.9 mg/dL

28. Classification of Jaundice

29. Causes of hyperbilirubinemia
A. According to the main type of bilirubin
increased in plasma
Hyperbilirubinemia
Predominantly
Unconjugated
Hyperbilirubinemia
Predominantly
Conjugated
Hyperbilirubinemia

30. Causes of hyperbilirubinemia
Predominantly
Unconjugated
Hyperbilirubinemia
Excess Bilirubin
production
Reduced hepatic
uptake
Impaired Bilirubin
conjugation
a) Hemolytic Anemia
b) Ineffective
Hematopoiesis
c) Reabsorption from
Hemorrhage
Drugs,e.g Rifampicin
a) Physiologic jaundice
b) Breast milk jaundice
c) Gilbert syndrome
d) Crigler-Najjar
syndrome(Both 1 & 2 )
e) Hepatocellular disesse(
Drugs, Cirrhosis,
Hepatitis)

31. Causes of
hyperbilirubinemia
a)Viral hepatitis
b)Drugs,e.g-OCP
c)Sepsis
d)Cirrhosis
Intrahepatic
Obstruction
Extrahepatic
Obstruction
Hepatocellular
Disease
Cholestasis
Hereditary
Acquired
DJ Syndrome
Rotor Syndrome
Predominantly
Conjugated
Hyperbilirubinemia
a)Viral hepatitis
b)PBC
c)Drugs,e.g-Steroid
a) Gall stone
b) Ca Pancrease
c) CA Bile duct

32. Types of Jaundice:
B. According to site of disease
Haemolytic or Pre-hepatic –
Hepatocellular or Hepatic -
Cholestatic (Obstructive) or Post-hepatic

33. Types of Jaundice:
 C. According to etiology:
 Hemolytic: increased rate of red cell destruction
 Hepatocellular: Inability of hepatocytes to
conjugate and/or excrete bilirubin.
 Obstructive: Failure of excretion of conjugated
bilirubin into the intestine, causing its regurgitation
in circulation.

34.  Most common cause of obstruction GB stone.

36. Increased hemolysis
↑ destruction of erythrocytes  ↑ bilirubin turnover
and unconjugated hyperbilirubinemia
Hemolysis alone cannot result in a sustained
hyperbilirubinemia >4 mg/dL.
Higher values imply concomitant hepatic dysfunction
Prolonged hemolysis  formation of gallstones

37. Ineffective Erythropoiesis
Thalassemia Major,
Megaloblastic Anaemias
Congenital Erythropoietic Porphyria，
Lead Poisoning，
Dyserythropoietic Anaemias
Fraction of total bilirubin production derived from
ineffective erythropoiesis is increased

38. Physiologic jaundice
 Seen both in term and preterms
 Self limiting. Develops after 24 hours
 Peaks by D2- D5 levels 5-10 mg/dl. Gradually subsides by 10-14
days.
 Hepatic physiologic processes incompletely developed at
birth.
 Low levels of UGT1A1.
 Intestinal flora undeveloped  enterohepatic circulation of
unconjugated bilirubin
 No Treatment necessary - phototherapy

39.  Develops after the first 4-7 days of life & persist for 3-12
weeks.
 Causes:
 An unusual metabolite of progesterone , pregnanediol 
inhibits UDP glucuronyl transferase.
 ↑ concentrations of nonesterified free fatty acids that inhibit
hepatic glucuronyl transferase.
 ↑ enterohepatic circulation of bilirubin due to increased
content of beta glucuronidase activity in breast milk .
Breast milk jaundice

40. Gilbert syndrome
 Autosomal dominant > recessive. Common disorder
 Diagnosed incidentally at or shortly after puberty or in adult life.
 Decreased activity of UGT1A1 enzyme -10-35% of normal(1/3rd of
normal)，
 Mild unconjugated hyperbilirubinemia ↑ bilirubin monoglucuronides
 Fluctuating manner & aggravating factors are Fasting, Sepsis,
strenous exercise, Illness.
 Serum bilirubin level range <3 to 8 mg/dl.
 No treatment needed.

41. Crigler-Najjar syndrome-1
 John Fielding Crigler and Victor Assad Najjar
 Crigler-Najjar syndrome 1(CN-1)- AR disease (rare)
 Complete absence of UGT1A1 enzyme.
 Intense jaundice appears in the first day of life and
persists .
 Majority (type IA) defects in the glucuronide conjugation
in bilirubin, including various drugs and other xenobiotics.

42. Crigler-Najjar syndrome-1
Encephalopathy (kernicterus) in infancy or early
childhood.
A few lived as long as early adult life with mild but
progressive brain damage.
Orthotopic liver transplantation

43. Crigler-Najjar syndome-2
CN-2 is Autosomal recessive predominantly.
Very reduced amount of UGT1A1 enzyme (≤10% of
normal).
Pathogenesis same as CN-1 but in less severity.
Usually survive into adulthood
Both CN 1 & 2 only curable by liver transplant.

44. Alcoholic liver disease
 3 overlapping forms of alcoholic liver injury:
 Hepatocellular steatosis or fatty change,
 Alcoholic (or steato-) hepatitis, and
 Steatofibrosis including cirrhosis in the late stages
of disease

45. Alcoholic liver disease
hepatic dysfunction, with elevated serum
aminotransferases
hyperbilirubinemia,
variable elevation of serum alkaline phosphatase,
hypoproteinemia and anemia.

46. Hepatitis
Acute viral hepatitis Chronic hepatitis
Hepatotropic virus
Non hepatotropic virusHepatotropic virus
HAV
HBV
HCV
HDV
HEV
viral hepatitis
Autoimmune
hepatitis Drug associated
HBV
HCV
HDV
EBV
CMV
 Acute Viral Hepatitis: symptoms last less than 6 months.
 Chronic Hepatitis: Inflammation of liver for at least 6 months.
Cryptogenic

47. Viral Hepatitis
Virus Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E
Route of
transmissio
n
Fecal-oral Parenteral,
sexual
contract,
perinatal
Parenteral;
intranasal
cocaine
Parenteral Fecal-oral
Mean
incubation
period
2–4 weeks 1–4 months 7–8 weeks Same as
HBV
4–5 weeks
Frequency
of chronic
liver
disease
Never 10% ∼80% 5% (co-
infection);
≤70% for
superinfecti
on
Never
Diagnosis Detection
of serum
IgM
Detection
of HBsAg or
anti HBcAg
PCR for
HCV RNA;
ELISA for
Antibody
Detection of
IgM and IgG
Ab, HDV
RNA serum;
HDAg in
liver
PCR for HEV
RNA;
detection
of serum
IgM and IgG
antibodies

51. Few terms explained
 Balloning degeneration : larger hepatocytes than
adjoining ones with clear cytoplasm cell (defective
osmotic regulation at the cell membrane)
 Acidophil bodies deeply eosinophilic staining apoptotic
hepatocytes
 Confluent necrosis widespread hepatic parenchymal loss
affecting contiguous parenchymal territories
 Bridging necrosis area of necrosis filled by cellular
debris, macrophages, and remnants of the reticulin
meshwork link central veins to portal tracts or bridge
adjacent portal tracts

52. Few terms explained
 Interface hepatitis loss and degeneration of
(limiting plate) hepatocytes at the interface
between hepatocellular parenchyma and portal
tract stroma.

53. Acute Hepatitis

54. Acute viral hepatitis showing disruption of lobular architecture, inflammatory
cells in the sinusoids, and hepatocyte apoptosis (arrow).

55. Chronic Hepatitis

56.  Chronic viral hepatitis B,
Ground glass hepatocytes,
characterized by more
pale, eosinophilic, and
homogeneous cytoplasm

57. Chronic viral hepatitis C
Portal tract expansion
by a lymphoid follicle

58. Viral Hepatitis contd…
 CMV & EBV virus induced acute hepatitis occurs after
systemic infection of these viruses.
 CMV mainly infects in immunocompromised pts. Or in
newborn (transplacental route).

59. Viral Hepatitis contd…
 CMV Hepatitis : lobular
lymphocytic infiltrate
with minimal
hepatocellular necrosis or
ballooning

60. Drug-induced and toxic liver injury
Pattern of Injury Morphologic Findings
Examples of Associated
Agents
Cholestatic Bland hepatocellular
cholestasis, without
inflammation
Contraceptive and anabolic
steroids; estrogen
replacement therapy
Cholestatic hepatitis Cholestasis with lobular
necroinflammatory
activity; may show bile
duct destruction
Numerous antibiotics;
phenothiazines
Hepatocellular necrosis Spotty hepatocyte necrosis Methyldopa, phenytoin
Submassive necrosis, zone
3
Acetaminophen, halothane
Massive necrosis Isoniazid, phenytoin
Steatosis Macrovesicular Ethanol, methotrexate,
corticosteroids,
Rifampicin,TPN
Steatohepatitis Microvesicular, Mallory
bodies
Amiodarone, ethanol
Fibrosis and cirrhosis Periportal and pericellular
fibrosis
Methotrexate, isoniazid,
enalapril

61. Autoimmune Hepatitis(AIH)
 Usually chronic, progressive hepatitis
 genetic predisposition – HLA association
 Viral infections, certain drugs, connective tissue
disorders – SLE, RA, thyroiditis etc.
 Attributed to T cell–mediated autoimmunity.

62. Autoimmune Hepatitis(AIH)
Autoimmune hepatitis
 Type 1, middle-aged to older individuals, antinuclear
(ANA), anti–smooth muscle actin (SMA),
 Type 2, usually seen in children and teenagers, the
main serologic markers are anti–liver kidney
microsome-1 (anti-LKM-1) Abs

63. Autoimmune Hepatitis(AIH)
 Acute AIH h/p features of :
 interface or lobular hepatitis
with lymphoplasmacytic
infiltration,
 In Chronic hepatitis
histologically tend to show
 substantial liver destruction
and
 scarring.

64. Dubin-Johnson syndrome
Autosomal Recessive.
Mutation in the canalicular Multiple drug resistance
protein 2(MRP2) gene  Impaired biliary excretion of
bilirubin glucuronides.
C/F :
 usually asymptomatic,
 mild predominantly conjugated jaundice, which may not
appear until puberty or adulthood

65. Dubin-Johnson syndrome
 A darkly pigmented liver is due to polymerized
epinephrine metabolites.
Oral cholecystography-GB not visualised.
T/t- Not needed
avoid alcohol, hepatotoxic drugs, exposure to
viral hepatitis, etc.

66. Dubin-Johnson syndrome
 Dubin-Johnson
syndrome, showing
abundant pigment
inclusions in otherwise
normal hepatocytes

67. Rotor syndrome
 Rare, relatively benign AR.
 Gene mutations , abnormally short, nonfunctional
Organic anion transporting polypeptide (OATP1B1 and
OATP1B3 proteins) or, an absence of these proteins 
Reduced reuptake of conjugated bilirubin

68. Cont.
Cl/f-
Chronic jaundice without evidence of haemolysis.
Jaundice is usually evident shortly after birth or in
childhood and fluctuant.
 Difficult to differ from D-J syndrome.
No black pigmentation in liver.
Oral cholecystography, GB seen.
Treatment & management same as D-J syndrome.

69. Primary Biliary cirrhosis
Primarily middle-aged women M:F = 1:10
Characteristic for PBC is the presence of
antimitochondrial antibodies (AMA)
Inflammatory destruction of small and medium sized
intrahepatic bile ducts

70. Primary Biliary cirrhosis
Interlobular bile ducts
are actively destroyed
by lymphoplasmacytic
inflammation with or
without granulomas

72. Workup in a case of
Jaundice
 A. History
 Duration
 Medication history
 Sexual activity and alcohol history.
 Family history- hemolytic anemias, congenital hyperbilirubinemias
 Travel history
 Accompanying symptoms- anorexia, weight loss, abdominal pain-
choledocholithiasis and ascending cholangitis
 B. Physical examination
 Assessment of patients nutritional status
 parotid enlargement or testicular atrophy.- advanced alcoholic
cirrhosis

73. Workup in a case of
Jaundice
C. Laboratory tests
 total and direct serum bilirubin measurement with fractionation
 Determination of urinary bilirubin , bile salts and urobilinogen,
fecal stercobilinogen
 determination of
 s.alanine aminotransferase ALT or SGPT , (7– 41 IU/L)
 aspartate aminotransferase AST or SGOT (12-38 IU/L)
 alkaline phosphatase ALP (44-145 IU/L)
 γ-Glutamyl transferase or GGT
 Albumin levels

74. Workup in a case of Jaundice
Marked elevations of ALT and AST (>15 times) to ALP
 acute viral hepatitis
Moderate elevations (5-15 times)  autoimmune
hepatitis, alcoholic hepatitis, and drug induced
hepatitis.
Mild elevations (1-3 times)  cirrhosis & cholestasis.

75. Workup in a case of
Jaundice
AST/ALT ratio ̴̴ 0.7 to 1.4.
 ratio (>2.0)  alcoholic hepatitis
 ratio <1.0  acute viral hepatitis

76. Workup in a case of
Jaundice
Estimation in Serum Bilirubin
 Diazo method (most commonly used)
 HPLC method
 Enzymatic methods
 Transcutaneous bilirubin method estimation

77. Workup in a case of
Jaundice
Tests for Detection of Bilirubin in Urine :
Gmelin’s test, Lugol iodine test, Fouchet’s test, and
reagent strip test.
Tests for Detection of Urobilinogen in Urine :
Ehrlich’s aldehyde test , Reagent strip test

78. Lab findings of predominantly Unconjugated
hyperbilirubinaemia
Pathophysiolo
gy
Cause
% of
Direct
bilirubin
Urine
Stool
Sterco
bilinog
en
Biliru
bin
Urobilin
ogen
Excess
production
a)Hemolytic Anemia
b)Ineffective Hematopoiesis
c)Reabsorption from
Hemorrhage
Less than
20 %
(- ve)
ed ed
Decreased
uptake
a)Gilbert syndrome
b)Drugs,e.g-Rifampicin
Variable
(N/ ed)
Normal
to ed
Impaired
conjugation
a) Physiologic jaundice
b) Breast milk jaundice
c) Crigler-Najjar syndrome
(Both 1 & 2 )
a) Hepatocellular disease
Variable
(N/ ed)
Normal
to ed

79. Lab findings of predominantly Conjugated
hyperbilirubinaemia
Pathophysi
ology Cause
% of
Direct
bilirubin
Urine Stool
Stercobili
nogenBiliru
bin
Urobili
nogen
Intrahepatic
obstruction
Hepatocellular disease
More
than 15% + ve
Normal
or
ed
ed
ed
Cholestasis
Posthepatic
obstruction
a. Gall stone
b. Ca Pancrease
c. CA Bile duct
ed ed

81. Workup in a case of
Jaundice
D. Other tests
 Viral serology
 Toxicology screen – acetaminophen levels
 Ceruloplasmin levels
 ANA, SMP, LKM1 levels
 AMA levels
E. Radiological Investigations : CT, MRCP, ERCP,
MRCP
F. Liver biopsy

82. History, Cl/F, Lab invst: Bilirubin with fractionation, ALT,AST,ALK-P,PT & Albumin
Isolated elevation of bilirubin Bilirubin & other liver test elevated
Indirect hyper-
bilirubinemia
Direct hyper-
bilirubinema
Cholestatic pattern:
ALK-P elevated out
of proportion to
ALT/AST
Hepatocellular
pattern: ALT/AST
elevated out of
proportion to ALK-P
3.
Drugs:
Rifampicin,
Probenecid
2.
Inherited
disorders:
Gilbert's
syndr, C N
syndromes
1.
Hemolytic
disorders,.
Ineffective
erythropoi
esis
Inherited
disorders:
Dubin-
Johnson
syndrome,
Rotor
syndrome
1. Viral serologies:
Hep A IgM, HBsAg & HBcA(IgM),
HepC RNA
2. Toxicology screen : PCM level
3. Ceruloplasmin (if patient <
40yrs)
4. ANA, SMA, SPEP
USG
Additional virologic
testing: CMV DNA, EBV
capsid antigen, Hepatitis D
antibody(if indicated),
Hepatitis E IgM(if indicated)
Liver biopsy
-ve result
-ve result
Dilate
d
ducts,
Extrah
epatic
choles
tasis
CT/MRCP/
ERCP
Ducts
not
dilated
,
Intrahe
patic
cholest
asis
Serologic testing AMA , Hepatitis
serologies Hep A, CMV, EBV , drugs
MRCP/Liver biopsy
-ve resultAMA +ve

83. Treatment
Management of underlying cause
Neonatal jaundice –
 Phototherapy
 Exchange transfusion

84. Take home message
 Reticuloendothelial system is the most important part of
bilirubin metabolism
 Jaundice is a sign but pathophysiology are different .
 Measurment of bilirubin along with other investigations are
required for find out pathophysiology of diseases

85. References
 Harrisons Principles of Internal Medicine - 19th Edn
 Tietze Textbook of Clinical chemistry and Molecular Diagnostics
2006 edition
 Robbins and Cotran Pathologic Basis of Disease 9th edition
 Sternberg’s Diagnostic surgical Pathology 5th edition
 Rosai and Ackerman’s Surgical Pathology 10th edition
 Harper’s Textbook of Biochemistry 30th edition

86. Our Interest
Q. Jaundice - Lab diagnosis
Q. Bilirubin and bile formation
Q. Causes of jaundice
Q. Hereditary hyperbilirubinemias
Q. Primary biliary cirrhosis

87. THANK YOU !