Jaundice, or icterus, refers to yellowing of the skin and eyes due to high bilirubin levels in the blood. Bilirubin is produced from the breakdown of hemoglobin and normally conjugated and excreted in bile. Jaundice can be pre-hepatic from excessive bilirubin production, hepatic from impaired conjugation or transport, or post-hepatic from bile duct obstruction. Hemolytic jaundice involves increased bilirubin from red blood cell destruction. Hepatocellular jaundice stems from liver disease impairing bilirubin excretion. Cholestatic jaundice occurs when conjugated bilirubin cannot enter bile ducts due

1. AMAR RAUT CHHETRI,
KATHMANDU MEDICAL COLLEGE
AND TEACHING HOSPITAL, NEPAL
JAUNDICE (Pathology)

2.  Jaundice or icterus refers to the yellow pigmentation
of skin or sclera by bilirubin.
Jaundice is the result of elevated levels of bilirubin in
the blood termed hyperbilirubinaemia.
Normal serum bilirubin concentration 0.3-1.2mg/dl
( 80% of which is unconjugated).
Jaundice becomes clinically evident when the total
serum bilirubin is >2mg/dl.

3. Bilirubin metabolism and elimination

4. • Sources of unconjugated bilirubin :
Hemoglobin breakdown
Catabolism of other haem containing protein
e.g. :myoglobin & cytochrome containing enzyme.
Ineffective erythropoiesis

5. • Rate of production of unconjugated
bilirubin 250 to 350 mg/day from
catabolism of haem after removal of its
iron component.
• Bilirubin in the blood is normally almost
all unconjugated.
It is not water soluble.
It is bound to albumin.
It does not pass into urine.

6. • In the endoplasmic reticulum :
Unconjugated bilirubin by glucoronyl
trasferase  bilirubin mono and di
glucoronide which are : water soluble
exported into bile.
• In the colon :
Conjugated bilirubin is metabolized by
colonic bacteria forming stercobilinogen
which is further oxidized into stercobilin.
Both stercobilinogen and stercobilin are
excreted in the stools.

7. Small amount of stercobilinogen (4 mg/dl) is
absorbed from the bowel, pass through the liver and
excreted in urine (urobilinogen) which is further
oxidized into urobilin.

8. Classification
Pre-hepatic (haemolytic) jaundice
Hepatic jaundice
Post-hepatic (obstructive) jaundice

9. Causes of Jaundice
Predominantly unconjugated
hyperbilirubinemia
Excess production of bilirubin
Hemolytic anemias
Resorption of blood from internal hemorrhage
(e.g., alimentary tract bleeding, hematomas)
Ineffective erythropoiesis (e.g., pernicious
anemia, thalassemia)

10. Reduced hepatic uptake
 Drug interference with membrane carrier systems
Some cases of Gilbert syndrome
Impaired bilirubin conjugation
Physiologic jaundice of the newborn (decreased
UGT1A1 activity, decreased excretion)
Breast milk jaundice (β-glucuronidases in milk)
Genetic deficiency of UGT1A1 activity (Crigler-Najjar
syndrome types I and II)

11. Gilbert syndrome
Diffuse hepatocellular disease (e.g., viral or drug-
induced hepatitis, cirrhosis)
Predominantly conjugated
hyperbilirubinemia
Deficiency of canalicular membrane transporters
(Dubin-Johnson syndrome, Rotor syndrome)
Impaired bile flow

12. Hemolytic jaundice
Etiology:
• Increased destruction of RBCs or their precursors
leading to increased bilirubin production.
• It is usually mild.
• Healthy liver can excrete a bilirubin load six times
greater than normal before unconjugated bilirubin
accumulates in the plasma.

13. In haemolytic jaundice:
Increased unconjugated bilirubin, urobilinogen,
stercobilinogen

14. Clinical features
• Pallor due to anemia.
• Increaed excretion of bilirubin and stercobilinogen
 normal coloured stool or dark stool.
• Increased urobilinogen excretion  urine darkens
on standing.
• Splenomegaly due to excess RE activity.
• Pigment stones.
• Leg ulcers.

15. Investigations
Biochemical tests:
-Unconjugated bilirubin is high.
-Liver function tests otherwise
normal.
 Blood count : anemia
 Blood film : evidence of hemolysis

16. Hepatocellular jaundice
Etiology:
• Inability of the liver to transport bilirubin into the
bile as a result of parenchymal liver disease.
• Bilirubin transport across the hepatocytes may be
impaired at any point between the uptake of
unconjugated bilirubin into the cells and transport of
conjugated bilirubin into canaliculi.

17. • In addition, swelling of the cells and
oedema resulting from the disease itself
may cause obstruction of biliary canaliculi.
• Hepatocellular jaundice:
Increaesd conjugated bilirubin,
unconjugated bilirubin, stercobilinogen,
urobilinogen

18. Clinical manifestations
• Lemon yellow jaundice.
• Dark urine.
• +/- manifestations of chronic liver disease:
- Ascites
-Circulatory changes: palmar eryth., spider naevi.
-Endocrine: hair loss, gynecomastia.
-Haemorrahgic tendency.
-Manifestations of hepatic encephalopathy.
-Manifestations of portal hypertension.
-Others: pigmentations, clubbing, low grade fever.

19. Investigations
Biochemical tests:
Plasma bilirubin : biphasic increase both
conjugated & unconjugated.
Greater elevation of enzymes.
Evidence of chronic liver disease: decrease plasma
protein, increased prothrombin time.

20. Cholestatic jaundice
Etiology & pathogenesis:
• Conjugated bilirubin is unable to enter the bile
canaliculi and passes back into blood.
• Failure of clearance of unconjugated bilirubin arriving
at the liver cells.
• Causes:
-Failure of hepatocytes to generate bile flow.
-Obstruction to the bile flow in bile ducts in the portal
tracts.
-Obstruction to bile flow in the extrahepatic bile ducts
between porta-hepatis and papillae of Vater.

21. Causes of intrahepatic obstruction
• 1 ry biliary cirrhosis
• Auto-immune hepatitis
• 1 ry sclerosing cholangitis
• Alcohol
• Drugs
• Pregnancy
• Viral hepatitis
• Severe bacterial infection

22. Causes of extrahepatic obstruction
Choledocholithiasis
Carcinoma
Parasitic infection
Traumatic: biliary stricture

23. In cholestatic jaundice:
-Increased S. bilirubin mainly conjugated.
-Decreased stercobilinogen and stercobilin.

24. Clinical features
Early: jaundice, pale stools, pruritis.
Late: xanthelasma & xanthomata,
malabsorption, weight loss, steatorrhea,
osteomalacia, bleeding tendency.
In addition to clinical picture of cholangitis
underlying chronic liver disease.

25. Investigations
Biochemical tests:
-Increased bilirubin mainly conjugated.
-Increased serum bile acids, alk. Phosphatase and
hyperlipidaemia.
Ultrasound to differentiate intra from extra- hepatic
biliary obstruction.

26. THANKS, Cheers 
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