This document provides an overview of jaundice, including its definition, classification, causes, relevant history taking, examination, investigations, and treatment. Jaundice is yellow pigmentation caused by excess bilirubin in the blood and can be classified as pre-hepatic, hepatic, or post-hepatic depending on the underlying cause and mechanism. Taking a thorough history including when jaundice began, associated symptoms, medical history, medications, and risk factors is important to determine the cause. Relevant examinations and investigations include blood tests, imaging, and potentially invasive tests like biopsy. Treatment focuses on removing toxins if applicable, relieving obstruction, and medication or procedures depending on the specific cause of jaundice.

1. Jaundice Dr E M Said

2. objectives About jaundice History taking Discussion

4. definition Jaundice (or icterus) is a term used to describe the yellow pigmentation of a patient's skin and sclerae caused by excess bilirubin in the blood. Jaundice become visible at >35umole/L Jaundice is not itself a diagnosis and the cause should always be sought. Many diseases cause jaundice through a variety of different mechanisms.

5. Classification & causes

6. Pre-hepatic hepatic post-hepatic haemoglobin bile duct breakdown Hepatocyte Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

7. Prehepatic jaundice: excess production or failure of uptake into liver Haemolysis, eg G6PD deficiency Autoimmune Congentital hyperbilirubinaemia eg Gilberts, Crigler Najar

8. Pre-hepatic hepatic post-hepatic haemolysis bile duct haem breakdown Hepatocyte Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

9. Hepatocellular jaundice Hepatocyte failure / damage (ALT>ALP) Alcohol Viral Hepatitis A, B and C , EBV Cirrhosis Drugs Auto immune Hepatoma Metastases Wilsons Hepatic congestion from cardiac failure

10. Pre-hepatic hepatic post-hepatic blood bile duct haem Hepatocyte damage Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

11. Chronic liver disease Alcohol & viral hepatitis are the most common causes of chronic liver disease and cirrhosis. Develop when the functional capacity of the liver can no longer maintain normal physiological conditions Jaundice is a feature of chronic liver disease

14. Cholestatic jaundice impaired excretion of bile (ALP>ALT) Gallstones Head of pancreas cancer Porta hepatis lymph nodes PBC Sclerosisng Cholangitis

15. Pre-hepatic hepatic post-hepatic blood bile duct haem Hepatocyte Unconjugated Bilirubin conjugation Liver uptake obstruction conjugated bilirubin

18. History When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature?

19. History When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature? Painful jaundice Alcoholic,infective,biliary colic,pancreatitis,cholecystitis,metastasis.

20. When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature? History Painless jaundice Haemolysis,PBS pancreatic/ biliary malignancy,cirrhosis Heamochromatosis,

21. Associated symptoms? Continue history…

22. Continue history… Associated symptoms? N/V Haematamesis Fatigue Malaise Fever Loss of apetite/Wt Rash/arthritis Abd swelling Confusion Sleep pattern

23. Continue history… Associated symptoms? Any cardiac/respiratory symptoms?

24. Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx. Continue history…

25. Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx Continue history… CAGE questionnaire Drinking at work Driving offences Psychological/social problems

26. Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx Relevant PMHx Continue history…

27. Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Continue history… Liver & gall stone disorder Malignancy,recent anaesthesia,blood transfusion,autoimmune disorders

28. Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Continue history…

29. Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Continue history… Antibiotics,antirhuematic,etc

30. Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Risk factors for viral hepatitis Continue history…

31. Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Risk factors for viral hepatitis Continue history…

32. examination Temp, pulse, BP Anaemia, lymph nodes Features of cirrhosis Encephalopathy Nutritional status Hepato / splenomegaly Tattoos

33. Investigations

34. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC

35. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen

36. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen blood film, reticulocytes, low haptoglobin, high LDH, DCT

37. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen

38. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Immunoglobulins, Auto antibodies (smoth muscle, ANA, AMA, LKM) Viral hepatitis serology ferritin, caeruloplasmin alpha 1 anti-trypsin

39. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Radiology USS MRCP

40. Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Radiology USS MRCP Invasive Tests ERCP Liver biopsy

41. Treatment Remove toxin Antibiotics Fluids Relieve obstruction – ERCP, Percutaneous drainage (PTC) Ursodeoxycholic acid Steroids / immunosupressants Liver transplant

42. Any Question?