It is characterized by a yellow appearance of the (1) Skin (2) Mucous membranes and (3) Sclera caused by bilirubin deposition. It is the most specific clinical manifestation of Hepatic dysfunction.
Jaundice is usually present clinically when the plasma bilirubin concentration reaches 2 to 3 mg/dl.
When bilirubin clearance from the Liver to the Intestinal tract is impaired (as in acute hepatitis and bile duct obstruction) it may be accompanied by alcoholic (Gray coloured) stools.Solubility increases in water , soluble conjugated bilirubin leads to Tea coloured urine.
It is characterized by a yellow appearance of the (1) Skin (2) Mucous membranes and (3) Sclera caused by bilirubin deposition. It is the most specific clinical manifestation of Hepatic dysfunction.
Jaundice is usually present clinically when the plasma bilirubin concentration reaches 2 to 3 mg/dl.
When bilirubin clearance from the Liver to the Intestinal tract is impaired (as in acute hepatitis and bile duct obstruction) it may be accompanied by alcoholic (Gray coloured) stools.Solubility increases in water , soluble conjugated bilirubin leads to Tea coloured urine.
The liver is the largest organ in the body
It is located below the diaphragm in the right upper quadrant of the abdominal cavity and extended approximately from the right 5th rib to the lower border of the rib cage.
Proteinuria – early indicator of renal disease
Increases the risk of renal impairment, hypertension & cardiovascular disease.
Proteinuria of 1+ or more persisting on 2 subsequent dipstick tests at weekly intervals – requires further investigations.
Causes of transient proteinuria to be excluded
Renal function tests are very useful for effective clinical evaluation of renal failure for effective management. So it is useful for medical and allied professional students and clinical practitioners.
Anemia Causes, Types, Symptoms, Diet, and Treatment Dr Medical
https://userupload.net/0gv9ijneu7hf
Anemia is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. Hemoglobin is a main part of red blood cells and binds oxygen. If you have too few or abnormal red blood cells, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen.
The liver is the largest organ in the body
It is located below the diaphragm in the right upper quadrant of the abdominal cavity and extended approximately from the right 5th rib to the lower border of the rib cage.
Proteinuria – early indicator of renal disease
Increases the risk of renal impairment, hypertension & cardiovascular disease.
Proteinuria of 1+ or more persisting on 2 subsequent dipstick tests at weekly intervals – requires further investigations.
Causes of transient proteinuria to be excluded
Renal function tests are very useful for effective clinical evaluation of renal failure for effective management. So it is useful for medical and allied professional students and clinical practitioners.
Anemia Causes, Types, Symptoms, Diet, and Treatment Dr Medical
https://userupload.net/0gv9ijneu7hf
Anemia is a condition that develops when your blood lacks enough healthy red blood cells or hemoglobin. Hemoglobin is a main part of red blood cells and binds oxygen. If you have too few or abnormal red blood cells, or your hemoglobin is abnormal or low, the cells in your body will not get enough oxygen.
Next day discharge following elective caesarean section using Enhanced Recovery Care Pathways.
Ian Wrench (Consultant Anaesthetist)
Andrea Galimberti (Consultant Obstetrician)
Jan Hall (Midwifery Sister – Postnatal ward)
Julie Humphries (Midwifery Sister – Postnatal Ward)
Sheffield Teaching Hospitals NHS Foundation Trust
Presentation from Shaping the Future Direction of Enhanced Recovery Care Pathway Seven Days a Week workshop held in London on 5 December 2013
Perioperative management of patients on corticosteroidsTerry Shaneyfelt
In these annotated PowerPoints I discuss the evaluation and perioperative management of patient taking or who have taken steroids. I discuss how to determine if the adrenal axis is suppressed and how to provide supplemental glucocorticoids if needed. Remember to download these slides to see the annotations for each slide.
Awareness Anesthesia occurs when a patient becomes conscious during a surgical procedure performed under general anesthesia and subsequently has recall of these events
Liver function tests and interpretation is a very important topic for students of medical and allied fields. It is essential for efficient practice of clinical and laboratory medicine.
For medical students, especially for early clinical exposure , it will help preclinical medical students. It gives details of about seven case reports in carbohydrate metabolism. MBBS students can use the information for theory exam also.
For medical students , it will help. Especially for preclinical students, as early clinical exposure, it will be very useful. Even for theory exam, it will help.
Extra cellular matrix is recently being explored in connection with cancer , metastases and autoimmune disorders. It is prepared for the benefit of both UG and PG medical and dental students.
Various neurotransmitters, mechanism of action and their physiological functions are explained and is useful for ug and pg students of medicine, neurology, psychiatry branches.
Porphyrias are difficult to diagnose . Here it is comprehensively explained to aid making diagnosis of porphyrias easier for the benefit of medical students and practitioners.
Test for pancreatic and intestinal functions are very important for clinical evaluation gastro intestinal disorders . So it will e useful for medical and allied professional students and practitioners.
Students of medical and allied subjects must be exposed to the concept of monoclonal antibodies for the efficient practice of clinical and laboratory medicine.
Concepts of acid base balance and its disorders are very important for practice of medicine.It is for the benefit of medical and students of allied fields.
Coronary heart disease due to atherosclerotic process is the major cause of death.Lipids have been implicated for enhanced atherosclerosis. The major lipids involved are triacy glycerol and cholesterol which are transported in the plasma by lipoproteins. So a better understanding of lipid transport and its abnormalities is essential for medical and health professional students.
Water and electrolyte balance is clinically very important topic . It will be very useful for both UG and PG medical students. Efforts are made to explain basic concepts clearly.
It gives basic things regarding urinalysis and will be very useful for medical students, house surgeons, laboratory technicians and postgraduates in medicine.
Students, digital devices and success - Andreas Schleicher - 27 May 2024..pptxEduSkills OECD
Andreas Schleicher presents at the OECD webinar ‘Digital devices in schools: detrimental distraction or secret to success?’ on 27 May 2024. The presentation was based on findings from PISA 2022 results and the webinar helped launch the PISA in Focus ‘Managing screen time: How to protect and equip students against distraction’ https://www.oecd-ilibrary.org/education/managing-screen-time_7c225af4-en and the OECD Education Policy Perspective ‘Students, digital devices and success’ can be found here - https://oe.cd/il/5yV
The Art Pastor's Guide to Sabbath | Steve ThomasonSteve Thomason
What is the purpose of the Sabbath Law in the Torah. It is interesting to compare how the context of the law shifts from Exodus to Deuteronomy. Who gets to rest, and why?
How to Split Bills in the Odoo 17 POS ModuleCeline George
Bills have a main role in point of sale procedure. It will help to track sales, handling payments and giving receipts to customers. Bill splitting also has an important role in POS. For example, If some friends come together for dinner and if they want to divide the bill then it is possible by POS bill splitting. This slide will show how to split bills in odoo 17 POS.
Operation “Blue Star” is the only event in the history of Independent India where the state went into war with its own people. Even after about 40 years it is not clear if it was culmination of states anger over people of the region, a political game of power or start of dictatorial chapter in the democratic setup.
The people of Punjab felt alienated from main stream due to denial of their just demands during a long democratic struggle since independence. As it happen all over the word, it led to militant struggle with great loss of lives of military, police and civilian personnel. Killing of Indira Gandhi and massacre of innocent Sikhs in Delhi and other India cities was also associated with this movement.
Unit 8 - Information and Communication Technology (Paper I).pdfThiyagu K
This slides describes the basic concepts of ICT, basics of Email, Emerging Technology and Digital Initiatives in Education. This presentations aligns with the UGC Paper I syllabus.
Palestine last event orientationfvgnh .pptxRaedMohamed3
An EFL lesson about the current events in Palestine. It is intended to be for intermediate students who wish to increase their listening skills through a short lesson in power point.
2024.06.01 Introducing a competency framework for languag learning materials ...Sandy Millin
http://sandymillin.wordpress.com/iateflwebinar2024
Published classroom materials form the basis of syllabuses, drive teacher professional development, and have a potentially huge influence on learners, teachers and education systems. All teachers also create their own materials, whether a few sentences on a blackboard, a highly-structured fully-realised online course, or anything in between. Despite this, the knowledge and skills needed to create effective language learning materials are rarely part of teacher training, and are mostly learnt by trial and error.
Knowledge and skills frameworks, generally called competency frameworks, for ELT teachers, trainers and managers have existed for a few years now. However, until I created one for my MA dissertation, there wasn’t one drawing together what we need to know and do to be able to effectively produce language learning materials.
This webinar will introduce you to my framework, highlighting the key competencies I identified from my research. It will also show how anybody involved in language teaching (any language, not just English!), teacher training, managing schools or developing language learning materials can benefit from using the framework.
Instructions for Submissions thorugh G- Classroom.pptxJheel Barad
This presentation provides a briefing on how to upload submissions and documents in Google Classroom. It was prepared as part of an orientation for new Sainik School in-service teacher trainees. As a training officer, my goal is to ensure that you are comfortable and proficient with this essential tool for managing assignments and fostering student engagement.
Model Attribute Check Company Auto PropertyCeline George
In Odoo, the multi-company feature allows you to manage multiple companies within a single Odoo database instance. Each company can have its own configurations while still sharing common resources such as products, customers, and suppliers.
How to Make a Field invisible in Odoo 17Celine George
It is possible to hide or invisible some fields in odoo. Commonly using “invisible” attribute in the field definition to invisible the fields. This slide will show how to make a field invisible in odoo 17.
Read| The latest issue of The Challenger is here! We are thrilled to announce that our school paper has qualified for the NATIONAL SCHOOLS PRESS CONFERENCE (NSPC) 2024. Thank you for your unwavering support and trust. Dive into the stories that made us stand out!
2. Battery of tests
Liver function tests are useful for
• the diagnosis
• assessment of prognosis
• monitoring of liver diseases.
Liver carries out diverse functions
So a battery of tests are needed.
3. Liver functions
1. Excretory function
Liver is involved in the uptake, conjugation
and excretion of bilirubin derived from
degradation of heme in reticuloendothelial
system.
The conjugated bilirubin is excreted via bile.
Liver also detoxifies ammonia, drug
metabolites and xenobiotics.
4. 2.Metabolic functions
carbohydrate metabolism- glycogen metabolism,
gluconeogenesis, blood glucose maintenance.
Lipid metabolism
Cholesterol metabolism, bile acid synthesis,
metabolism of lipoproteins, VLDL synthesis, synthesis
of triacyglycerol .
Protein metabolism
Catabolism of proteins, synthesis of non- essential
amino acids, formation of urea from ammonia
5. 3 . Synthesis of plasma
proteins
Liver synthesizes albumin,
coagulation factors such as
prothrombin.
4. Storage function
Vitamin A, D, K, B12 , Iron as
Ferritin are stored in liver.
6. Serum Enzymes
Serum enzymes
In liver cell damage, liver tissue enzymes
leak into circulation and their levels are
increased in plasma.
Aspartate transaminase (AST)
Alanine transaminase (ALT)
Alkaline phosphatase(ALP)
Gamma glutamyl transpeptidase (GGT)
7. Bilirubin metabolism
Heme is degraded in reticuloendothelial system
Iron is reutilized.
Globin protein – catabolized into amino acids
The bilirubin is formed from porphyrin ring of
heme which is water insoluble
It is called unconjugated bilirubin.
Unconjugated bilirubin is transported by albumin
to liver.
8. Role of liver
It is involved in the uptake of
unconjugated bilirubin and conjugates
them to bilirubin diglucuronide by the
enzyme UDP-glucuronyl transferase
using UDP- glucuronic acid, the active
donor of glucuronyl units. The
conjugated bilirubin is water soluble
and excreted in bile.
9. In the intestine- Conjugated bilirubin
gets deconjugated by bacterial beta-
glucuronidase enzyme in the terminal
ileum and large intestine.
The pigment is further reduced by fecal
flora to a group of colorless, tetra pyrrolic
compounds known as urobilinogens.
A small fraction of urobilinogens is
absorbed in the terminal ileum and re-
excreted by liver.
This is called enterohepatic circulation.
10. Then some of the urobilinogens being
water soluble, escape into urine normally.
In the intestine, further reduction of
urobilinogens form stercobilinogen which
is excreted in feces.
Some Urobilinogen gets back to liver
and reexcreted into intestine via bile . This
is enterohepatic circulation.
Oxidized products form urobilin and
stercobilin which are yellow colored.
11. Jaundice is the yellowish discoloration of
skin , mucous membrane and sclera.
It is due to hyperbilirubinemia. Normal
serum bilirubin level is 0.2 - 1 mg/dl.
Hyperbilirubinemia may be of conjugated or
unconjugated or both.
Normal serum unconjugated bilirubin level
is 0.2-0.8 mg/dl and conjugated bilirubin
level is 0.2-0.4 mg/dl.
Jaundice clinically appears when the serum
bilirubin level goes beyond 3 mg/dl.
12.
13. Vanden bergh test
Bilirubin reacts with diazotized sulfanilic acid to form
purple colored complex azobilirubin.
Conjugated bilirubin gives color in aqueous medium
immediately and is direct positive.
Unconjugated bilirubin, in methanol only color develops
and is indirect positive.
If both fractions are there, the color developed in aqueous
medium deepens on adding methanol and is called
biphasic.
Van den Bergh test is indirect positive in hemolytic
jaundice, direct positive in obstructive jaundice and
biphasic in hepatic jaundice.
14. Hemolytic Jaundice
Hemolytic jaundice or pre-hepatic jaundice or
unconjugated hyperbilirubinemia
Investigations
Serum unconjugated bilirubin is increased.
Urine bile salts and bile pigments will be negative.
So it is called as acholuric jaundice.
Urine urobilinogen will be excess.
Motion is high colored (dark brown).
Causes
Hemolytic anemia, hemoglobinopathies, mismatched
blood transfusion.
15. Inborn errors
Gilbet’s syndrome (GS): is the most common
hereditary cause of increased bilirubin
characterized by elevated levels of unconjugated
bilirubin in the bloodstream.
Enzyme glucuronyltransferase deficiency.
Crigler Najjar syndrome: It is a rare , AR disorder
with high levels of unconjugated
hyperbilirubinemia affecting brain.
UDP- glucuronyl transferase enzyme is defective.
16. Obstructive jaundice or post hepatic jaundice
or conjugated hyperbilirubinemia
Serum conjugated bilirubin is increased.
Urine bile salts, bile pigments will be positive.
Urine urobilinogen will be less or absent.
Motion is clay colored.
Causes
Biliary duct obstruction - due to gall stones,
tumor in the bile duct, carcinoma head of
pancreas, lymph node enlargement in porta
hepatis,
17. Inborn errors
Dubin Johnson syndrome : AR disorder
Increase of conjugated bilirubin in the serum without
elevation of liver enzymes (ALT, AST).
Defective secretion of conjugated bilirubin into the
bile. Liver cell are pigmented.
Rotor syndrome . Rare , AR disorder with increase in
conjugated bilirubin
similar to Dubin Johnson syndrome except that the
liver cells are not pigmented.
18. Hepatic jaundice
Both unconjugated and conjugated bilirubin levels
are increased in serum.
Urine bile salts, bile pigments are positive.
Urine urobilinogen is lesser than normal amounts.
Motion is pale yellow colored.
Causes
Alcoholic hepatitis, viral hepatitis, drug induced
intra hepatic cholestasis.
19. Tests based on synthesis of plasma
proteins
Serum albumin level - half- life is 20 days.
In liver cirrhosis, albumin level is decreased.
Normal serum albumin level is 3.5-4.5 gm/dl
and globulin level is 2.5-3.5 gm/dl.
Normal albumin globulin ratio (AG ratio) is
1.2 to 1.8 :1 . In cirrhosis, AG ratio is reversed
Serum globulins are increased in chronic
active hepatitis and cirrhosis of liver.
20. Prothrombin time
Normal – 10-14 secs.
In liver dysfunction, it is prolonged.
It is not recovered by Vitamin K
administration.
In vitamin K deficiency due to obstructive
jaundice also, there will be prolonged
prothrombin time
But that will recover after parenteral
administration of vitamin K.
21. Tumor marker- α-feto protein (AFP) is elevated in
hepatocellular carcinoma.
Ceruloplasmin
Its level is decreased in Wilson’s disease.
Serum protein electrophoresis
In cirrhosis of liver, albumin is decreased and gamma
globulins are increased.
In biliary obstruction, α2 and β2 globulins are
increased.
22. Serum enzymes
Hepatocellular damage
Serum amino transferases- Aspartate amino transferase
(AST) and Alanine amino transferase (ALT) are
elevated.
Normally both are lesser than 40 U/L.
In acute hepatitis, may increase to more than 1000 U/L.
ALT is found in cytosol and is more liver specific.
AST/ALT ratio is lesser than 1.
But in alcoholic hepatitis, AST is increased more than ALT
and the ratio is more than 2. This is due to release of AST
from mitochondria.
23. Obstructive liver disease
Serum alkaline phosphatase (ALP) level is increased in
case of cholestasis, hepatic carcinoma and biliary tract
obstruction.
ALP is present in bone, liver, intestine and placenta.
In the absence of bone disease or pregnancy, ALP elevation
indicates cholestasis.
Gamma glutamyl transferase (γ-GT) level is increased in
obstructive jaundice.
Its level is a sensitive biomarker of alcohol abuse or
alcoholic liver disease.
5-nucleotidase enzyme is increased in hepatobiliary
disease.
24. Blood ammonia
It is increased in severe
hepatocellular damage either
acute or chronic. Normal blood
ammonia level - 15- 60 µg/dl.
Serum bile acids
They are increased in liver
disease with cholestasis.
25. Bromosulphathalein (BSP) excretion test
BSP dye (5mg/kg, 5% w/v solution ) given by
intravenous route is rapidly removed by liver and
excreted in bile.
Normally 95% of dye is cleared within 45 minutes
only less than 5% of dye is found in blood after 45
min.
In hepatic dysfunction, it is more than 5%.
Higher level of dye after 2 hours than at 45 min
due to secondary rise is diagnostic of Dubin
Johnson syndrome.
27. Unconjugated Conjugated
Hemolytic anemia Obstruction of biliary
tree
Physiological jaundice Dubin-Johnson
syndrome
Crigler-Najjar
syndrome type I & II
Rotor syndrome
Gilbert syndrome Hepatitis (Both)
-conj and unconj
Toxic
hyperbilirubinemia
28. Flow Chart - Jaundice
J (suspected)
History
Clinical examination
VD Berg test
Sr.Bili. – Total/Difference (CHB/UCHB)
Total Bili. Increased Total bili. Increased
UCHB increased CHB increased
VD Berg test VD Berg test
(indirect +ve) Direct +ve
Hemo Jaundice Obst. J. + HC.J
29. Obst. J+ HC.J
Sr.ALP (Crucial test)
>35 <35
?. Obst.J HC.J
1. Sr.Trans (<300) Sr.Trans. (>300)
2. Sr.ALP increased Sr.GGT increased
3. PT after iv vit.k – normal PT even after vit.k
abnormal
4. Urine – bilirubinuria Urine – bili. + or -
5. Urobilinogen – neglibile Serological tests
or absent
30. Bio-Chem tests
Lab tests – determined severity of J
Its type whether obstructive or HC
1. Vanden Berg reaction
- direct
- indirect
2. Bilepigments in urine
- may be detected even before clincial jaundice
is noticed
- bili is found in urine – Obstr. Jaundice
- not found in urine – hemolytic jaundice
3. Feces – bili is not found in normal
Found in children, neo mycin, meconiun
31. Urobilinogen
Faecal (50-250 mg/day)
Increased in hemo.J
Absent in Obst.J
Complete absent in maligancy
Urine (<4 mg/day)
Obstr.J - no urobilinogen
Hemolytic J – increased urobilinogen with no
bilirubin