3. Jaundice is not a disease
but rather a sign that can
occur in many different
diseases.
Jaundice is the yellowish
staining of the skin ,
sclerae (the whites of the
eyes) and other mucous
membranes that is
caused by high levels in
blood of the chemical
bilirubin.
The color of the skin and
sclerae vary depending
on the level of bilirubin.
When the bilirubin level
What is jaundice?
4. Normal serum total bilirubin is >>5-17 μmol/L (< 1 mg/dL)
Jaundice is clinically evident when serum total bilirubin > 2-3x normal
(2.5 mg/dL)
11. Disruption of bilirubin metabolism and excretion can cause
hyperbilirubinaemia and subsequent jaundice
Hyperbilirubinaemia maybe unconjugated (indirect) or conjugated
(direct) depending on the cause
Some inherited syndromes of bilirubin handling can result in
hyperbilirubinaemia
Gilbert’s syndrome – reduced activity of glucuronyl transferase
therefore reduced conjugated bilirubin therefore elevated
unconjugated bilirubin
Criggler-Najjar – reduction in amount of glucoronyl transferase
therefore elevated unconjugated bilirubin
Rotor’s/Dubin-Johnson syndrome – defective excretion of conjugated
bilirubin into the biliary cannaliculi therefore elevated conjugated
bilirubin
12.
13. PREHEPATIC JAUNDICE
Hemolytic disorders
Thalassemias
G6PD deficiency
Hereditary spherocytosis
Autoimmune hemolytic anemias
Incompatible blood transfusion
“A healthy liver can excrete 6x the normal load of bilirubin before
unconjugated bilirubin starts to accumulate”
Gilbert syndrome, Criggler-Najjar syndrome
14. HEPATOCELLULAR JAUNDICE
INTRA-HEPATIC
Basically any acute or chronic liver disease!
Viral hepatitis Drug-induced hepatotoxicity Alcoholic and non-
alcoholic liver disease (NASH) PBC PSC Autoimmune hepatitis
Hemochromatosis Wilson’s disease Cirrhosis Liver tumors
All the causes of hepatitis/cirrhosis (e.g. Alcohol, viral, auto-immune,
primray biliary cirrhosis , Primary sclerosing cholangiti
haemochromatosis, wilsons, alpha-1 antitrypsin deficiency , Drug-
induced, )
Rotor’s syndrome, Dubin-Johnson syndrome
Can result in hepatocyte destruction and therefore unconjugated
hyperbilirubinaemia or in bile cannaliculi destruction and therefore
conjugated hyperbilirubinaemia or both
15. Is caused by an interruption to the drainage of bile containing conjugated bilirubin
in the biliary system.
The most common causes are gallstones in the CBD, and cancer head of the
pancreas.
Also, a group of parasites known as "liver flukes" can live in the CBD, causing
obstructive jaundice. Other causes include strictures of the CBD, biliary atresia,
cholangiocarcinoma, pancreatitis, cholestasis of pregnancy, and pancreatic
pseudocysts. A rare cause of obstructive jaundice is Mirizzi's syndrome.
The presence of pale stools and dark urine suggests an obstructive or post-
hepatic/liver cause as normal feces get their color from bile pigments. They can,
however, occur in many liver conditions and are therefore not a reliable clinical
feature to distinguish obstruction from liver causes of jaundice.
People also can present with elevated serum cholesterol, and often complain of
severe itching or "pruritus" because of the direct and indirect effects of pruritogens
in bile such as bile salts.
A combination of liver function tests is essential to arrive at a diagnosis.
16. PAINFUL VS. PAINLESS
One of the main distinguishing symptoms between
benign and malignant causes is pain.
Painful obstructive jaundice is usually related to
gallstones, while painless obstructive jaundice tends to
be related to tumors (red flag).
The reason for this difference is that stones tend to
harbour bacteria and cause bile duct infection, resulting
in pain and fever.
Interestingly, as pain is not a key feature for malignant
causes, patients with tumors tend to seek expert help
later. These patients may also have worrisome
symptoms of weight loss and loss of appetite.
17. Intraluminal obstruction: stones, hydatid cysts worms
Wall pathologies “Intra-mural”
Benign stricture
1. Congenital BILIARY ATRESIA
2. IATROGENIC: BILIARY SURGERY , GASTRECTOMY, HEPATIC
RESECTION ,LIVER TRANSPLANT
3. INFLAMMATORY; CHOLANGITIS, PANCREATITIS, SCLEROSING
CHOLANANGITIS.
4. TRAUMA
5. IDIOPATHIC
6. RADIOTHERAPY
Malignant stricture: cholangiocarcinoma
External compression: pancreatitis, tumor of the head of the pancreas, pancreatic
pseudocyst, tumor of the ampulla of Vater, Mirizzi syndrome.
18.
19. STONE VS. MALIGNANCY
It is important to distinguish between the possible
causes of obstructive jaundice.
While the common causes are related to gallstone
disease, the more frightening causes are related to
cancer (pancreatic cancer, bile duct cancer,… ).
Benign causes: Gallstones, choledochal cyst,
benign bile duct strictures
Malignant causes: malignant tumors in the
pancreas, bile duct, gallbladder
20. STONE SLIPPING INTO THE BILIARY TREE “Choledocholithiasis”
Common bile duct stone, may be small or large and single or
multiple, and are found in 6% to 12% of patients with stones in
the gallbladder.
There are two possible origins for common duct stones;
secondary stones (cholesterol stones) : most cholesterol stones
develop within the gallbladder and reach the duct after traversing
the cystic duct.
primary common duct stone (Brown pigment stones)
21. Elevation of serum bilirubin, alkaline phosphatase, and transaminases are
commonly seen in patients with bile duct stones (almost 2/3).
US, MRC, PTC, Endoscopic cholangiography is the gold standard for diagnosing
common bile duct stones.
TT:sphincterotomy and ductal clearance of the
stones, followed by a laparoscopic cholecystectomy
22. MALIGNANCY CAUSES OF
JAUNDICE
in malignant causes of jaundice, the jaundice is
painless and progressive.
Malignancy causing complete blockage of bile can
result in significant itching due to accumulation of
bile pigments within the skin, and malnutrition as
bile is part of the digestive system.
23. About two-thirds of pancreatic adenocarcinomas arise within the
head or uncinate process of the pancreas; 15% are in the body,
and 10% in the tail
24. For potentially resectable pancreatic head cancer, the standard operation is
pancreaticoduodenectomy (the Whipple procedure)
25. is an adenocarcinoma of the bile ducts; it forms in the biliary
epithelial cells
About two thirds are located at the hepatic duct bifurcation.
Painless jaundice is the most common presentation.
Pruritus, mild right upper quadrant abdominal pain,
anorexia, fatigue, and weight loss also may be present.
Diagnosis : CT and MRI
26.
27. Risk factors
primary sclerosing cholangitis, choledochal cysts, ulcerative colitis,
hepatolithiasis, biliary-enteric anastomosis, and biliary tract
infections.
Other risk factors: dietary nitrosamines, thorotrast, and exposure to
dioxin.
Surgical resection offers the only chance for cure; however, many
patients have advanced disease at the time of diagnosis.
Most patients with unresectable disease die within 1 year of
diagnosis.
28. is a cancer that forms in The ampulla of Vater ( a small opening
that enters into the duodenum)
the most common presenting symptom is obstructive jaundice
(80%), caused by compression of the distal bile duct by the tumor.
Additional symptoms may include diarrhea due to fat malabsorption
(steatorrhea), mild weight loss, and fatigue
ERCP is the single most useful endoscopic study for diagnosing
ampullary carcinoma because it permits identification of the
tumor, biopsy, and decompression, if needed.
Whipple procedure (pancreaticoduodenectomy)
29. BILE DUCT STRICTURES
Benign causes :
operative injury, most commonly by laparoscopic cholecystectomy
fibrosis due to chronic pancreatitis, common bile duct stones, acute
cholangitis, biliary obstruction due to cholecystolithiasis (Mirizzi’s
syndrome), sclerosing cholangitis
Malignant causes :
cholangiocarcinoma, adenocarcinoma of the pancreas and ampullary
tumors
30. most commonly present with episodes of cholangitis
An ultrasound or a CT scan will show dilated bile ducts
proximal to the stricture, as well as provide some information
about the level of the stenosis.
Treatment depends on the location and the cause of the
stricture.
Roux-en-Y choledochojejunostomy or hepaticojejunostomy is the
standard of care with good or excellent results in 80% to 90% of
patients
Percutaneous or endoscopic dilatation and/or stent placement
31. • the cystic duct is densely adherent to the
common bile duct
• (a stone ulcerating through the neck of the
gallbladder into the common hepatic duct)
• the infundibulum of the gallbladder should be
opened, the stone removed and the
infundibulum over sewn.
• Attempts to dissect out the cystic duct
completely will only lead to injury to the
common hepatic or common bile duct.
33. Personal profile
Name , Age (and date of birth) , Sex ,
Marital status , Occupation , Address ,
Admission (Date , time and route) ,
referral (if apply)
Chief complaint
Complaint + duration
34. Analyze the jaundice
Distribution: skin , eyes or both
Carotenemia spares the eyes
Onset: sudden vs gradual
Sudden in Hepatitis A , Hepatitis secondary to alcohol use
, Autoimmune hepatitis , Gallstone diseases ,
Gradual in Carcinoma (pancreatic or biliary)
Duration
Course: intermittent vs continuous (progressive vs
constant)
Intermittent in Gallstone diseases ,
Continuous in Carcinoma ,
35. Accompanying symptoms:
fever, chills, rigors and RUQ pain acute
cholangitis
anorexia, malaise, and myalgias viral hepatitis
Acholic stool (clay colored) & Dark urine (tea or
cola colored) cholestasis (gallstones , cancer ,
viral hepatitis)
Skin itching
Weight loss cancer
36. Start with the involved system (in case of
jaundice it is the alimentary system and
abdomen):
Appetite. Diet. Weight. Nausea. Dysphagia.
Regurgitation. Flatulence. Heartburn. Vomiting.
Hematemesis. Indigestion pain. Abdominal pain.
Abdominal distension. Bowel habit. Nature of stool.
Rectal bleeding. Mucus. Slime. Prolapse.
Incontinence. Tenesmus
Then review the RS , CVS , GUS , NS , MSS
for a full history
37. History of inherited disorders, including liver
diseases and hemolytic disorders
A past history of hepatitis chronic active
hepatitis
History of abdominal operations, including
gallbladder surgery acute cholangitis
39. Recent contact with jaundiced person
hepatitis
Recent travel hepatitis
Immunization history hepatitis
Family history of jaundice
Occupational history as sewerage
workers or people exposed to hepatotoxic
chemicals.
47. EXAMINATION
Abdominal examination ::
Palpation: liver edge:
The liver edge in cirrhosis >> is firm
An irregular liver edge malignant disease
Gallbladder
If the gallbladder is palpable, it is probable that the cause of jaundice is not
a stone (Courvoisier's law)
spleen
Splenomegaly is suggestive of cirrhosis, hematological disorders or
reticulosis.
Percussion: liver span ,, ascites ..
Auscultation.
51. Test with normal
range
Pre-hepatic Hepatic Post-hepatic
Total bilirubin
0.1to 1.2 mg/dl
+ ++ +++
Conjugated
bilirubin less than
0.3 mg/dl
Normal Increased Increased
Unconjugated
bilirubin 0.2 to 0.8
mg/dl
Increased Increased Normal
Total bilirubin and its conjugated and
unconjugated levels help to determine nature of
jaundice
52. Liver Enzymes
ALT/AST mainly present in hepatocytes
ALP/GGT mainly present in bile cannaliculi biliary tree
Test Pre-hepatic Hepatic Post-hepatic
ALT 7to 55 u/l
AST 8 to 48 u/l
Normal +++ raised +
ALP 40 to 129 u/l
GGT 8to 61 u/l
Normal + +++ raised
53. Test Pre-hepatic Hepatic Post-hepatic
Urine colour Normal Normal
If Dark (urobilinogen +
conjugated bilirubin )
Dark
(conjugated bilirubin )
Urine Bilirubin negative Negative Increased
Urine urobilinogen
0.2to 1 mg/dl
Increased Normal present Decreased/negative
Stool colour Normal Normal Pale
54. Test Prehepatic Hepatocellular Obstructive
Urine Urobilinogen Urobilinogen Bilirubin
Serum bilirubin Unconjugated Mixed Conjugated
AST and ALT Normal Raised Normal – raised
ALP Normal Normal – raised Raised
Blood glucose Normal Low if liver failure May be raised in
pancreatic CA
Reticulocyte count Raised in
hemolysis
Normal Normal
Haptoglobin Low Normal or low if
liver failure
Normal
PT/INR Normal Prolonged Prolonged
U/S Normal May show
abnormal liver
texture
Dilated bile ducts
56. Commonly obtained for initial evaluation of all patients with jaundice
Preferred initial image for suspected cholestasis
Cheap, noninvasive, good sensitivity , readily available, inexpensive and quick to perform
Best initial test for gallstones. Also useful for biliary dilation due to any cause, and screen for liver
tumors
Operator dependent. Limited visualization of stones in CBD, limited in obese patients & in
intraluminal bowel gases.
Endoscopic U/S provides accurate imaging of stones in CBD, diagnosing and staging pancreatic and
periampullary cancers. FNA can be used with the advantage of avoiding spillage of tumor cells into
the peritoneal cavity
57.
58. Noninvasive visualization of biliary tree
It avoid the complications of diagnostic ERCP & PTC ( but these methods should
be done if there is therapeutic need )
Not theraputic
59.
60. Ct Is indicated if we suspect malignancy ( painless jaundice)
Very useful for hepatic and pancreatic masses, may be used with guided biopsy
MRI may be a good alternative (e.g. patients who can’t take contrast)
61. Diagnostic and therapeutic
Used for biliary obstruction distal to the bifurcation of hepatic ducts, when
intervention is anticipated.
Theraputic: -sphincterotomy(stone in lower CBD) -stent(exernal
compression/stricture) – drainage(pancreatitis and cholangitis)
Check coagulation profile and give prophylactic antibiotics
Complications: Pancreatitis, cholangitis, bleeding, duodenal perforation.
62.
63. May be used when ERCP is not possible (e.g. patient had done a gastrectomy/
pancreatoduodencectomy)
“In general, in the jaundiced patient, if a malignant stricture at the level of the
confluence of the right and left hepatic ducts or higher is suspected, a PTC is
preferred to ERCP as successful drainage is more likely”
Complications: intraperitoneal hemorrhage, subphrenic abscess, sepsis
64. You should also pay attention to
bengn stricture in obstructive
jaundice(80% post op & 20%
inflammatory)
65. NPO
I.V.F
Prophylactic broad spectrum antibiotic????
Parenteral vitamin K +/- fresh frozen plasma.
Cholestyramine and antihistamine for symptomatic relief of pruritis
In patient cannot tolerate surgery,consider choledochostomy(drainage)
Editor's Notes
Gilbert syndrome: Mildly low UGT activity; autosomal recessive. >> Jaundice during stress (e.g., severe infection); otherwise, not clinically significant.
Criggler-Najjar syndrome: Absence of UGT>> usually seen in the fetus>> Kernicterus; usually fatal
PBC: Primary biliary cirrhosis.
PSC: Primary sclerosing cholangitis.
Dubin-Johnson syndrome: Deficiency of bilirubin canalicular transport protein; autosomal recessive, the liver is dark.
Rotor’s is the same but the liver is not dark.
Urine bilirubin
Normally, tiny amount bilirubin (conjugated) excreted in urine
* Pre-hepatic jaundice: Haemolysis causes rise in unconjugated bilirubin (water insoluble) and this is not excreted by the kidney therefore there is no rise in urine bilirubin
* Some causes of Hepatic jaundice: result in damage to biliary cannaliculi and therefore result in poor biliary drainage and therefore elevated conjugated bilirubin levels in blood, excreted into urine (giving dark urine)
* Post-Hepatic juandice: Obstruction to biliary drainage and so conjugated bilirubin (water soluble) levels in the blood increase and appear in the urine (giving dark urine)
Urine urobilinogen
Pre-hepatic jaundice: Haemolysis results in increased bilirubin production and subsequent increase bilirubin metabolism and urobilinogen in stool and therefore in the urine.
Some causes of Hepatic jaundice : result in hepatocellular destruction and therefore reduced re-excretion of re-absorbed urobilinogen (i.e. Reduction in entero-hepatic circulation of urobilinogen) resulting in elevated levels in urine
Post-Hepatic jaundice: Less bilirubin reaching intestine therefore reduction in urobilinogen therefore reduction in urine urobilinogen
Four Fs”:
Female
Fat
Forty
Fertile (multiparity)
What are the types o stones? Cholesterol stones (75%) / Pigment stones (25%)
What are the types of pigmented stones?
Black stones (contain calcium bilirubinate)
Brown stones (associated with biliary tract infection)
What are the causes o black pigmented stones?
Cirrhosis, hemolysis
What is the pathogenesis of cholesterol stones?
Secretion of bile supersaturated with cholesterol (relatively decreased amounts of lecithin and bile salts); then, cholesterol precipitates out and forms solid crystals, then gallstones
is a cancer of the cells that make up the ducts in the pancreas
Cholangicarcinoma is a rare malignancy. The overall annual incidence is 1–1.5 per 100 000
Male : female ratio is approximately 1.5:1.
Risk factors for cholangiocarcinoma
Chronic inflammatory conditions
●● Primary sclerosing cholangitis (PSC) 20 fold
●● Hepatitis C infection
Congenital
●● Choledochal cysts
●● Caroli’s disease
Chemical agents
●● Thorium dioxide (Thorotrast)
●● Vinyl chloride
●● Dioxin
●● Asbestos
Post surgical
●● Biliary–enteric anastomosis
Most patients present with abnormal liver function tests or puritus + jaundice, wt loss, anorexia , abd. pain
●Diagnosis by ultrasound, CT or MRCP scanning
●The majority of patients receive palliative care only
●Complete surgical excision possible in <10%
●Prognosis poor: 90% die within 1 year, from hepatic failure or biliary sepsis
●Adjuvant chemoradiation therapy has a limited role
Surgery involves excision of the extrahepatic biliary tree with or without a liver resection and a Roux loop reconstruction
Complication if left untreated : recurrent cholangitis, secondary biliary cirrhosis, and portal hypertension
Less commonly, they may present with jaundice without evidence of infection
Surgery with
Haptoglobin binds free Hb
Ultrasound examination. Gallstones noted at the neck of the gallbladder with associated acoustic shadowing.
Ultrasound examination. Multiple gallstones noted within the gallbladder.
Endoscopic ultrasonography. CBD, common bile duct; PD, pancreatic duct.
Magnetic resonance cholangiopancreatography
Magnetic resonance cholangiopancreatography: projectional images demonstrating stones and hilar obstruction (arrow).
Magnetic resonance cholangiopancreatography: cross-sectional image demonstrating a hilar mass (thick arrow) and gallstones (thin arrow).
Endoscopic retrograde cholangiopancreatography: normal cholangiogram.
Endoscopic retrograde cholangiopancreatography: common duct obstruction (arrow).
Endoscopic retrograde cholangiopancreatography: partial occlusion of the bile duct by a malignant stricture (arrow).