Approach To A Patient With Jaundice


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  • AST, ALT, Alkaline phosphatase => almost normalSerum protein level => normalAlbumin:globulin ratio => normal
  • Tender hepatomegaly: acute hepatitis
  • Hepatocellular => disproportonate rise in aminotransferases compared to alkaline phosphataseCholestatic => disproportonate rise in alkaline phosphatase compared to aminotransferases
  • Approach To A Patient With Jaundice

    1. 1. Dr.tanujpaulbhatia<br />Approach to a patient with jaundice<br />
    2. 2. What is jaundice?<br />Yellowish discoloration of skin, sclerae and mucus membranes due to hyperbilirubinemia<br />Total bilirubin > 1.5 mg/dl <br />
    3. 3. Types of jaundice<br />
    4. 4. Hemolytic Jaundice<br />Excess production of bilirubin due to excess breakdown of hemoglobin<br />Indirect bilirubin (insoluble in water since unconjugated)<br />E.g.<br />Hemolytic anemia<br />Malaria<br />Glucose-6-phosphate dehydrogenase deficiency<br />
    5. 5. Hepatic Jaundice<br />Liver’s ability to conjugate or excrete bilirubin is affected<br />Increased level of conjugated and unconjugatedbilirubin<br />E.g.:<br />Hepatitis, cirrhosis, hepatocellular carcinoma, prolonged use of drugs metabolized by liver<br />Genetic disorders: <br />Gilbert’s syndrome<br />Criggler-Neijer Syndrome<br />
    6. 6. Obstructive Jaundice<br />Bilirubin formation rate is normal<br />Conjugation is normal = direct bilirubin<br />Obstruction of bile duct so exit is blocked<br />Tumor of the head of the pancreas<br />Cholecystitis (gallstones)<br />
    7. 7. History <br />Pain<br />Fever<br />Alcohol<br />Medications<br />Pruritus<br />Color of urine<br />Type of stools<br />Fatigue<br />
    8. 8. Physical examination<br />BP/HR/Temp.<br />Degree of jaundice<br />Presence of anemia<br />Abdominal tenderness<br />Size and character of liver<br />Any palpable mass e.g. gall bladder(curvoisier’s law)<br />Signs of liver failure<br />Mental status <br />
    9. 9. Icterus .…………………………………. Ascites<br />
    10. 10. Lab investigations<br />Complete blood count<br />Liver function tests<br />BT/CT<br />PT/INR<br />Serum albumin<br />?blood culture<br />
    11. 11. Other investigations<br />Ultrasound:<br />More sensitive than CT for gallbladder stones<br />Equally sensitive for dilated ducts<br />Portable, cheap, no radiation, no IV contrast<br />CT:<br />Better imaging of the pancreas and abdomen<br />PTC- percutaneoustranshepaticcholangiogram<br />Gives a picture of the intra and extrahepaticbiliary tree<br />
    12. 12. MRCP:<br />Imaging of biliary tree comparable to ERCP<br />Non invasive<br />ERCP:<br />Therapeutic intervention for stones<br />Brushing and biopsy for malignancy<br />Invasive, chances of developing pancreatitis post procedure<br />
    13. 13. Liver function tests<br />
    14. 14. Enzymes <br />Alkaline phosphatase<br />Bone and liver<br />Specific for obstructive jaundice<br />Released from biliarycanaliculi in case of bile duct obstruction<br />Aspartateaminotransferase (AST/SGOT)<br />Reflects damage to hepatic cell<br />Less specific<br />May be elevated in MI<br />Used with ALT to diffrentiate between heart and liver disease<br />Alanineaminotransferase (ALT/SGPT)<br />Produced withing the cells of the liver<br />Most sensitive marker for liver cell damage<br />
    15. 15. Patient A<br />42 year old female with history of general weakness of 4 months. She was found to have moderate anemia, jaundice and mild splenomegaly.<br />Hemolytic Jaundice<br />
    16. 16. Clinical Findings—Hemolytic Jaundice<br />Decreased hemoglobin<br />Explains weakness<br />Has moderate anemia<br />Splenomegaly<br />Increased activity of reticuloendothelial system<br />Site of RBC filtration<br />Liver Function Tests:<br />Increased Serum bilirubin<br />Increased load to the liver (increased hemolysis) => increased hemoglobin metabolism<br />
    17. 17. Patient B<br />30 year old male with history of fever of 2 weeks, nausea and highly colored urine. He had palpable, soft tender liver. <br />Hepatic Jaundice<br />
    18. 18. Clinical Findings—Hepatic Jaundice<br />Highly colored urine<br />Increased amount of bilirubin excretion<br />Tender hepatomegaly<br />Liver function tests<br />High serum bilirubin<br />AST and ALT highly increased<br />Alkaline phosphatase increased moderately <br />Seen in both hepatocellular jaundice and cholestatic jaundice<br />
    19. 19. Patient C<br />35 yr old male with complaints of pain abdomen, jaundice,itching and passing clay colored stools.<br />Previously he was diagnosed with gall bladder stones but has not taken treatment.<br />Gall bladder is not palpable.<br />Obstructive jaundice due to CBD stones.<br />
    20. 20. Patient D<br />60 yr old male patient with progressive jaundice, itching, loss of weight .<br />On palpation gall bladder is palpable.<br />Obstructive jaundice due to malignancy<br />Periampulary carcinoma<br />
    21. 21. Clinical findings in obstructive jaundice<br />Deep jaundice<br />Scratch marks on body<br />High colored urine<br />Clay colored stools<br />Other features<br />?pain<br />?weight loss<br />?palpable gall bladder<br />?ascites<br />
    22. 22. Curvoisier’s law<br />“In a case of obstructive jaundice, if the gall bladder is palpable, it is unlikely to be due to stones.”<br />Explanation : <br />
    23. 23. How to differentiate the types of jaundice?<br />Hemolytic:<br />Increased unconjugated (indirect) more than direct (conjugated) bilirubin <br />Hemoglobin level low<br />Anemia<br />Hepatic:<br />Increased amount of both indirect and direct <br />Increase in AST and ALT more than increase in ALP<br />Obstructive:<br />Increased amount of direct (conjugated)<br />Significant increase in ALP more than AST and ALT<br />
    24. 24. Treat<br />
    25. 25. Obstructive jaundice<br />
    26. 26. Obstructive jaundice - etiology<br />CHOLEDOCHOLITHIASIS<br />NEOPLASMS- periampullary carcinomas<br />3. BILIARY ATRESIA<br />4. CHOLEDOCHAL CYST<br />5. LYMPHADENOPATHY-PORTA HEPATIS<br />6. TRAUMATIC- POST CHOLECYSECTOMY<br />
    27. 27. Diagnosis <br />LFT<br />USG abdomen<br />CT abdomen<br />PTC<br />ERCP<br />MRCP<br />
    28. 28. USG abdomen<br />
    29. 29. CT abdomen<br />
    30. 30. ERCP<br />
    31. 31. Treatment<br />Choledocholithiasis<br />Open / laparoscopic CBD exploration with stone extraction and T tube placement.<br />Endoscopic papillotomy and extraction<br />Periampularry carcinoma<br />Curative – whipple’s procedure<br />Palliative – <br /> - endoscopic stenting of ampulla<br /> - bypass prcodures for<br />Food e.g. gastrojejunostomy<br />Bile e.g. choledochojejunostomy<br />
    32. 32. 1. Gall stones removed from CBD2. T-tube cholangiogram<br />
    33. 33. Whipple’s operation<br />3 structures removed<br />C-loop of duodenum<br />Head and neck of pancreas<br />Pylorus of stomach<br />3 anastomosis are made<br />Gastro-jejunostomy<br />Choledocho-jejunostomy<br />Pancreatico-jejunostomy<br />
    34. 34. Resectedg.b. and opened C-loop showing periampullary growth<br />
    35. 35. Thank you <br />