APPROACH TO A PATIENT WITH JAUNDICE

Dr f.Kamani

JAUNDICE

Yellow discoloration of skin & sclera due to excess serum bilirubin. >40umol/l, (3mg/dl)

Conjugated & Unconjugated types

Obstructive & Non Obstructive (clinical)

Pre-Hepatic, Hepatic & Post Hepatic types

Jaundice - Not necessarily liver disease *

BILIRUBIN METABOLISM

•Blood

•Conjugated &

Unconjugated

•Urine – Urobilinogen

•Stool – Stercobilin

COMMON CAUSES OF JAUNDICE

Pre Hepatic (Acholuric) - Hemolytic

Unconjugated/Indirect Bil, pale urine

Hepatic – Viral, alcohol, toxins, drugs

Liver damage - unconjugated

Swelling, canalicular obstruction - Conjugated

Post Hepatic (Obstructive) – Stone, tumor

Conjugated/Direct Bil, High colored urine,

CRITICAL QUESTIONS IN THE EVALUATIONOF THE JAUNDICED PATIENT

Acute vs. Chronic Liver Disease

Hepatocellular vs. CholestaticBiliary Obstruction vs. Intrahepatic Cholestasis

FeverCould the patient have ascending cholangitis?

EncephalopathyCould the patient have fulminant hepatic failure?

EVALUATION OF THE JAUNDICED PATIENT

HISTORY

Pain

Fever

Confusion

Weight loss

Sex, drugs, R&R

Alcohol

Medications

pruritus

malaise, myalgias

dark urine

abdominal girth

edema

other autoimmune dz

HIV status

prior biliary surgery

family history liver dz

EVALUATION OF THE JAUNDICED PATIENT

PHYSICAL EXAM

BP/HR/Temp

Mental status

Asterixis

Abd tenderness

Liver size

Splenomegaly

Ascites

Edema

Spider angiomata

Hyperpigmentation

Kayser-Fleischer rings

Xanthomas

Gynecomastia

Left supraclavicular adenopathy (Virchow’s node)

CIRRHOSISCLINICAL FEATURES

YesYes

Treat

EVALUATION OF THE JAUNDICED PATIENT

LAB EVALUATION

AST-ALT-ALP

Bilirubin – total/indirect

Albumin

INR

Glucose

Na-K-PO4, acid-base

Acetaminophen level

CBC/plt

Ammonia

Viral serologies

ANA-ASMA-AMA

Quantitative Ig

Ceruloplasmin

Iron profile

Blood cultures

EVALUATION OF THE JAUNDICED PATIENT

Ultrasound:

More sensitive than CT for gallbladder stones

Equally sensitive for dilated ducts

Portable, cheap, no radiation, no IV contrast

CT:

Better imaging of the pancreas and abdomen

MRCP:

Imaging of biliary tree comparable to ERCP

ERCP:

Therapeutic intervention for stones

Brushing and biopsy for malignancy

NEW ONSET JAUNDICEViral hepatitis

Alcoholic liver disease

Autoimmune hepatitis

Medication-induced liver disease

Common bile duct stones

Pancreatic cancer

Primary Biliary Cirrhosis (PBC)

Primary Sclerosing Cholangitis (PSC)

JAUNDICED EMERGENCIES

Acetaminophen Toxicity

Fulminant Hepatic Failure

Ascending Cholangitis

JAUNDICE UNRELATED TO INTRINSIC LIVER DISEASE

Hemolysis (usually T. bili < 4)

Massive Transfusion

Resorption of Hematoma

Ineffective Erythropoesis

Disorders of Conjugation

Gilbert’s syndrome

Intrahepatic Cholestasis

Sepsis, TPN, Post-operation

HBV SEROLOGY

HBSAg HBcAb

IgM

HBcAb

IgG

HBSAb

Acute HBV

+ + - -

Resolved HBV

- - + +

Chronic HBV

+ - + -

HBV vaccinated

- - - +

Jaundice

Jaundice

YELLOW HANDS ON TOP, RED PALMS UNDERNEATH - A SIGN OF LIVER DAMAGE

ASCITIS IN CIRRHOSIS

ASCITIS IN CIRRHOSIS

GYNAECOMASTIA IN CIRRHOSIS