JAUNDICE

Index Case Term 2

Jaundice

•Definition•Causes•History• Investigation-Imaging•Clinical Cases

Definition

• Jaundice is a yellowing of the skin, conjunctiva and mucous membranes caused by hyperbilirubinaemia.

Anatomy

Causes

• excess bilirubin production (Haemolysis)• impaired uptake by the hepatocyte

(hepatocellular jaundice)• failure of conjugation (hepatocellular jaundice)• impaired secretion of conjugated bile into the

bile canaliculi (hepatocellular jaundice)• impairment of bile flow subsequent to

secretion by the hepatocyte (obstructive or cholestatic jaundice)

Obstructive Jaundice• Common

– Common bile duct stones– Carcinoma of the head of pancreas– Malignant lymph nodes at the porta hepatis

• Infrequent– Ampullary carcinoma– Pancreatitis– Liver secondaries

• Rare– Benign strictures - iatrogenic, trauma– Recurrent cholangitis– Mirrizi's syndrome– Sclerosing cholangitis– Cholangiocarcinoma– Bilary atresia– Choledochal cysts

History

• Abdominal pain, weight change, fever• Drug history• Injections• Alcohol• Transfusion blood, blood products• Contact with jaundiced individuals• Sexual activity• Ingestion raw shellfish, wild mushrooms

NN+Haemolytic

++++++Hepatocellular

+++++++Cholestatic

AlkPTransaminases

Bilirubin

Liver Function Tests

Jaundice

•Clinical Case 1

• 50 year old female• Acute, severe pain in RUQ• Nausea and vomiting• Calls GP – pethidine pain relief• Next few days notices dark urine and

pale stools• Her husband comments she has a pale

yellow tinge

Emergency admission

• What investigations would you do ?

• What results would you expect?

Abdominal Ultrasound showing multiple gallstones in gallbladder

US shows stone in Common Bile Duct

MRCP showing stone in Common Bile Duct

ERCP showing stone in Common Bile Duct

Case 1

• Obstructive jaundice due to gallstone in common bile duct

• Blood tests show high bilirubin and high alkaline phosphatase

• Urine contains bilirubin• Treatment includes ERCP to

remove stone and then plan Cholecystectomy

Clinical Case 2

• 65 year old female• Loss of appetite and weight loss• Develops jaundice and itching• Scratch marks and bruising• Liver enlarged, palpable gallbladder

Emergency admission

• What investigations and what results?

Abdominal Ultrasound

• Dilated common bile duct measuring 14mm

• Obstruction at lower end of bile duct

• Cause not clear on US

CT Abdomen

• Mass in head of pancreas

• Obstruction of common bile duct

• Liver metastasis• Peritoneal disease

and ascites

Endoscopic Ultrasound showing mass in head of pancreas

obstructing the CBD

EUS Biopsy of pancreatic mass

Diagnosis

• Histology of pancreatic biopsy shows adenocarcinoma.

• Not suitable for surgery as already spread to other organs eg peritoneum

• Relieve jaundice and consider chemotherapy

Therapeutic ERCP

• Put guide wire across the obstruction of CBD

• Insert bilary stent• Relieves jaundice

and some of symptoms

In Summary

• Anatomy• Disease processes that cause

jaundice • 2 Clinical cases of obstructive

jaundice• Thought about investigation of

jaundiced patient