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Approach to a patient with jaundice Dr Ali Tumi Slide 2 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 * Slide 3 Bilirubin Metabolism Blood Conjugated & Unconjugated Urine Urobilinogen Stool Stercobilin Slide 4 Slide 5 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, Slide 6 Critical Questions in the Evaluation of the Jaundiced Patient Acute vs. Chronic Liver Disease Hepatocellular vs. Cholestatic Biliary Obstruction vs. Intrahepatic Cholestasis Fever Could the patient have ascending cholangitis? Encephalopathy Could the patient have fulminant hepatic failure? Slide 7 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 Slide 8 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 (Virchows node) Slide 9 Cirrhosis Clinical Features Slide 10 Yes Treat Slide 11 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 Slide 12 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 Slide 13 New Onset Jaundice Viral hepatitis Alcoholic liver disease Autoimmune hepatitis Medication-induced liver disease Common bile duct stones Pancreatic cancer Primary Biliary Cirrhosis (PBC) Primary Sclerosing Cholangitis (PSC) Slide 14 Jaundiced Emergencies Acetaminophen Toxicity Fulminant Hepatic Failure Ascending Cholangitis Slide 15 Jaundice Unrelated to Intrinsic Liver Disease Hemolysis (usually T. bili < 4) Massive Transfusion Resorption of Hematoma Ineffective Erythropoesis Disorders of Conjugation Gilberts syndrome Intrahepatic Cholestasis Sepsis, TPN, Post-operation Slide 16 HBV Serology HBSAgHBcAb IgM HBcAb IgG HBSAb Acute HBV ++-- Resolved HBV --++ Chronic HBV +-+- HBV vaccinated ---+ Slide 17 Jaundice Slide 18 Slide 19 Yellow hands on top, red palms underneath - a sign of liver damage Slide 20 Ascitis in Cirrhosis Slide 21 Slide 22 Gynaecomastia in cirrhosis Slide 23 Slide 24 Slide 25 Slide 26 Slide 27 Slide 28 Slide 29 Slide 30 Slide 31 Slide 32 Slide 33 Slide 34 Slide 35 Slide 36