Approach to Jaundice Patient

7/31/2019 Approach to Jaundice Patient

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Approach to theJaundiced

Patient

By:Dr. Berhane Redae


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Introduction :

not a common presentingcomplaint in adults . whenpresent, it may indicate a serious

problem. Patients with jaundice may

present with no symptoms at allor they may present with a life-threatening condition


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variety of underlying causes.

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)

A systematic approach is warranted toclarify the cause quickly so that treatmentcan begin as soon as possible


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Jaundice

Definition: Jaundice Yellowish colouration of

sclera,mucous membrane & skin.

It is Symptom not a disease.

Literally, means yellow.

Caused by high Bilirubin.

Normal range 0.3-1.2 mg /dL.

Clinically obvious 2.5 mg /dl.


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Bilirubin

Bilirubin is formed by a b/downproduct of heme rings.

Approximately 80 % of the

heme moiety comes fromcatabolism of red blood cells.

Remaining 20 % resulting fromineffective erythropoiesis andbreakdown of muscle myoglobinand cytochromes.


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Causes of hyperbilirubinemia :

Overproduction by reticuloendothelial

system.

Failure of hepatocyte uptake.

Failure to conjugate or excrete.

Obstruction of biliary excretion into

intestine.


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Pre-hepatic (Haemolytic):

Excessive haemolysis due to any cause:

RBC disorder

Hereditary spherocytosis.Sickle cell anaemia.

Auto-immune

Mismatched blood transfusion.

Paroxysmal cold hemoglobinuria.

Infective Sepsis.

Malaria.


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Hepatic Jaundice :

Hepatic Jaundice Due to a disease

affective hepatic tissue eithercongenital or acquired diffusehepatocellular injury.


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Post-hepatic (Obstructive) :

Post-hepatic (Obstructive) It is due tointra or extra hepatic obstruction ofbile ducts.

Extra-hepatic Gallstones. Carcinoma of the head of pancreas or

CBD.

Intra-hepatic: Primary Biliary Cirrhosis

. Sclerosiing cholangitis.

Drugs.


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Main features :

:Main features:

Jaundice.

Dark urine. Pale stool.

Prurities.

Absent Urobilinogen in urine. Alkaline phosphatase .


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Critical Questions in the Evaluationof 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?


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Evaluation of the JaundicedPatient

HISTORY

The Following Aspects of the

history should be covered. Duration of the illness .Recent outbreaks of

jaundice . Intravenousdrug abuse, recentinjection,blood transfusion.

Alcohol consumption .


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Evaluation of the Jaundiced Patient

HISTORY ( cont )

Drug Taken .

Travel.

Family History.

Recent Surgery of Biliary Tractor carcinoma

. Fever or Rigors.


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PHYSICAL EXAM

BP/HR/Temp

Mental status

Asterixis

Abd tenderness

Liver size

Splenomegaly

Ascites

Edema

Spider angiomata

Hyperpigmentation

Kayser-Fleischerrings

Xanthomas

Gynecomastia

Left supraclavicularadenopathy(Virchows node)


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Physical Examination

The physical examination should focusprimarily on:

Stigmata of chronic liver disease

Marks of itching .

Charcots triad: fever + rigors +

jaundice .

Courvoisiers Law: obstructivejaundice + palpable gallbladder =malignant cause.


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Certain findings suggest specificdiseases such as:

Hyperpigmentation in

hemochromatosis.

A Kayser-Fleischer ring in Wilson's

disease.

Xanthomas in primary biliarycirrhosis.


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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


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Evaluation of the

Jaundiced Patient Ultrasound

More sensitive than CT forgallbladder stones.

Equally sensitive for dilatedducts.

Portable, cheap, no radiation,

no IV contrast.


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Evaluation of the Jaundiced Patient :

CT Better imaging of the pancreas andabdomen. is commonly used to identifyhepatic masses, particularly small

metastases, with an accuracy of about80%.

MRCP

is more sensitive than CT or ultrasoundin diagnosing common bile ductabnormalities, particularly stones.

Imaging of biliary tree comparable to

ERCP. Evaluation of the Jaundiced Patient


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ERCP

* Diagnostic:

Calculi, tumours, strictures.Biopsy of pancreatic or distal CBD.

* Therapeutic

Extract stones and drain bile.

Stent to relieve obstruction.


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PTC

Percutaneous transhepatic

cholangiography is valuable whenintrahepatic ductal dilatation ispresent. This procedure can be used

to determine the location of biliarytract obstruction.


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Liver Biopsy Conditions in which needle

biopsy is useful include:

cirrhosis.

chronic hepatitis.

granulomatous hepatitis

tumors, undiagnosed

hepatomegaly.

cholestasis of unknown cause,infiltrative processes and miliarytuberculosis


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JaundiceSummary

Patients history of greatimportance . Physical findings

can narrow the differentialdiagnosis.

Simple Laboratory Tests can

focus evaluation. Ultrasound important if

diagnosis not obvious.


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Selected Laboratory testsconfirms diagnosis and leads to

successful treatment.

Use treatment that is proven tobe effective, is of no harm, andwhere cost is justified.

Approach to Jaundice Patient

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