Approach to a Case of Jaundice

Definition …

Yellowish discoloration of sclera, mucosa

& skin due to hyperbilirubinemia

Usually Serum bilirubin > 2-3 mg/dL

Jaundice/ Carotenederma / Mepacrine

Jaundice/ Mepacrine/ carotenederma

Sites to look for Jaundice

Sclera

Under surface of tongue

Skin

Metabolismof Bilirubin

• Haem

• Senescent RBCs

• Ineffective Erythropoesis

• Myoglobin

• Cytochrome oxidase

Bilirubin metabolism …

RBC Breakdown

Unconjugated bilirubin

Hepatic uptake

Conjugation

Hepatocellular excretion

Intrahepatic biliary canaliculi

Extrahepatic biliary pathway

Water insoluble

Alb bound, not in urine

Water soluble

Present in urine

Inside hepatocyte

Causes of Jaundice

Congenital

Acquired

1. Pre -Hepatic

Gilberts, Criggler NajarI & II

Hemolysis,Vit B12 & FA def

2. Hepatocellular

Dubin

Johnson, Rotors synd

Virus, drugs, alcohol

3. Obstructive

Drugs, gall stones, carcinoma

Obstructive Jaundice: Gall stones

Aim of the lecture …

Differentiate

Unconjugated vs Conjugated

hyperbilirubinemia

Medical vs Surgical jaundice

Unconjugated hyperbilirubinemia …

Causes

•Hemolysis•Ineffective erythropoesis

•Gilbert’s syndrome•Criggler Najjar syndrome (I, II)•Sepsis

RBC Breakdown

Unconjugated bilirubin

Hepatic uptake

Conjugation

Hepatocellular excretion

Intrahepatic biliary canaliculi

Extrahepatic biliary pathway

•Sepsis Causes

Clinical features …• Hemolysis –

• lemon tinge sclera, pallor, splenomegaly

• Normal colored urine (cola colored in cases of Intra Venous hemolysis) Acholuric jaundice

• Gilbert’s syndrome:

• mild jaundice

• with fasting

•Criggler Najjar syn (I): Kernicterus

Conjugated hyperbilirubinemia …

RBC Breakdown

Unconjugated bilirubin

Hepatic uptake

Conjugation

Hepatocellular excretion

Intrahepatic biliary canaliculi

Extrahepatic biliary pathway

•DJ/Rotor syndrome

•Hepatocellular damage•Hepatotrophic virus•Alcohol•Drugs/toxins•Autoimmune

•Primary biliary cirrhosis•Perihepatocyte edema•Primary sclerosing cholangitis

•Surgical obstructive jaundice

•Stones, strictures, malignancy

CausesINTRAHEPATIC

Clinical features …

• Hepatocellular damage

•Acute: bleeding manifestation, encephalopathy

•Chronic: edema, parotid enlargement*, gynecomastia*, testicular atrophy, spider angioma*

• Portal htn: varices, splenomegaly (hypersplenism), encephalopathy, ascites

• Underlying diseases: Viral-prodrome, cholangitis

* Features s/o alcoholism

Clinical features …

• Cholestasis: itching, high colored urine, clay

colored stools, fat/fat sol vitamins malabsorption

• Courvoisier's law

• Cholangitis: Fever with chills, jaundice, rt upper abdominal pain

Obstructive Jaundice

URINESTOOL

Lab Investigations LFT

Serum bilirubin > 2- 3 mg/dl ( < 6mg% in hemolytic anaemia)

Van den Bergs reaction Direct: Conjugated > 15 % In direct: UnConjugated: > 85 %

Enzymes ALT & AST raised in Hepatocellular Alk phosphatase & GGT in obstructive jaundice

Prothrombin time: raised in hepatocellular jaundice Serum proteins:

Albumin < globulin in Chronic liver disease

Urine Bilirubin

Present Absent

Conjugated Unconjugated

Urine Urobilinogen

Increased Absent

Hemolysis Cholestasis

Laboratory features of hemolysis …

Increased reticulocyte count (N in ineffective erythropoeisis)

Increased LDHIncreased urinary urobilinogenIV hemolysis:

PBS: schistocytes Hemoglobinemia/hemoglobinuria Hemosiderinuria (Chronic) Decrease haptoglobin

Surgical jaundice … Ultrasound abdomen

CBD/intrahepatic biliary radicals dilatation CBD stones Malignancy

ERCP/MRCP Distal blocks: distal to cystic duct Level, nature & extent of obstruction

Percutaneous transhepatic cholangiography Proximal blocks: proximal to cystic duct

CECT/MRI abdomen

Obstructive Jaundice

Liver ultrasound showing (a) dilated intrahepatic bile ducts (arrow)

Common bile duct (arrow). The normal bile duct measures 6 mm at the porta hepatis.

Obstructive Jaundice:

Oral Cholecystography