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Dr. Siddeeg Addow Pediatric Resident Khartoum, Sudan Clinical Approach to Neonatal Jaundice.
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Transcript of Dr. Siddeeg Addow Pediatric Resident Khartoum, Sudan Clinical Approach to Neonatal Jaundice.
Dr. Siddeeg AddowPediatric Resident Khartoum, Sudan
Clinical Approach to Neonatal Jaundice
CONTENTS:
INTRODUCTIONPATHOPHYSIOLOGYDIFFERENTIAL DIAGNOSISHISTORYEXAMINATIONINVESTIGATION
INTRODUCTIONBilirubin is the end product of heme Bilirubin is the end product of heme degradationdegradation
Most of the daily production comes Most of the daily production comes from the breakdown of RBCs in the from the breakdown of RBCs in the RESRES
Heme biliverdin Heme biliverdin bilirubin bilirubin
Bilirubin is released & bound to Bilirubin is released & bound to serum albuminserum albumin
Bilirubin is uptake & conjugated with Bilirubin is uptake & conjugated with glucuronic acidglucuronic acid
Finally conjugated bilirubin is Finally conjugated bilirubin is excreted in bile excreted in bile
PATHOPHYSIOLOGY
UNCONJUGATED B. CONJUGATED B.Tightly Tightly compounded to s. compounded to s. albumin albumin
Normally very Normally very small amount is small amount is present as albumin present as albumin free free
Insoluble in water Insoluble in water can not be can not be excreted in urineexcreted in urine
Toxic Toxic
Non toxicNon toxic
Water solubleWater soluble
Loosely bound to Loosely bound to albumin. Delta albumin. Delta fraction fraction
Both conjugated & unconjugated Both conjugated & unconjugated bilirubin may accumulate bilirubin may accumulate systemically & deposit in tissues systemically & deposit in tissues
Normally s. bilirubin level vary Normally s. bilirubin level vary b/w 0.3 & 1.2mg/dl. b/w 0.3 & 1.2mg/dl.
The rate of systemic bilirubin The rate of systemic bilirubin production is = to the rate of production is = to the rate of hepatic uptake, conjugation & hepatic uptake, conjugation & biliray excretion .biliray excretion .
Jaundice becomes evident when Jaundice becomes evident when the s.bilirubin levels rise above the s.bilirubin levels rise above 2.0 to 2.5mg/dl 2.0 to 2.5mg/dl
Levels as high as 30 to 40mg/dl Levels as high as 30 to 40mg/dl can occur with sever diseasecan occur with sever disease
Jaundice occurs when the = b/w Jaundice occurs when the = b/w bilirubin production &clearance bilirubin production &clearance is disturbed by one or more of is disturbed by one or more of the following mechanisms:the following mechanisms:
1.1.Excessive production of bilirubinExcessive production of bilirubin
2.2.Reduced hepatic uptakeReduced hepatic uptake
3.3.Impaired conjugationImpaired conjugation
4.4.Decreased hepatocellular Decreased hepatocellular excretionexcretion
5.5.Impaired bile flowImpaired bile flow
CAUSES OF JAUNDICE
Excessive production of Excessive production of bilirubinbilirubin
hemolytic anemia'sresorption of blood from internal hemor.ineffective erythropoiesis
Reduced hepatic uptake:
drugs some cases of Gilbert syndrome
Impaired bilirubin Impaired bilirubin conjugation:conjugation:
physiologic jaundicebreast milk jaundicegenetic deficiency of glcuronosyl transferasedecreased expression of glcuronosyl transferasediffuse hepatocellular diseases
Decrease excretion of conjugated bilirubin:
deficiency in canalicular membrane transportdrug induced canalicular membrane dysfunctionhepatocelluler damage or toxicity
Decreased intrahepatic bile flow :
inflammatory destruction of intrahepatic bile ducts
Extra hepatic biliary Extra hepatic biliary obstruction:obstruction:
gall stone obstruction of biliary treeextra hepatic biliary atresiabiliary stricture & choledochal cystprimary sclerosing cholangitisliver fluke infestationcarcinoma
HISTORYonset / durationpainnausea & vomitingloss of weight itchingcolor of stoolcolor of urinepast historyttt &family history
EXAMINATIONcolor of skinseverity of jaundiceanemialiverspleengall bladderascites
INVESIGATIONCBCLFTProthrombin timeAlfa feto proteinsUGSGU/SERCP & PTCLiver biopsy
The EndThe End