JAUNDICE
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Transcript of JAUNDICE
DR NILESH KATE
MBBS,MD ASSOCIATE PROF
DEPT. OF PHYSIOLOGY
JAUNDICE
OBJECTIVES. Definition Mechanism of production Types Characteristic features Physiological Jaundice Prevention Treatment .
Monday, May 1, 2023
DEFINITION JAUNDICE is defined
as Yellowish discoloration of skin, sclera & mucous membrane
Monday, May 1, 2023
CAUSE
Increase bilirubin concentration
( Hyperbilirubinemia) in the body fluids.
Normal range of serum bilirubin – 2-3 mg/100ml.
Jaundice when plasma bilirubin > 2-3 gm/dl.
Monday, May 1, 2023
EXCEPTION
All internal tissue & body fluids are yellow coloured
except BRAIN
d/t – BLOOD BRAIN BARRIER which not allow
bilirubin to pass except in neonatal period.
Monday, May 1, 2023
KERNICTERUS Deposition of excess
bilirubin to brain mainly Basal Ganglia – Kernicterus.
C/f – 3 phases Decreased alertness,
Hypotonia, poor feeding, Hypertonia, Opisthotonus Hypotonia.
Monday, May 1, 2023
BILIRUBIN & JAUNDICEBILIRUBIN FORMATION.
Monday, May 1, 2023
Tetra pyrrole straight chain with Globin & Iron
BILIRUBIN & JAUNDICEUPTAKE OF BILIRUBIN.
After degradation of Hb bilirubin is released into circulation. Its free of Un-conjugated Bilirubin.
Its lipid soluble in plasma & bound to albumin
This binding prevents its excretion by the kidneys.
Monday, May 1, 2023
CONJUGATION OF BILIRUBIN This un-conjugated taken
up by liver, albumin removed & enters hepatic cells
Conjugate with UDP-Glucoronic acid to form conjugated bilirubin
Enzyme – UDP-Glucoronyl transferase.
Monday, May 1, 2023
EXCRETION OF BILIRUBIN Conjugated Bilirubin
from liver is excreted into Bile Canaliculi against conc gradient.
Enters Intestine
Monday, May 1, 2023
FORMATION & EXCRETION OF UROBILINOGEN.
In intestine Conjugated bilirubin is degraded by intestinal bacteria
β Glucoronidase convert Bilirubin to Urobilinogen & Stercobilinogen.
20% of Urobilinogen reabsorbed into portal system to liver & escape into general circulation & re-excreted into bile
From General Circulation some filtered by kidney & excreted in Urine.
Monday, May 1, 2023
BILIRUBIN CIRCULATION IN THE BODY
Monday, May 1, 2023
MECHANISM OF PRODUCTION Excessive breakdown
( Hemolysis) of RBC so called Hemolytic Jaundice or Prehepatic Jaundice.
Damage to liver cells – Hepatic or Hepatocellular Jaundice.
Obstruction to bile duct – Post hepatic or Cholestatic Jaundice.
Monday, May 1, 2023
TYPES Hemolytic Jaundice
( Pre-Hepatic) Hepatocellular
Jaundice (Hepatic Jaundice)
Cholestatic or Obstructive Jaundice.(Post-Hepatic)
Monday, May 1, 2023
HEMOLYTIC JAUNDICE ( PRE-HEPATIC)
Mechanism of production Types of serum bilirubin
accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests
Monday, May 1, 2023
MECHANISM OF PRODUCTION Excessive Breakdown
of RBC – Produces Un-
conjugated bilirubin more than healthy liver can conjugate & excrete.
Monday, May 1, 2023
TYPES OF SERUM BILIRUBIN ACCUMULATED.
Unconjugated Hyperbilirubinaemia.
Monday, May 1, 2023
VAN DEN BERGH TEST Reagent used – Diazo
reagent ( Mixture of Sulphanilic acid, Hydrochloric acid & sodium Nitrite)
Test – 2 types Direct Indirect.
Monday, May 1, 2023
VAN DEN BERGH TEST Direct – when Diazo reagent added to serum
containing Conjugated Bilirubin Reddish Brown colour developed in 30 sec.
Indirect - when Diazo reagent added to serum containing Un-Conjugated Bilirubin No colour developed but when some alcohol added which dissolves Unconjugated Bilirubin – reddish Brown colour is obtained.
Monday, May 1, 2023
VAN DEN BERGH TEST
Indirect Positive
Reaction – Due to Un-
Conjugated Bilirubin.
Monday, May 1, 2023
URINE BILIRUBIN Unconjugated
Bilirubin is insoluble in water & transported n plasma with albumin.
Since albumin is not Filtered it is not appear in Urine.
Monday, May 1, 2023
URINE UROBILINOGEN.
Liver excrete lots of conjugated bilirubin in
intestine in bile & more Urobilinogen is formed
So Urine Urobilinogen is increased.
Monday, May 1, 2023
FAECAL STERCOBILINOGEN.
Normal 25-250 mg/day.
Same as more Urobilinogen & stercobilinogen
is formed
Faeces is Dark Brown in colour.
Monday, May 1, 2023
FAECAL FAT LEVEL.
Normal
5-6% of total intake /day
Monday, May 1, 2023
SPECIFIC BLOOD TESTS
Peripheral blood film – Haemolysis, Anaemia,
Reticylocytosis.
Normal Plasma Albumin: Globulin ratio.
Serum alkaline phosphatase Normal
Liver function tests – Normal ( As liver is normal)
Monday, May 1, 2023
HEPATOCELLULAR JAUNDICE (HEPATIC JAUNDICE)
Mechanism of production Types of serum bilirubin
accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests
Monday, May 1, 2023
MECHANISM OF PRODUCTION
Inability of liver to conjugate & transport
bilirubin into bile duct due to Liver damage.
Monday, May 1, 2023
TYPES OF SERUM BILIRUBIN ACCUMULATED.
Both conjugated & Unconjugated bilirubin
increased.
Monday, May 1, 2023
VAN DEN BERGH TEST
Biphasic Reaction as
both Conjugated & Un-
conjugated bilirubin
present.
Monday, May 1, 2023
URINE BILIRUBIN Present As conjugated
bilirubin is water soluble is dissolved, filtered & appear in urine
Also called Choluric Jaundice.
Monday, May 1, 2023
URINE UROBILINOGEN.
Decreases
As damaged liver cells are producing & excreting
less of conjugated Bilirubin & thus less
Urobilinogen.
Monday, May 1, 2023
FAECAL STERCOBILINOGEN.
Less
As less formation of Stercobilinogen
So Faeces are Pale Coloured.
Monday, May 1, 2023
FAECAL FAT LEVEL.
Increased up to 40-50%.
As less bile in intestine – less emulsification &
absorption of fat
So bulky, pale, greasy & foul smelling faeces-
steatorrhoea.
Monday, May 1, 2023
SPECIFIC BLOOD TESTS
Peripheral blood film – Normal
Albumin decreased, so albumin: globulin ratio Decreased
Serum alkaline phosphatase – Increased.
Liver function test – impaired.
Monday, May 1, 2023
CHOLESTATIC OR OBSTRUCTIVE JAUNDICE.(POST-HEPATIC)
Mechanism of production Types of serum bilirubin
accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests
Monday, May 1, 2023
MECHANISM OF PRODUCTION Obstruction to the
bile flow from Hepatocytes to duodenum.
Monday, May 1, 2023
TYPES OF SERUM BILIRUBIN ACCUMULATED.
Conjugated Hyperbilirubinaemia due to
impaired flow of bile.
Monday, May 1, 2023
VAN DEN BERGH TEST
Direct Positive
reaction.
As only conjugated
bilirubin present.
Monday, May 1, 2023
URINE BILIRUBIN
Present.
As conjugated
bilirubin filtered in
urine.
Monday, May 1, 2023
URINE UROBILINOGEN.
Markedly decreased or absent.
As due to obstruction conjugated bilirubin is not
released in intestine
No Urobilinogen is formed.
Monday, May 1, 2023
FAECAL STERCOBILINOGEN.
Absent – when obstruction is complete.
Stools are clay coloured.
Monday, May 1, 2023
FAECAL FAT LEVEL. Increased.
Monday, May 1, 2023
SPECIFIC BLOOD TESTS
Peripheral blood film – normal.
Plasma albumin, globulin & ratio – Normal
Serum Alkaline phosphatase – markedly increased.
Liver function tests - normal
Monday, May 1, 2023
Monday, May 1, 2023
PHYSIOLOGICAL JAUNDICE NEONATAL JAUNDICE. Mechanism of
production Appears 2-5 days after
birth & disappears in 2 weeks.
Excessive destruction of RBC & hepatic Immaturity in first 7-10 days.
Monday, May 1, 2023
SIGNS & SYMPTOMS
Monday, May 1, 2023
Monday, May 1, 2023
PREVENTION
By giving Hepatic Microsomal enzyme inducers
(Phenobarbital) to pregnant mother or
newborn-
Increases activity of Glucoronyl Transferase.
Monday, May 1, 2023
TREATMENT . PHOTOTHERAPY Exposure of skin to
white light – PHOTO-ISOMERIZATION of Bilirubin to water soluble Lumirubin which is excreted in Bile without conjugation
Monday, May 1, 2023
TREATMENT OF PATHOLOGICAL JAUNDICE IN ADULT
Monday, May 1, 2023
Thank You