Jaundice (Icterus)

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Transcript of Jaundice (Icterus)

  • 1.JAUNDICE (ICTERUS)
    • YELLOWISH DISCOLORATION OF SKIN & MUCOUS MEMBRANES
  • EXCESS BILIRUBIN IN PLASMA.
  • NORMAL RANGE5-17 micromol/L
  • (0.3 1.0mg/dl)
  • LEVEL ABOUT 50 micromol/L (3mg/dl)
  • -> CLINICAL JAUNDICE
  • (SCLERA,SKIN,PALATAL MUCOSA)

2. CONTD

  • DIAZO REAGENT(DIAZOTISED
  • SULPHANILIC ACID)->DEMONSTRATES
  • +BILIRUBIN
  • SODIUM NITRITE
  • +
  • HCL->A RED COMPD. AZOBILIRUBIN
  • CONJUGATED BILIRUBIN->IMMEDIATE
  • (POLAR MOLECULE)REACTION
  • DIRECT van den Berg reaction
  • UNCONJ.BILIRUBIN->NO REACTION until alc.is added
  • (NONPOLAR)->INDIRECT van den Berg reaction

3. 4. contd

  • UROBILINOGEN-CONSISTS OF
  • UROBILINOGEN,
  • MESOBILINOGEN,
  • & STERCOBILINOGEN.
  • Conj. B. (soluble in water)- excreted in
  • urine.
  • Unconj.B.(bound to albumin)- lipid soluble (does not enter gl.filtrate)
  • DANGER- binding capacity of albumin exhausted--- absorbed by lipid rich areas in Brain.
  • Plasma level 340 micromol/l (20mg/dl)
  • Basal ganglia deeply bile stained- irreparable damage to neurons
  • KERNICTERUS

5. TYPES OF JAUNDICE

  • HAEMOLYTIC.
  • OBSTRUCTIVE.&
  • HEPATOCELLULAR.

6. HAEMOLYTIC JAUNDICE

  • BILIRUBIN LOAD DUE TO- EXCESSIVE
  • BREAKDOWN OF RBCs.
  • -INEFFECTIVE
  • ERRYTHROPOIESIS (IN
  • THALASSEMIA,PERNICIOUS ANAEMIA)
  • CONDITIONSARE THOSE ASSOC. WITH HAEMOLYTIC ANAEMIA.
  • UNCONJ. HYPERBILIRUBINAEMIA +HEPATIC DYSFUNCTION DUE TO ANAEMIA

7. CONTD.

  • BIOCHEM. MANIFESTATIONS
  • INDIRECTLY REACTING BILIRUBIN IN PLASMA.
  • STERCOBILINOGEN IN FAECES
  • UROBILINOGEN IN URINE.
  • ABSENCE OF BILIRUBIN IN URINE.
  • Jaundice not severe. seldom85micromol/l(5mg/dl)except
  • Rh haemolytic disease of newborn.

8. OBSTRUCTIVE JAUNDICE

  • OBSTRUCTION TO PASSAGE OF CONJ. BILIRUBIN FROM LIVER CELLS->INTESTINE.
  • CHOLESTASIS EXTRAHEPATIC
  • INTRAHEPATIC
  • EXTRAHEPATIC CHOLESTASIS( surgical jaundice)
  • 1.Blockage of CBD by Gallstones.
  • 2.Occlusion of Duct by Ca head of Pancrease
  • 3.Pressure by enlarged L.nodes in Porta hepatis.
  • 4.Ca. of Duct itself either at Ampulla of Vater or higher
  • up.

9. Contd.

  • INTRAHEPATIC CHOLESTASIS
  • LESS OBVIOUSLY ASSOC. WITH MECH. OBSTRUCTION.
  • 1.Sclerosing cholangitis
  • cholangiography -> multiple areas of stenosis& dilatations of intra & extra hepatic ducts.
  • Pr. 85% assoc.with U. Colitis.
  • Sec.in pts.with AIDS &in those with untreated bile duct stenosis
  • All varieties of sec. cholangitis progress to Cirrhosis.
  • 2.Pr. Biliary cirrhosis

10. contd

  • 3.Rare compln.of last trimester of pregnancy
  • (effect of oestrogen),oral contraceptives.
  • 4. Drugs(cholestatic drug jaundice)
  • Chlorpromazine & other phenothiazines.
  • Halothane,Steroids.
  • BIOCHEMICAL MANIFESTATIONS
  • 1. Conjugated bilirubin in plasma.
  • 2. stercobilinogen in faeces. (pale, bulky, offensive)
  • Bile salts excluded from bowel(absorption of fat)
  • Long standing casesMalabsorption syndrome,
  • Fat soluble vitamins.Vit. K->bleeding
  • Hypovitaminosis D -Osteomalacia

11. Contd

  • 3.Absence of urobilinogen in urine.
  • 4.Presence of bilirubin & bile salts in urine.
  • 5. levels of Pl. alk.PO4ase& glutamyl transferase.
  • -- Pruritis (pl. bile salt concn.&unconj. bile salts in skin)
  • -- Hypercholesterolaemia->cut. Xanthomas.
  • -- in LDLs & in HDLs
  • Abn.LDL-LipoproteinX(high proportion of
  • unesterified cholesterol& phospholipid)
  • --Hepatocellular damage
  • --Cirrhosis

12. HEPATOCELLULAR JAUNDICE

  • DIRECT & INDIRECT reacting BILIRUBIN
  • ---Failure of conjugating mechanism
  • ---Obstruction to escape of cong. bilirubin
  • (from cells to canaliculi &from canaliculi)
  • intrahepatic cholestasis

13. contd

  • 1.Enzyme deficiency.
  • 2.Intrahepatic cholestasis complicating liver cell damage.
  • a)Acute fatty liver-obstruction-pr.
  • b)Severe neonatal jaundice obstruction-
  • inspissated bile in canaliculi.
  • 3.Cirrhosis-ac.exacerbation &terminally.
  • 4.Postop. Jaundicehepatic necrosis(shock)
  • ----hepatitis(drugs)
  • ----red cell destruction(site, haemolysis of transfused cells)

14. 15. STEPS IN DIAGNOSIS OF JAUNDICED PATIENT

  • CLINICAL HISTORY &EXAMINATION.
  • URINE,STOOL
  • SERUM BIOCHEMICAL TESTS
  • BILIRUBIN
  • TRANSAMINASE(AST,SGOT)
  • ALKALINE PHOSPHATASE,
  • GAMMA GT.
  • ALBUMIN
  • QUANTITATIVE IMMUNOGLOBULINS.
  • HAEMATOLOGY-Hb,WBC,PLATELETS
  • BLOOD FILM
  • PROTHROMBIN TIME(before & after IM Vit.K)
  • XRAY CHEST