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