Objectives:-

•Definition .

•Bilirubin Pathophysiology

•Classefication of jaundice

•Causes

•Approach a jaundice pt

•Management

Definition:-

-Jaundice ( hyperbilirubinemia ) is a yellowish discoloration of the skin & sclera due to accumulation of the pigment bilirubin in the blood & tissue.

-Bilirubin level has to exceeds 35-40 Mmol/L before jaundice is clinically apparent.

Classefication:-

1.Prehepatic jaundice (hemolytic jaundice = acholuric jaundice)

2.Hepatic jaundice ( disturbed conjugation or uptake) .

3.Post-hepatic jaundice (disturbed excretion )= surgical/ obstructive.

Causes:-1- prehepatic Jaundice:- (hemolytic/acholuric)

•Hereditary spherosytosis

•Hereditary non-spherosytosis anemias

•Sickle cell anemia

•Thalasemia

•Acquired hemolytic anemia

•Incompatible blood transfusion

•Sever sepsis

•Drugs(chloropromazine,paracetamol,methyldopa,repeated exposure to halothane)

2) Hepatic Jaundice:-

•Viral hepatitis

•Hepatotoxins

•Cirrhosis

•Familial neonatal hyperbilirubinemia

•Gilbert’s familial hyperbilirubinemia

•Criglar-Najjar’s familial jaundice

•Dubin-jhonson syndrom

3)Post-hepatic Jaundice:-

-Intrahepatic(without mechanical obstruction):

•Cirrhosis.

•Viral (chronic active hepatitis).

•Certain drugs (methyltestosteron).

•Primary biliary cirrhosis.

•Parentral or enteric feeding with synthetic nutrition.

-Extrahepatic(surgical-obstructive):

•Intraductal>>> gall stones , foreign body (broken T-tube , parasites (hydatid , liver flukes).

•Wall>>> congenital atresia , traumatic stricture , sclerosing cholangitis , tumor of bile duct .

•Extraductal>>> pancreatic head cancer , ampullary cancer , pancreatitis , L.N metastasis .

•N.B>>>>>> commonest in surgical jaundice are gall stones & pancreatic carcinoma

1) History:-

•Personal data>>> age, sex, occupation .

•HPI>>> yellow discoloration of skin and sclera , abdominal pain (details) , fever , nausea , vomiting , chills , dark urine , pale stool ,itching , diarrhea , steatorrhea , contact with viral hepatitis patients.

•Hx of blood transfusion.

•PMHx , PSHx , Medications

•FHx of anemia , splenectomy or gall stones

2) Examination:-•General condition of patient & color.

•Vitals.

•Hand(clubbing , palmar errythema , duputeryn contractures , flapping tremors>>liver stigmata)

•Face & neck >>jaundice , pallor ,L.N

•Chest>>spider nevi , gynecomastia

•Genetalia>>>testicular atrophy

•Lower limbs >>> edema

-Abdominal Ex:-

•Inspection>>>scars , distended veins , diverted umbilicus , pigmentations

•Palpation>>> tenderness, masses , liver , spleen & gallbladder (murphy’s) .

•Percussion>>> ascitis

•Auscultation>> venous hums

3) Investigations:-A) LAB:-

• CBC>> Hb , WBC , PLT.

• Chemistry>> electrolytes, albumin,haptoglobin LFT(transaminases.ALP.GGT.5-Nucleotidase) , Bilirubin , Amylase ,BUN.

• Coagulation profile , pt , ptt

• Urine & Stool.

• Serology >> hepatitis , tumor markers , kazoni test

B) Imaging:-

1.x-ray: - galls tones 10%

- gas in biliary tree

2. U/S (1st line):

-intra/extra hepatic ducts

- gall bladder

-CBD

-pancrease

-liver parynchyma

3. CT: better reolution than U/S in:

.demonstrating pancreatic lesions

.obese pt

.intrahepatic lesions(tumor,abcess,cyst)

.pt with excess bowel gas shadow

4.

ERCP/MRCP(if intrahepatic ducts are not dilated)

PTC(if intrahepatic ducts are dilated)

4.PTC:

•If dilated intrahepatic ducts on ct

•ideal for demonstrating anatomy above extrahepatic obstruction

•Contraindications:-

-coagulopathy,prolonged pt & ptt , plt below 40,000

-peri/intra hepatic sepsis

-ascitis

-disease of right lower lung or pleura

•Complications:-

-bile peritonitis -bilothorax -pneumothorax

-sepsis -hemobilia -bleeding

5.ERCP/MRCP:-

•If no dilated intrahepatic ducts on ct

•Visualize >>>upper GIT , ampullary region , biliary & pancreatic ducts

•Complications:-

-traumatic pancreatitis

-biliary sepsis

6.HIDA(unreliable if bilirubin more than 20 mg/dl).

7.Liver Bx

4) Management:-

-It includes:-

•Establishing the cause of jaundice

•Assesment of patient general condition

•Staging patient with tumor

•Appropriate treatment which maybe surgical, endoscopic , radiological

**Preoperative management:--includes:-

1-correction of metabolic abnormalities

2-improvement of general condition

3-institution of general measures designed to minimize the incidence of complications assosciated with prolonged or sever cholestasis (infection , renal failure , Liver failure , fluid & electrolytes abnormalities )

•Drugs & anasthetics agents metabolism & conjugation

•Hypokalemia

•Viral screen

•Prophylactic Antibiotics

•Coagulation disorder (prolonged PT)>>I.M phytomenadione 10-20 mg

•Renal failure>>adequate hydration & preoperative induction of natriuresis / diuresis

•(I.V 5% dextrose/12-24 h prior to surgurey – followed by osmotic diuretic (mannitol) or loop diuretic (furosemide) I.V at time of induction

•Pt undergoing surgurey>>>catheterization & measure urine output hourly

•Liver failure in pt with preexisting chronic hepatocelullar disease or with complete large duct obstruction

-if jaundice sever> 150Mmol/L or pt with signs of impending liver failure >>period of decompression before surgurey is indicated

-other prophylactic measures against encephalopathy includes correction of hypokalemia , restricted use of sedatives , hypnotics & potent analgesics & prompt ttt of infections.

Treatment of some conditions

•Gall stone with a CBD stone

•Pancreatic carcinoma

•Cholangitis

•Bile duct stricture

1)Gall stone with a CBD stone:-

-ERCP for CBD stone , 1-2 days after proceed for choecystectomy

2)Benign traumatic stricture:-

Damaged area should be bypasses & choledojejunostomy is done (Roux-en-Y).

3)pancreatic cancer:-

a)Resectional surgurey>>whipple’s operation

b)Palliative surgurey>>aim to relieve

..biliary obstruction& duodenal obstruction endoscopic or radiologic stenting(biliary bypass & gastrojejunostomy)

.. Painceliac plexus block , splanchnicectomy

c) Palliative therapy

d) Chemotherapy / radiotherapy .

4)Cholangitis:-

-resuscitation >> I.V fluids , blood culture ,systemic AB

-endoscopic decompression (sphincterotomy& calculi extraction) / temporary stenting for drainage

-surgical exploration with ductal clearance and T-tube insertion