JAUNDICE

By Bish

Objectives
Define hyperbilirubinemia (Jaundice). Differentiate between physiological and

pathological jaundice. State causes of hyperbilirubinemia. Describe the most dangerous complication of hyperbilirubinemia. Discuss the management of hyperbilirubinemia

Definition: Hyperbilirubinemia
Hyperbilirubinemia:
excessive level bilirubin in the blood characterized by jaundice, a yellowish
Typically seen at bili levels of: 85-120

discoloration of the skin, sclerae, mucous membranes and nails

Unconjugated bilirubin = Indirect

bilirubin. Conjugated bilirubin = Direct bilirubin.

Why am I learning this?

Is it important?

Why?
Jaundice is quite common Full term infants: at least 60% Preterm infants: over 80%

Most Importantly

Most Importantly
Kernicterus: unconjugated bilirubin deposits in the brain yellow staining + degenerative lesions Phase 1: decreased alertness Hypotonia Poor feeding

Phase 2: Hypertonia,
Retrocollis, opisthotonus Phase 3: Hypotonia

Source Of Bilirubin
85% from old RBC , the rest

from non haem proteins Hb is degraded to Haem and Globin Iron is extracted from Haem Rest is converted to bilirubin Bilirubin travels to liver bound to albumin

Journey through the liver

Bilirubin taken up Conjugated to form water soluble conjugate Conjugate secreted into bile

In The Gut
Bilirubin diglucuronide may be
Deconjugated or Metabolised by bacteria to urobilinogen

partially reabsorbed (remainder makes the stool brown)

So where can things go wrong?

Pathophysiology Of Jaundice
Hyperbilirubinemia is due to: Excess bilirubin production

Haemolytic Impaired uptake by hepatocyte Hep/cellular. Failure of Conjugation Hep/cellular. Impaired secretion of conj.bil. Hep/cellular. Impaired bile flow. Obst.Jaundice

Classifications

Classifications
Physiological Jaundice Pathological Jaundice

Physiological jaundice :
1. General state of baby is well 2. Appears 2-3days 3. Disappears <2 week (term infants) <4 weeks (preterm infants)
Pathophysiology increased hematocrit and decreased RBC lifespan immature glucuronyl transferase enzyme system

(slow conjugation of bilirubin) increased enterohepatic circulation

Pathological Jaundice
1. Appears earlier (first 24 hours of life) 2. Fades >2 weeks (term infants) >4 weeks (preterm infants)

Back to our table..lets break things down into basics..

Hint

Good Job!

Now that youre a pro..

Youre called by a nurse for a new admission

regarding a baby with elevated bili..what do you want to know

Approach to jaundiced baby

Get age of baby (hours), gestational age,

pregnancy hx, septic risk factors, complications with delivery Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological Look for evidence of kernicterus* in deeply jaundiced NB
*review..what do you look for?

Approach to jaundiced baby

Get age of baby (hours), gestational age,

pregnancy hx, septic risk factors, complications with delivery Assess clinical condition (well or ill) Decide whether jaundice is physiological or pathological Look for evidence of kernicterus* in deeply jaundiced NB
*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions

Why does the age (hours) of baby matter?

Causes of jaundice
Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABO Infections: TORCH, malaria, bacterial Appearing between 24-72 hours of life Physiological G6PD deficiency Dehydration (breast feeding jaundice) Sepsis Polycythemia Concealed hemorrhage Intraventricular hemorrhage Increased entero-hepatic circulation Appearing beyond 1 week Breast milk jaundice Prolonged physiologic jaundice in preterm Hypothyroidism Neonatal hepatitis Conjugation dysfunction - e.g. Gilbert syndrome, Crigler-Najjar syndrome Inborn errors of metabolism - e.g. galactosemia Biliary tract obstruction - e.g. biliary atresia

What workup/labs do you order

Workup
Initial laboratory tests

Total & direct bilirubin Blood group and Rh for mother and baby CBC/d, retic count and peripheral smear Coomb test TSH, G6PD screen Conjugated hyperbilirubinemia:
AST, ALT, PT, PTT, serum albumin, ammonia, TSH, TORCH screen, septic work-up

Treatment?

Treatment
During pregnancy (if severe)

Intrauterine blood transfusion Early delivery

After pregnancy
Increase feeds (especially in breast feeding

jaundice) Phototherapy Exchange transfusion (if severe)

Bilirubin chart

Side effects of phototherapy

Increased insensible water loss Loose stools Skin rash Bronze baby syndrome Hyperthermia Upsets maternal baby interaction