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Jaundice
By
Petrus Irianto
Bilirubin Metabolism
15% of bilirubin comes from the catabolism of other haemcontaining proteins, such as myoglobin.
History:
Hepatocellular Jaundice
Acute or subacute hepatocellular injury
Viral hepatitis, alcohol, drugs, ischemic hepatitis, Wilson's disease,
acute fatty liver of pregnancy
Mechanism
Isolated elevation
of serum Bilirubin
Hepatocellular
Jaundice
Type of Jaundice
Cause of Jaundice
Unconjugated
* Bil. production (e.g. haemolysis, resorption
Hyperbilirubinaemia
of haematoma)
*
Hepatocellular uptake (e.g. rifampcin)
*
conjugation (e.g. Gilbert S, Crig. Nagar S)
Conjugated
* Dubin-Junson sundrome
Hyperbilirubinemia
* Roter syndrom
Acute or subacute
Viral hepatitis, alcohol, drugs, ischemic hepatiti
hepatocellular injury Wilsons disease, acute fatty liver of pregnancy
Chronic hepatocellu Viral hepatitis, alcoholic, autoimmune hepatitis
disease.
Haemochromatosis, Wilson dis., NASH, alpha
1 antitrypsin deficiency.
Hepatic disorders
with prominent
cholestasis.
Obstruction of
The bile duct
Benign
Malignant
Physical Examination:
Serum Enzymes:
Enzymes raised in hepatocellular injury:
Aminotransferases include ALT (located in cytosol) &
AST (located in mitochondria & cytosol).
ALT is found mainly in liver while AST is also found in
other tissues such as skeletal & cardiac muscle.
ALT is more specific than AST in detecting liver dise.
AST & ALT are released following hepatocyte necrosis.
A marked raise in transaminases > 1000 U/L, is seen in
AVH, ischaemic hepatitis & drug-induced liver disease.
In alcoholic liver disease, the enzyme levels are rarely
> 200-300 U/L, with AST:ALT ratio >2:1.
Proteins:
Albumen:
Other tests:
-Serological/replicative markers for specific
diagnosis of acute or chronic viral hepatitis.
-Antimitochondrial antibody (AMA) for PBC;
antinuclear factor (ANA), anti-smooth muscle
antibody (ASMA) & anti-liver kidney microsome
(LKM) antibody seen in autoimmune hepatitis;
alpha-fetoprotien, which is raised in HCC & s.
caeruloplasmin for Wilson disease.
Imaging Procedures:
Radiological imaging is important for the
diagnosis of a focal liver mass or biliary
disease. However, imaging plays little role in
the evaluation of diffuse hepatocellular e.g.
hepatitis
Ultrasonography (US):
It is a valuable but operator-dependent
investigation.
It has sensitivity of 55-91% & specificity of
82-95% for biliary obstruction.
Although US may not detect stones in the
extrahepatic bile duct, which may be
obscured by overlying gas, it reliably
establishes the presence of a dilated bile
ducts
Ultrasonography (US):
Cont
Endoscopic retrograde
cholangiopancreaticography
(ERCP):
ERCP not only permits direct visualization of the
biliary tree but also allows therapeutic
intervention e.g. removal of CBD stones or
biliary stenting. It is the gold standard test for
the evaluation of extrahepatic biliary disease
causing jaundice.
Percutaneous transhepatic
cholangiography: PTC
IN PTC, direct contrast visualization of the
biliary tree is obtained via a percutaneous
needle puncture of the liver. It is useful if
there is high biliary obstruction e.g. a tumour
at the bifurcation of the hepatic ducts.
It also permits therapeutic intervention such as
stent insertion to bypass a ductal malignancy.
Magnetic resonance
cholaniopancreaticography:
MRCP
MRCP is superior to US & CT in detecting
biliary obstruction. It has a sensitivity of 82100% & a specificity of 92-98% to detect
biliary obstruction.
Liver Biopsy:
It has relatively low risk, it is needed in only
a minority of cases with hepatic
dysfunction.
Major indications include chronic hepatitis,
cirrhosis, unexplained liver enzyme
abnormalities, hepatosplenomegaly of
unknown aetiology, suspected infiltrative
disorder, suspected granulomatous
disease.
Liver Biopsy:
Cont