Approach to a Case of Jaundice

Definition
 Yellowish discoloration of sclera, mucosa
& skin due to hyperbilirubinemia

 Usually Serum bilirubin > 2-3 mg/dL

Jaundice/ Carotenederma / Mepacrine

Jaundice/ Mepacrine/ carotenederma

Sites to look for Jaundice

 Sclera  Under surface of tongue  Skin

Metabolism of Bilirubin
Haem Senescent RBCs Ineffective Erythropoesis Myoglobin Cytochrome oxidase

Bilirubin metabolism
RBC Breakdown Unconjugated bilirubin Hepatic uptake Conjugation Hepatocellular excretion Intrahepatic biliary canaliculi Extrahepatic biliary pathway
Water soluble Present in urine Water insoluble Alb bound, not in urine

Inside hepatocyte

Causes of Jaundice
Congenital 1. Pre Hepatic
Gilberts, Criggler Najar I & II

Acquired
Hemolysis, Vit B12 & FA def Virus, drugs, alcohol Drugs, gall stones, carcinoma

2. Hepato Dubin Johnson, cellular 3. Obstructi ve

Rotors synd

Obstructive Jaundice: Gall stones

Aim of the lecture

 Differentiate
Unconjugated vs Conjugated hyperbilirubinemia Medical vs Surgical jaundice

Unconjugated hyperbilirubinemia
RBC Breakdown Unconjugated bilirubin Hepatic uptake Conjugation Hepatocellular excretion Intrahepatic biliary canaliculi Extrahepatic biliary pathway Sepsis Hemolysis Ineffective erythropoesis

Causes

Gilberts syndrome Criggler Najjar syndrome (I, II) Sepsis

Clinical features
Hemolysis lemon tinge sclera, pallor, splenomegaly Normal colored urine (cola colored in cases of Intra Venous hemolysis) Acholuric jaundice Gilberts syndrome: mild jaundice o with fasting Criggler Najjar syn (I): Kernicterus

Conjugated hyperbilirubinemia
RBC Breakdown Unconjugated bilirubin Hepatic uptake Conjugation Hepatocellular excretion DJ/Rotor syndrome Hepatocellular damage
Hepatotrophic virus Alcohol Drugs/toxins Autoimmune

INTRAHEPATIC
Intrahepatic biliary canaliculi Extrahepatic biliary pathway

Primary biliary cirrhosis Perihepatocyte edema Primary sclerosing cholangitis Surgical obstructive jaundice
Stones, strictures, malignancy

Causes

Clinical features
Hepatocellular damage Acute: bleeding manifestation, encephalopathy Chronic: edema, parotid enlargement*, gynecomastia*, testicular atrophy, spider angioma* Portal htn: varices, splenomegaly (hypersplenism), encephalopathy, ascites Underlying diseases: Viral-prodrome, cholangitis

* Features s/o alcoholism

Clinical features
Cholestasis: itching, high colored urine, clay colored stools, fat/fat sol vitamins malabsorption Courvoisier's law Cholangitis: Fever with chills, jaundice, rt upper abdominal pain

Obstructive Jaundice

STOOL

URINE

Lab Investigations
 LFT
 Serum bilirubin > 2- 3 mg/dl ( < 6mg% in hemolytic anaemia)  Van den Bergs reaction
 Direct: Conjugated > 15 %  In direct: UnConjugated: > 85 %
 Enzymes

ALT & AST raised in Hepatocellular  Alk phosphatase & GGT in obstructive jaundice


 Prothrombin time: raised in hepatocellular jaundice  Serum proteins:

Albumin < globulin in Chronic liver disease

Urine Bilirubin

Present

Absent

Conjugated

Unconjugated

Urine Urobilinogen

Increased

Absent

Hemolysis

Cholestasis

Laboratory features of hemolysis

 Increased reticulocyte count (N in ineffective erythropoeisis)  Increased LDH  Increased urinary urobilinogen  IV hemolysis:
PBS: schistocytes Hemoglobinemia/hemoglobinuria Hemosiderinuria (Chronic) Decrease haptoglobin

Surgical jaundice
 Ultrasound abdomen
 CBD/intrahepatic biliary radicals dilatation  CBD stones  Malignancy

 ERCP/MRCP
 Distal blocks: distal to cystic duct  Level, nature & extent of obstruction

 Percutaneous transhepatic cholangiography

 Proximal blocks: proximal to cystic duct

 CECT/MRI abdomen

Obstructive Jaundice
Liver ultrasound showing (a) dilated intrahepatic bile ducts (arrow)

Common bile duct (arrow). The normal bile duct measures 6 mm at the porta hepatis.

Obstructive Jaundice:

Oral Cholecystography