This document defines and describes jaundice, including its causes and classifications. Jaundice is yellowish pigmentation of the skin and eyes due to high bilirubin levels in the blood. It is clinically detected at bilirubin levels over 2-2.5 mg/dl. Jaundice can be predominantly unconjugated or conjugated based on the underlying cause and liver dysfunction. Causes, signs, and investigations are provided for different types of jaundice including hemolytic, hepatocellular, and obstructive.
This document defines and describes jaundice, including its causes and classifications. Jaundice is yellowish pigmentation of the skin and eyes due to high bilirubin levels in the blood. It is clinically detected at bilirubin levels over 2-2.5 mg/dl. Jaundice can be predominantly unconjugated or conjugated based on the underlying cause and liver dysfunction. Causes, signs, and investigations are provided for different types of jaundice including hemolytic, hepatocellular, and obstructive.
This document defines and describes jaundice, including its causes and classifications. Jaundice is yellowish pigmentation of the skin and eyes due to high bilirubin levels in the blood. It is clinically detected at bilirubin levels over 2-2.5 mg/dl. Jaundice can be predominantly unconjugated or conjugated based on the underlying cause and liver dysfunction. Causes, signs, and investigations are provided for different types of jaundice including hemolytic, hepatocellular, and obstructive.
This document defines and describes jaundice, including its causes and classifications. Jaundice is yellowish pigmentation of the skin and eyes due to high bilirubin levels in the blood. It is clinically detected at bilirubin levels over 2-2.5 mg/dl. Jaundice can be predominantly unconjugated or conjugated based on the underlying cause and liver dysfunction. Causes, signs, and investigations are provided for different types of jaundice including hemolytic, hepatocellular, and obstructive.
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JAUNDICE
Definition- Jaundice (icterus) is defined as yellowish pigmentation of skin, mucus membranes and sclera due to increased levels of bilirubin in the blood. The scleral involvement is because of its rich elastic tissue that has special affinity for bilirubin. Normal serum bilirubin level is – 0.3 to 1.2 mg/dl. Jaundice is clinically detected when the serum bilirubin level is above 2.0 to 2.5 .mg/dl . Classification of Jaundice
Based on the underlying cause
Predominantly unconjugated hyperbilirubinemia
Predominantly conjugated hyperbilirubinemia Predominantly unconjugated hyperbilirubinemia 1) Increased 2) Reduced Hepatic 3) Impaired bilirubin production of bilirubin Uptake conjugation
•Hemolytic anemias • Drug that interference •Physiologic jaundice of
with membrane carrier the newborn • Resorption internal system hemorrhage (e.g. GI • Crigler-Najjar syndrome bleeding, hematomas) • Diffuse liver disease types I and II (hepatitis, cirrhosis) • Ineffective erythropoisis •Gilbert syndrome • Some cases of Gilbert syndrome •Diffuse liver disease (hepatitis cirrhosis) Predominantly conjugated hyperbilirubinemia 1) Decreased hepatocellular 2) Impaired intra/extrahepatic bile excretion flow
• Liver damage or toxicity (e.g. hepatitis) • Inflammatory destruction of bile ducts
(e.g. primary biliary cirrhosis) • Deficiency of membrane transporters Dubin-Johnson syndrome, Rotor syndrome • Gall Stones
or their precursors causes increased production of bilirubin.
Unconjugated bilirubin accumulates in
the plasma and results in jaundice.
Jaundice is usually mild because normal
liver cas easily handle the increased Conjunctiva showing mild jaundice in bilirubin production. hemolytic anemia Causes:-
Intracorpuscu Extracorposc lar defects ular defects • Autoimmune, alloimmune • Hereditary: Spherocytosis, hemolytic anemias Sickle cell disease, • Fragmentation syndromes: Thalassemia, G6PD deficiency Prosthetic valves • Drugs e.g. Sulfasalazine, • Acquired: Vitamin B12 and dapsone folate deficiency • Infections of RBCs, Malaria Clinical features
2) Mild jaundice 1) Pallor due without any signs to anemia of liver disease
3) Dark Stools 4) Urine turns
due to increased dark yellow Pallor due to anemia
sterecobilinogen on standing
5) Investigations
1 • Peripheral smear – shows features of hemolysis
2 • Urinary urobilinogen is increased (more than 4mg/24 hours)
Hemolysis
3 • No bilirubin in urine because unconjugated bilirubin is water insoluble
4 • Predominantly unconjugated hyperbilirubinemia. Serum bilirubin is raised (<6mg%)
Hepatocellular Jaundice It occurs as a consequence of parenchymal liver disease. This leads to inability of the liver to transport bilirubin across the hepatocyte into the bile. Defect in transport may occur at any point between:- - Uptake of unconjugated bilirubin into the hepatocyte - Transport of conjugated bilirubin into the Deep jaundice in viral hepatitis biliary canaliculi Both unconjugated and conjugated bilirubin level rise in the blood. Clinical Features:-
Yellowing of Conjunctiva of Clinical Dark urine eyes Features or pale stool
1 • Raised transaminases (AST and ALT) •Acute Jaundice with AST>1000 U/L is highly suggestive of an infectious cause (e.g. hepatitis A,B), drugs (e.g. paracetamol) or hepatic ischemia
obstruction to the outflow of bile is called obstructive jaundice.
Since these cases are to be
managed by surgical interventions, it is also called surgical jaundice. Continued… Cholestasis can be intrahepatic of extrahepatic. Consequences of cholestasis: - Retention of bile acids and bilirubin in the liver and blood - Deficiency of bile acids in the intestine Aetiology
3) Causes from 1) Causes in 2) Causes in outside (due to the lumen the wall pressure) • Stones in the common • Carcinoma head bile duct • Periampullary • Ova, cysts, ascaris of pancreas carcinoma • Chronic worms • Hydatid cyst of the • Choledochal cyst • Bile duct stricture pancreatitis biliary tree • Lymph nodes at • Stones in the • Klatskin’s tumour pancreatic duct the porta hepatitis Continued… Courvoisier’s law
In a jaundiced patient, if the gall bladder is
palpably enlarged, it is not due to stones. In case of stones, previous inflammation would have made gall bladder fibrotic and hence, will not be palpable.
90% of cases of obstructive jaundice are due
to stones, periampullary carcinoma or carcinoma of the head of pancreas. Exceptions to Courvoisier
Double impaction: One Stone in the CBD and one stone in
the cystic duct.
Periampullary carcinoma in a patient who has undergone
cholecystectomy.
Primary oriental cholangiohepatitis causing stones in the
CBD (gall bladder is normal in these cases.) Reynold’s Pentad of acute obstructive cholangitis 1) Persistent Pain
2) Fever
3) Persistent jaundice
4) Shock
5) Altered mental status
Clinical Features
Symptoms Signs • Jaundice • Deep jaundice with a greenish hue • Pruritus • Scratch marks • Pale, clay colored stool • Xanthelasmas on eyelids and • Dark urine (increased conjugated xanthomas over tendons bilirubin) Depending on the cause Depending on the cause • Fever with chills and rigors • Palpable gallbladder observd in (cholangitis) carcinoma head of pancreas • Weight loss (malabsorption) • Large hard irregular liver (malignancy) • Bleeding tendency (Vit K deficiency) • Late features: Secondary biliary • Abdominal pain (gall stones) cirrhosis and signs of liver cell failure Investigations
1) Hb% is low in malignancy.
2) TC, DC are increased in cases of infections.
3) BT, CT, PT are altered in cases of obstructive jaundice.
4) Urine for urobilnogen is negative in obstructive jaundice.
5) Serum alkaline phosphatase: Normal Value is 60-300 units/L. More
than 500 units is suggestive of obstructive jaundice. Continued…
6) Abdominal ultrasound: It is most useful,
noninvasive, reliable and quick investigation for obstructive jaundice. - Dilated biliary radicals, both intrahepatic and extrahepatic can be demonstrated. - Stones can be diagnosed with their posterior acoustic shadow. Continued…
7) CT scan: A head mass of even 2-3
cm in size and portal vein infilteration can be demonstrated CT Scan by CT scan.
8) Endoscopy: useful to diagnose
periampullary carcinoma.
Endoscopy showing growth
in the periampullary region. Continued…
9) ERCP (Endoscopic Retrograde
Cholangio-pancreato-graphy) - Stones appear as filling defects in the CBD or in the common hepatic duct (CHD) - Chronic pancreatitis may show the dilated duct and stones in the pancreatic duct- ERCP showing stones in the CBD 'chain of lakes' appearance. Continued…
10) MRI scan (MRCP)
- It is noninvasive and delineates the bile ducts very well so that a biliary bypass can also be planned.
MRC (magnetic resonance
cholangiogram) showing high stricture Treatment of Obstructive Jaundice
Preoperational prepration:- 1) Correction of fluid and electrolyte status and adequate hydration before surgery for 2-3 days 2) Injection dopamine 2 μg/kg/min can be given to improve the urinary output. 3) Injection vitamin K, 10 mg, subcutaneously or intravenously for 3 days is given to correct the prothrombin time. 4) Broad spectrum antibiotics are given before, during and after surgery 5) Adequate blood transfusion to correct anaemia. Investigation and treatment of Obstructive Jaundice Treatment of CBD stones
Cholecystectomy is done first. This is followed by
introduction of a cannula into the cystic duct and a radio- opaque dye is injected
This is called OTC (On Table Cholangiography)
Clinical features useful in differentiating different types of jaundice Feature Hemolytic Hepatocellular Obstructive
