Jaundice

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Jaundice

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

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Overview

• Normal Physiology
• Pathophysiology
• Broad Differential Diagnosis
• DDx of Obstructive Jaundice
• Work-up for Medical Jaundice
• Work-up if Obstructive Jaundice
• Treatment of Obstructive Jaundice

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Normal Physiology

• Bilirubin is from breakdown of hemoglobin
• Unconjugated bilirubin transported to liver
• Bound to albumin because insoluble in water
• Transported into hepatocyte conjugated
• With glucuronic acid ? now water soluble
• Secreted into bile
• In ileum colon, converted to urobilinogen
• 10-20 reabsorbed into portal circulation and
  re-excreted into bile or into urine by kidneys

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Pathophysiology

• Jaundice bilirubin staining of tissue _at_ lvl
  greater than 2
• Mechanisms
• ? production of bilirubin
• ? hepatocyte transport or conjugation
• Impaired excretion of bilirubin
• Impaired delivery of bilirubin into intestine
• surgically relevant jaundice or obstructive
  jaundice
• Cholestasis refers to the latter two, impaired
  excretion and obstructive jaundice

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Broad Differential Diagnosis
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DDx Unconjugated bilirubinemia

• ?production
• Extravascular hemolysis
• Extravasation of blood into tissues
• Intravascular hemolysis
• Errors in production of red blood cells
• Impaired hepatic bilirubin uptake(trnsport)
• CHF
• Portosystemic shunts
• Drug inhibition rifampin, probenecid

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DDx Unconjugated bilirubinemia

• Impaired bilirubin conjugation
• Gilberts disease
• Crigler-Najarr syndrome
• Neonatal jaundice (this is physiologic)
• Hyperthyroidism
• Estrogens
• Liver diseases
• chronic hepatitis, cirrhosis, Wilsons disease

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DDx Conjugated Bilirubinemia

• Intrahepatic cholestasis/impaired excretion
• Hepatitis (viral, alcoholic, and non-alcoholic)
• Any cause of hepatocellular injury
• Primary biliary cirrhosis or end-stage liver dz
• Sepsis and hypoperfusion states
• TPN
• Pregnancy
• Infiltrative dz TB, amyloid, sarcoid, lymphoma
• Drugs/toxins i.e. chlorpromazine, arsenic
• Post-op patient or post-organ transplantation
• Hepatic crisis in sickle cell disease

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DDx Obstructive Jaundice

• This is the slide to remember for surgeons
• Obstructive Jaundice extrahepatic cholestasis
• Choledocholithiasis (CBD or CHD stone)
• Cancer (peri-ampullary or cholangioCA)
• Strictures after invasive procedures
• Acute and chronic pancreatitis
• Primary sclerosing cholangitis (PSC)
• Parasitic infections
• Ascaris lumbricoides, liver flukes
• Just remember top 5 (not parasites)

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Initial Evaluation History

• Jaundice, acholic stools, tea-colored urine
• Fever/chills, RUQ pain (cholangitis)
• Could lead to life-threatening septic shock
• Reasons to have hepatitis or cirrhosis?
• Alcohol, Viral, risk factors for viral hepatitis
• Exposure to toxins or offending drugs
• Inherited disorders or hemolytic conditions
• Recent blood transfusions or blood loss?
• Is patient septic or on TPN?
• Recent gallbladder surgery? (CBD injury)

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Initial Evaluation Physical Exam

• Signs of end stage liver disease (cirrhosis)
• Ascites, splenomegaly, spider angiomata, and
  gynecomastia
• Jaundice evident first underneath the tongue,
  also evident in sclerae or skin
• Courvoisiers sign painless, but palpable or
  distended gallbladder on exam
• Could indicate malignant obstruction

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Screening Labs

• NL LFT r/o hepatic injury or biliary tract dz
• Consider inherited disorders or hemolysis
• ?Alk Phos moreso than AST/ALT implies
  cholestasis (intrahepatic vs obstruction)
• ?Alk Phos also seen in sarcoid, TB, bone
• In this case, GGT is specific for biliary origin
• Predominant ?AST/ALT implies intrinsic
  hepatocellular disease
• AST/ALT ratio gt 2 in alcoholic hepatitis
• ?albumin or ?INR c/w advanced liver dz

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Subsequent Labs

• If no concern for obstructive jaundice
• Viral (Hep BC) serologies for viral hepatitis
• anti-mitochondrial Ab (PBC)
• anti-smooth muscle Ab (Auto-immune)
• iron studies (hemochromatosis)
• ceruloplasmin (Wilsons)
• Alpha-1 anti-trypsin activity (for deficiency)

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Imaging for Obstructive Jaundice

• RUQ Ultrasound
• See stones, CBD diameter
• CT scan
• Identify both type level of obstruction
• ERCP
• Direct visualization of biliary tree/panc ducts
• Procedure of choice for choledocholithiasis
• Diagnostic AND- therapeutic (unlike MRCP)
• PTC useul of obstruction is prox to CHD
• Endoscopic Ultrasound or EUS

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Treatment

• If Medical, then treat the etiology
• If Obstructive Jaundice
• Should r/o ascending cholangitis, ABC/resusc
• For cholangitis IVF, IV Antibiotics,
  Decompression
• Stones (remove stones vs stent vs drainage)
• Done via ERCP or PTC or open (surgery)
• Benign stricture (stent vs drainage catheter)
• Cancer (Stent vs drainage /- resect the CA)
• The key principle is decompression, either
  externally(drainage) or internally(stenting) the
  duct open to allow better drainage

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Take Home Points

• Above is a comprehensive approach
• For surgery clerkship, all you need to know is
• 1. Broad categories (no specific diagnoses)
• 2. The four DDx of obstructive jaundice
• 3. HP (ask about fevers/chills, jaundice,
  acholic stools, dark urine, weight loss for CA),
  r/o ascending cholangitis emergency
• 4. Labs (LFT ?cholestatic, CBC w diff, BMP)
• 5. Imaging (U/S, CT, MRCP, EUS)
• 6. Therapy (ERCP vs PTC vs surgery)