How to evaluate apatient with jaundice

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How to evaluate apatient with jaundice

• By
• Dr. Ali Abdul Hussein Handoz
• M.B.Ch.B F.I.C.M.S

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Jaundice

• Definition
• Yellowish discoloration of skin and mucous
  membranes due to staining with bilirubin. 
• Normal bilirubin 0.3 1.3 mg/dl.
• Conjugated (direct) 0.1 0.3 mg/dl.
• unconjugated (indirect) 0.2 0.7 mg/dl .
• jaundice detected clinically at level of gt 3
  mg/dl.

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Physiology of bilirubin

• -Break down of old RBCs in the RET releases HB
  .
• -In liver UB converted to conjugated (H2o
  soluble), this is mediated by bilirubin UDP
  glucuronyl transferase
• -Conjugated bilirubin passes via biliary tree to
  duodenum
• -In small bowel
• conjugated bilirubin is deconjugated by
  bacterial glucuronidase
• unconjugated bilirubin is reduced to
  urobilinogen

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• Most of urobilinogen is excreted in faeces as
  stercobilinogen. Some is reabsorbed and partly
  excreted by liver (enterohepatic circulation) and
  rest is excreted by kidneys .

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Causes of jaundice (Hyperbilirubinaemia)

• Hyperbilirubinaemia result from
• Over production of bilirubin (haemolysis)
  PREHEPATIC.
• Impaired uptake, conjugation or excretion of
  bilirubin HEPATIC.
• Regurgitation of unconjugated or conjugated
  bilirubin from damaged hepatocytes or bile ducts
  POSTHEPATIC.

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• Causes of unconjugated hyperbilirubinaemia
• Either overproduction (haemolysis)
• Or impairment of uptake
• Or impairment of conjugation
•  
• Causes of conjugated hyperbilirubinaemia
• Either decreased excretion into bile ductules
• Or backward leakage of the pigment
  (bilirubin)

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Hepatocellular conditions that may produce
jaundice

• -viral hepatitis
• hepatitis A,B,C,D and E
• EBV
• CMV
• Herpes simplex
• -Drug toxicity
• Predictable, dose-dependent, e.g., acetaminophen
• Unpredictable, idosyncratic, e.g., isoniazid
• -alcohol
• -Environmental toxins
• vinyl chloride
• Wild mushrooms amanita phalloides or verna
• -Wilsons disease
• -autoimmune hepatitis
•  

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Cholestatic conditions that may produce jaundice

• 1-INTRAHEPATIC
• -viral hepatitis
• fibrosing cholestatic hepatitis B and C
• hepatitis
• EBV
• -Drug toxicity
• pure cholestasis anabolic and contraceptive
  steroids
• -alcoholic hepatitis
• -vanishing bile duct syndrome
• chronic rejection of liver transplants
• sarcoidosis
• drugs
• -inherited
• benign recurrent cholestasis
• -total parenteral nutrition
• -benign postoperative cholestasis

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• 2 EXTRAHEPATIC
• A- Malignant
• -cholangio ca.
• -pancreatic ca.
• -gall bladder ca.
• -ampullary ca.
• -malignant involvement of the porta hepatis
  lymph nodes
• B- Benign
• -CBD stone (choledocholithiasis) the most
  common
• -1ry sclerosing cholangitis
• -chronic pancreatitis
• -AIDS cholangiopathy
• -Hydatid cyst

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Evaluation

• HISTORY TAKING
• HPI
• -duration of the jaundice
• -onset
• sudden CBD stone, viral hepatitis
• gradual cirrhosis, pancreatic Ca.
• -pattern
• -pain
• painful CBD stone, pancreatic disease
• painless malignancy, viral hepatitis
  (although there is dragging subcostal pain)
• -history of
• blood transfusion
• anorexia
• wt. loss malignancy
• abdominal pain (RUQ)
• fever

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• Past Hx
• Biliary surgery (stricture, residual stone)
• Social Hx
• alcohol
• Family Hx
• SCD G6PD
• spherocytosis
• Drug Hx
• hx of any hepatotoxic drug

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Physical Examination

• General appearance
• Cachexia (muscle wasting gt in malignant
  disease)
• General examination
• stigmata of chronic liver disease.
• Abdominal examination
• heptomegaly
• spleenomegaly
• RUQ tenderness
• Murphys (ve)

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INVESTIGATION

• 1- BLOOD
• serum bilirubin
• conjugated or unconjugated 
• liver enzymes
• ALT
• AST
• ALP
• CBC
• Hb in hemolytic jaundice
• Reticulocytes
• Leucopenia viral hepatitis esp. HBV
  aplastic anemia
• Lymphocytes
• coagulation profiles
• serum antigens (hepatitis profile)
• -HBs Ag, HBe Ag ,..

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• LDH (lactate dehydrogenase)
• found in muscles and RBCs. 
• Albumin.
• immunological tests
• autoantibodies,
•  

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• 2- URINE
• urobilinogen
• in hemolytic jaundice
• or absent in obstructive jaundice (no more bile)
• conjugated bilirubin
• in obstructive (cholestatic) or
  hepatocellular jaundice 
• Hb urea intravascular hemolysis

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• 3- STOOL
• Pale stool in obstructive jaundice
• stercobilinogen
• in hemolytic jaundice
• or absent in obstructive jaundice (pale
  stool) 
• occult blood
• carcinoma of GI (metastasis to liver)
• esophageal varices (2ry to liver cirrhosis)

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• 4- RADIOLOGICAL INVESTIGATION
• US
• Gall stones
• Intrahepatic or extrahepatic biliary
  dilation (due to obstruction by stone, stricture,
  or tumor)
• CT
• assessing the head of pancreas (if there is
  Ca.)
• identify stones in the distal CBD 
• ERCP 
• PTC

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• THANK YOU