JAUNDICE

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JAUNDICE

• By Anfal Gadour

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Objectives

• Definition of Jaundice
• Bilirubin Metabolism
• Investigations
• Categories
• Common causes and management

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What do you already know?

• How would you define jaundice?
• What is the difference between conjugated and
  unconjugated bilirubin?
• How would you class the different causes of
  jaundice?
• What would you ask about in the history?
• What would you look for on examination?
• What is corvorsiers law?
• What are the most important investigations?

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Jaundice (icterus)

• Definition Yellow discoloration of the skin and
  mucous membranes
• Due to increased Bilirubin concentration in the
  body
• Detectable when plasma levels are greater than 50
  micromol/l (normal 3-17)

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Bilirubin Metabolism

• Haemoglobin

GLOBIN
FE 2
LIVER
BILE
SI
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Investigations

• LFTS Bilirubin, ALP, AST, ALT, GGT
• USS abdo GB, Cystic Duct, mass
• ERCP/MRCP Stone, Biliary system

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Categories

• Prehepatic
• Hepatic
• Posthepatic

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Prehepatic

• Due to Haemolysis causing increased bilirubin
  production
• Decreased uptake by liver
• Decreased conjugation
• ? unconjugated bilirubin builds up in blood
• Water insoluble therefore doesnt enter urine
• Causes Physiological (neonates), haemolysis,
  Gilberts syndrome

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Hepatic/Hepatocellular

• Hepatocyte Damage
• Causes hepatitis, alcoholic hepatitis, liver
  cirrhosis, liver metastases, rarer
  haemochromatosis, AIH

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Posthepatic

• Obstructive jaundice
• Common bile duct is blocked
• Bilirubin overspills into blood build up of
  conjugated bilirubin
• Water soluble excreted in urine dark
• Less conjugated bilirubin can reach the bowel
  pale stools
• If severe pruritus
• Causes common bile duct stones, pancreatic cancer

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Gallstones

• Present in 10-20 of population
• Cholesterol and mixed
• Usually asymptomatic
• Risk factors 4Fs
• Complications..

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Biliary colic

• Pain associated with temporary obstruction of
  cystic or CBD by a stone
• Severe constant pain, subsides over several hours
• Pain radiates to right shoulder. Vomiting
• Examination normal
• Diagnosis hx, raised ALP and bilirubin. ABSENCE
  OF INFLAMMATORY FEATURES.
• Manage analgesia, elective cholecystectomy

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Acute Cholecystitis

• Stone in cystic duct or GB neck
• Hx similar to biliary colic.
• However, progresses to constant severe pain in
  RUQ
• Fever, tenderness and guarding
• Murphys sign
• INFLAMMATORY FEATURES rasied WCC, fever,
  deranged LFTS, USS
• Manage conservatively NBM, IV fluids, Analgesia,
  IV abx
• Cholecystectomy

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Ascending Cholangitis

• Infection on biliary tree
• Charcots triad RUQ pain, Fever, Jaundice
• Dark urine, pale stools, pruritus
• Inv raised WCC, Blood cultures, Deranged LFTS,
  USS, CT, ERCP
• Manage Fluid resus, Analgesia, IV abx, ERCP

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Pancreatic cancer

• Painless Jaundice
• Older
• Pale stools, dark urine
• Weight loss
• Palpable GB?
• Usually head of the pancreas
• Diagnosed on CT
• Poor prognosis

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• Any Questions?