Jaundice

Jaundice

1. APPROACH TO JAUNDICE

2. JAUNDICE Yellowish discoloration of skin, sclera and mucous membrane resulting from deposition of bilirubin . It is a sign of liver disease or less often a hemolytic disorder or disorder of bilirubin metabolism

3. SEQUENTIAL SITES OF JAUNDICE 1 st STAGE Frenulum of tongue(>1.5mgdl) 2nd STAGE Sclera of eye (>2.5mgdl) 3 rd stage Skin(>3.5 mg/dl)

4. Differential diagnosis of Yellowing of skin Carotenoderma -yellow color imparted to the skin because of carotenes prsent in Carrots, green leafy vegetable, squash, peaches and oranges. Palms, soles, forehead and nasolabial folds. Spares the sclera (differentiated from jaundice) Quinacrine an ANTIMALARIAL DRUG - 4-37% yellowish discoloration of skin, also sclera.

5. METABOLISM OF BILIRUBIN 1 . Production of bilirubin 2. Excretion of bilirubin

6. Production of bilirubin Tetrapyrrole pigment Break down product of Heme 80-85%- Breadown of Old RBCS Rest- Premature destruction of erythroid cells in the bone marrow and from turnover of hemoproteins myoglobin and cytochromes . Formation- RE Cells in liver and spleen

7. MEASUREMENT OF SERUM BILIRUBIN BASED ON VAN DE BERG REACTION

8. MEASUREMENT OF URINE BILIRUBIN Unconjuated bilirubin always bound to albumin - not found in urine Conjugated bilirubin filtered by the glomerulus and majority is reabsorbed by the prox tubules. Urine dipstick test- ICTOTEST False negative in prolonged cholestasis due to conjugated BR bound to albumin.

9. HOW TO APPROACH

10. DIFFERENTIAL DIAGNOSIS OF JAUNDICE Inherited disorders of bilirubin metabolism a---- Unconjugated hyperbilirubinemia b----Conjugated hyperbilirubinemia 2.Liver Diseases a---- Hepatocellular dysfunction b----Hepatic disorders with prominent cholestasis 3.Bile duct disorders a---- Choledocholithiasis b----Bile dut diseases

11. ISOLATED DISORDER OF BILIRUBIN METABOLISM

12. A- Unconjugated hyperbilirubinemia Increased bilirubin production- Due to hemolysis and ineffective erythropoeisis Decreased hepatocellular uptake -Drugs like Rifampicin Decreased conjugation- Gilberts syndrome , Criggler – Najjar syndrome

13. B. Conjugated or mixed hyperbilirubinemia Dubin johnson syndrome Rotors syndrome

14. LIVER DISEASE Hepatocellular dysfunction Acute or subacute hepatocellular injury seen in viral hepatitis , hepatotoxins ,, ischaemia Chronic hepatocellular disease autoimmune hepatitis, celiac disease, wilsons disease

15. B-Hepatic disorders with prominent cholestasis Infiltrative disease such as sarcoidosis , mycobacterial infections Cholangiocyte injury due to primary biliary Cirrhosis

16. BILE DUCT OBSTRUCTION A.Choledocholithiasis B.Bile duct diseases Inflammation - primary sclerosing cholangitis Pancreatitis Neoplasms - Pancreatic carcinoma Vascular enlargement -portal cavernoma

17. TAKE HOME MESSAGE Jaundice is a hallmark of liver disease Through clinical examination and history becomes vital in all cases Classified as pre hepatic, hepatocellular and cholestatis although overlaps do occur Biochemical and radiological evaluation helps in making a diagnosis. This is just a overview.

18. PATIENT A 42YEAR OLD FEMALE WITH HISTORY OF GENERAL WEAKNESS OF4 MONTHS . SHE WAS FOUND TO HAVE MODERATE ANEMIA , JAUNDICE AND MILDSPLENOMEGALY .

19. Ans . HEMOLYTIC JAUNDICE

20.  Patient B 30 YEAR OLD MALE WITH HISTORY OF FEVER OF 2 WEEKS , NAUSEA AND dark COLORED URINE . HE HAD PALPABLE , SOFT TENDER LIVER .

21. Ans. Hepatic Jaundice

22. PatientC   35YR OLD MALE WITH COMPLAINTS OF PAIN ABDOMEN , JAUNDICE , ITCHING AND PASSING CLAY COLORED STOOLS . • PREVIOUSLY HE WAS DIAGNOSED WITH GALL BLADDER STONES BUT HAS NOT TAKEN TREATMENT . • GALL BLADDER IS NOT PALPABLE .

23. Ans. OBSTRUCTIVE JAUNDICE