JAUNDICE

JAUNDICE - PREHEPATIC, HEPATIC AND POSTHEPATIC

1. DR NILESH KATE
MBBS,MD
ASSOCIATE PROF
DEPT. OF PHYSIOLOGY
JAUNDICE

2. OBJECTIVES.
Definition
Mechanism of production
Types
Characteristic features
Physiological Jaundice
Prevention
Treatment .
Thursday, November 3, 2016

3. DEFINITION
JAUNDICE is defined
as Yellowish
discoloration of skin,
sclera & mucous
membrane
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4. CAUSE
Increase bilirubin concentration
( Hyperbilirubinemia) in the body fluids.
Normal range of serum bilirubin – 2-3 mg/100ml.
Jaundice when plasma bilirubin > 2-3 gm/dl.
Thursday, November 3, 2016

5. EXCEPTION
All internal tissue & body fluids are yellow coloured
except BRAIN
d/t – BLOOD BRAIN BARRIER which not allow
bilirubin to pass except in neonatal period.
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6. KERNICTERUS
Deposition of excess
bilirubin to brain mainly
Basal Ganglia –
Kernicterus.
C/f – 3 phases
Decreased alertness,
Hypotonia, poor feeding,
Hypertonia, Opisthotonus
Hypotonia.
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7. BILIRUBIN & JAUNDICE
BILIRUBIN FORMATION.
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Tetra pyrrole straight chain with
Globin & Iron

8. BILIRUBIN & JAUNDICE
UPTAKE OF BILIRUBIN.
After degradation of Hb
bilirubin is released into
circulation. Its free of Un-
conjugated Bilirubin.
Its lipid soluble in plasma
& bound to albumin
This binding prevents its
excretion by the kidneys.
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9. CONJUGATION OF BILIRUBIN
This un-conjugated taken
up by liver, albumin
removed & enters hepatic
cells
Conjugate with UDP-
Glucoronic acid to form
conjugated bilirubin
Enzyme – UDP-
Glucoronyl transferase.
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10. EXCRETION OF BILIRUBIN
Conjugated Bilirubin
from liver is excreted
into Bile Canaliculi
against conc gradient.
Enters Intestine
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11. FORMATION & EXCRETION OF
UROBILINOGEN.
In intestine Conjugated bilirubin is degraded by
intestinal bacteria
β Glucoronidase convert Bilirubin to Urobilinogen
& Stercobilinogen.
20% of Urobilinogen reabsorbed into portal system
to liver & escape into general circulation & re-
excreted into bile
From General Circulation some filtered by kidney &
excreted in Urine.
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12. BILIRUBIN CIRCULATION IN
THE BODY
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13. MECHANISM OF PRODUCTION
Excessive breakdown
( Hemolysis) of RBC so
called Hemolytic Jaundice
or Prehepatic Jaundice.
Damage to liver cells –
Hepatic or Hepatocellular
Jaundice.
Obstruction to bile duct –
Post hepatic or Cholestatic
Jaundice.
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14. TYPES
Hemolytic Jaundice
( Pre-Hepatic)
Hepatocellular
Jaundice (Hepatic
Jaundice)
Cholestatic or
Obstructive
Jaundice.(Post-
Hepatic)
Thursday, November 3, 2016

15. HEMOLYTIC JAUNDICE ( PRE-
HEPATIC)
Mechanism of production
Types of serum bilirubin
accumulated.
Van den Bergh test
Urine bilirubin
Urine urobilinogen.
Faecal stercobilinogen.
Faecal fat level.
Specific blood tests
Thursday, November 3, 2016

16. MECHANISM OF PRODUCTION
Excessive Breakdown
of RBC –
Produces Un-
conjugated bilirubin
more than healthy
liver can conjugate &
excrete.
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17. TYPES OF SERUM BILIRUBIN
ACCUMULATED.
Unconjugated
Hyperbilirubinaemia.
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18. VAN DEN BERGH TEST
Reagent used – Diazo
reagent ( Mixture of
Sulphanilic acid,
Hydrochloric acid &
sodium Nitrite)
Test – 2 types
Direct
Indirect.
Thursday, November 3, 2016

19. VAN DEN BERGH TEST
Direct – when Diazo reagent added to serum
containing Conjugated Bilirubin Reddish Brown
colour developed in 30 sec.
Indirect - when Diazo reagent added to serum
containing Un-Conjugated Bilirubin No colour
developed but when some alcohol added which
dissolves Unconjugated Bilirubin – reddish Brown
colour is obtained.
Thursday, November 3, 2016

20. VAN DEN BERGH TEST
Indirect Positive
Reaction – Due to Un-
Conjugated Bilirubin.
Thursday, November 3, 2016

21. URINE BILIRUBIN
Unconjugated
Bilirubin is insoluble in
water & transported n
plasma with albumin.
Since albumin is not
Filtered it is not appear
in Urine.
Thursday, November 3, 2016

22. URINE UROBILINOGEN.
Liver excrete lots of conjugated bilirubin in
intestine in bile & more Urobilinogen is formed
So Urine Urobilinogen is increased.
Thursday, November 3, 2016

23. FAECAL STERCOBILINOGEN.
Normal 25-250 mg/day.
Same as more Urobilinogen & stercobilinogen
is formed
Faeces is Dark Brown in colour.
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24. FAECAL FAT LEVEL.
Normal
5-6% of total intake /day
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25. SPECIFIC BLOOD TESTS
Peripheral blood film – Haemolysis, Anaemia,
Reticylocytosis.
Normal Plasma Albumin: Globulin ratio.
Serum alkaline phosphatase Normal
Liver function tests – Normal ( As liver is normal)
Thursday, November 3, 2016

26. HEPATOCELLULAR JAUNDICE
(HEPATIC JAUNDICE)
Mechanism of production
Types of serum bilirubin
accumulated.
Van den Bergh test
Urine bilirubin
Urine urobilinogen.
Faecal stercobilinogen.
Faecal fat level.
Specific blood tests
Thursday, November 3, 2016

27. MECHANISM OF PRODUCTION
Inability of liver to conjugate & transport
bilirubin into bile duct due to Liver damage.
Thursday, November 3, 2016

28. TYPES OF SERUM BILIRUBIN
ACCUMULATED.
Both conjugated & Unconjugated bilirubin
increased.
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29. VAN DEN BERGH TEST
Biphasic Reaction as
both Conjugated & Un-
conjugated bilirubin
present.
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30. URINE BILIRUBIN
Present
As conjugated
bilirubin is water
soluble is dissolved,
filtered & appear in
urine
Also called Choluric
Jaundice.
Thursday, November 3, 2016

31. URINE UROBILINOGEN.
Decreases
As damaged liver cells are producing & excreting
less of conjugated Bilirubin & thus less
Urobilinogen.
Thursday, November 3, 2016

32. FAECAL STERCOBILINOGEN.
Less
As less formation of Stercobilinogen
So Faeces are Pale Coloured.
Thursday, November 3, 2016

33. FAECAL FAT LEVEL.
Increased up to 40-50%.
As less bile in intestine – less emulsification &
absorption of fat
So bulky, pale, greasy & foul smelling faeces-
steatorrhoea.
Thursday, November 3, 2016

34. SPECIFIC BLOOD TESTS
Peripheral blood film – Normal
Albumin decreased, so albumin: globulin ratio
Decreased
Serum alkaline phosphatase – Increased.
Liver function test – impaired.
Thursday, November 3, 2016

35. CHOLESTATIC OR OBSTRUCTIVE
JAUNDICE.(POST-HEPATIC)
Mechanism of production
Types of serum bilirubin
accumulated.
Van den Bergh test
Urine bilirubin
Urine urobilinogen.
Faecal stercobilinogen.
Faecal fat level.
Specific blood tests
Thursday, November 3, 2016

36. MECHANISM OF PRODUCTION
Obstruction to the
bile flow from
Hepatocytes to
duodenum.
Thursday, November 3, 2016

37. TYPES OF SERUM BILIRUBIN
ACCUMULATED.
Conjugated Hyperbilirubinaemia due to
impaired flow of bile.
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38. VAN DEN BERGH TEST
Direct Positive
reaction.
As only conjugated
bilirubin present.
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39. URINE BILIRUBIN
Present.
As conjugated
bilirubin filtered in
urine.
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40. URINE UROBILINOGEN.
Markedly decreased or absent.
As due to obstruction conjugated bilirubin is not
released in intestine
No Urobilinogen is formed.
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41. FAECAL STERCOBILINOGEN.
Absent – when obstruction is complete.
Stools are clay coloured.
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42. FAECAL FAT LEVEL.
Increased.
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43. SPECIFIC BLOOD TESTS
Peripheral blood film – normal.
Plasma albumin, globulin & ratio – Normal
Serum Alkaline phosphatase – markedly
increased.
Liver function tests - normal
Thursday, November 3, 2016

44. Thursday, November 3, 2016

45. PHYSIOLOGICAL JAUNDICE
NEONATAL JAUNDICE.
Mechanism of
production
Appears 2-5 days after
birth & disappears in 2
weeks.
Excessive destruction of
RBC & hepatic Immaturity
in first 7-10 days.
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46. SIGNS & SYMPTOMS
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47. Thursday, November 3, 2016

48. PREVENTION
By giving Hepatic Microsomal enzyme inducers
(Phenobarbital) to pregnant mother or
newborn-
Increases activity of Glucoronyl Transferase.
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49. TREATMENT .
PHOTOTHERAPY
Exposure of skin to
white light – PHOTO-
ISOMERIZATION of
Bilirubin to water
soluble Lumirubin
which is excreted in
Bile without
conjugation
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50. TREATMENT OF PATHOLOGICAL
JAUNDICE IN ADULT
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51. Thank
You