Jaundice

1. JAUNDICEJAUNDICE
By Dr. Osman BukhariBy Dr. Osman Bukhari

3. DefinitionDefinition
Yellow discoloration of the sclera, mucus Yellow discoloration of the sclera, mucus
membranes & skin from increased serum membranes & skin from increased serum
bilirubin concentration in the body fluids, bilirubin concentration in the body fluids,
detectable when serum level is above detectable when serum level is above
3mg/100ml3mg/100ml
Mechanism Mechanism
1-Increased production in haemolysis 1-Increased production in haemolysis
2-Imparied excretion 2-Imparied excretion
a) Congenital non-haemolytic hyper a) Congenital non-haemolytic hyper
bilirubinaemia bilirubinaemia

4. b) Hepatocellular jaundice : acute or chronic b) Hepatocellular jaundice : acute or chronic
parenchymal liver diseaseparenchymal liver disease
c) Cholestasis c) Cholestasis
Haemolytic jaundiceHaemolytic jaundice
1-Due to increased RBC destruction 1-Due to increased RBC destruction
2-Jaundice is mild & urine is dark.2-Jaundice is mild & urine is dark.
3-Anaemia 3-Anaemia
4-Spleenomegaly +_4-Spleenomegaly +_
5-Increased uncongugated bilirubin in the 5-Increased uncongugated bilirubin in the
bloodblood

5. 6-Increased urobilinogen in urine in the 6-Increased urobilinogen in urine in the
absence of bile pigmentsabsence of bile pigments
7-Reticulocytosis 7-Reticulocytosis
8-Decreased haptoglobin 8-Decreased haptoglobin
9-Peripheral blood macrocytosis , 9-Peripheral blood macrocytosis ,
polychromasia & red cells abnormality polychromasia & red cells abnormality
(spherocytosis & sickles )(spherocytosis & sickles )
10-Bone marrow erythrocytosis with 10-Bone marrow erythrocytosis with
megaloblastic changes from folate deficiencymegaloblastic changes from folate deficiency
11-Decreased RBC survival 11-Decreased RBC survival

6. . 12-Increased serum L.D.H. 12-Increased serum L.D.H
13-Normal L.F.T13-Normal L.F.T
Congenital non haemolytic hyper Congenital non haemolytic hyper
bilirubinaemiabilirubinaemia
Inherited disorders due to either defective Inherited disorders due to either defective
bilirubin uptake, conjugation or excretionbilirubin uptake, conjugation or excretion
1-Gilberts (unconjugated hyper bilirubinaemia)1-Gilberts (unconjugated hyper bilirubinaemia)
-Autosomal dominant-Autosomal dominant
-Deficient glucuronyl transferase & defective -Deficient glucuronyl transferase & defective
bilirubin uptake from plasma leading to bilirubin uptake from plasma leading to
Unconjugated hyper bilirubinaemia Unconjugated hyper bilirubinaemia

7. -Commonest variety affecting youngs-Commonest variety affecting youngs
-Mild jaundice which may follow recovery -Mild jaundice which may follow recovery
from viral hepatitis or precipitated by from viral hepatitis or precipitated by
infection, fatigue or fasting infection, fatigue or fasting
-May be asymptomatic or dyspeptic symptoms -May be asymptomatic or dyspeptic symptoms
-Normal life spam -Normal life spam
-No evidence of haemolysis -No evidence of haemolysis
-No treatment but occasionally Phenobarbitone -No treatment but occasionally Phenobarbitone

8. 2-2-Crigler – Najjar (unconjugated)Crigler – Najjar (unconjugated)
-Rare-Rare
-Type I is A.R in neonates with absent -Type I is A.R in neonates with absent
glucuronyl transferase with rapid death from glucuronyl transferase with rapid death from
kernictorus kernictorus
-Type 2 is A D in neonates with reduce -Type 2 is A D in neonates with reduce
glucuronyl transferase activity leading to glucuronyl transferase activity leading to
severe jaundice & patient can survive to adult severe jaundice & patient can survive to adult
life with Phenobarbitone, photothearapy & life with Phenobarbitone, photothearapy &
liver transplantationliver transplantation

9. 3-3-Dubin – Johnson (conjugated)Dubin – Johnson (conjugated)
-A.R -A.R
-Defective canalicular excretion of bilirubin-Defective canalicular excretion of bilirubin
-Any age-Any age
-Jaundice is mild-Jaundice is mild
-Liver histology shows black pigmentation-Liver histology shows black pigmentation
-Normal life span -Normal life span

10. 4-4-Rotors (conjugated)Rotors (conjugated)
-AD-AD
-Similar to Dubin – Johnson but no -Similar to Dubin – Johnson but no
pigmentation in Liver histologypigmentation in Liver histology

11. --Hepatocellular jaundiceHepatocellular jaundice
1-Impaired bilirubin transport to the bile at any 1-Impaired bilirubin transport to the bile at any
point between uptake of unconjugated point between uptake of unconjugated
bilirubin into hepatocytes & transport of bilirubin into hepatocytes & transport of
conjugated bilirubin into the canaliculaeconjugated bilirubin into the canaliculae
2-Cholestasis may occur from inflammatory 2-Cholestasis may occur from inflammatory
aedema aedema
3-Both conjugated & unconjugated hyper 3-Both conjugated & unconjugated hyper
bilirubinanemiabilirubinanemia
4-Jaundice is variable 4-Jaundice is variable

12. 5-Urine is dark5-Urine is dark
6-Increased Amino transferases6-Increased Amino transferases
Cholestatic jaundice (obstruction)Cholestatic jaundice (obstruction)
1-Intra hepatic1-Intra hepatic: due to failure of hepatocytes to : due to failure of hepatocytes to
generate bile flow or obstruction of bile flow generate bile flow or obstruction of bile flow
in the bile ducts within the liver e.g. PBC, in the bile ducts within the liver e.g. PBC,
Drugs, Viral hepatitis, pregnancy, primary Drugs, Viral hepatitis, pregnancy, primary
Sclerosing cholengitis, idiopathic Sclerosing cholengitis, idiopathic
2-Extra hepatic2-Extra hepatic: due obstruction of bile flow in : due obstruction of bile flow in
extra hepatic bile ducts extra hepatic bile ducts
-Choledocholithiasis -Choledocholithiasis

15. -Carcinoma (Ampullary, Pancreatic, -Carcinoma (Ampullary, Pancreatic,
Cholangio carcinoma & secondaries in the Cholangio carcinoma & secondaries in the
porta hepatisporta hepatis
-Benign tumours -Benign tumours
-Cystic fibrosis-Cystic fibrosis
-parasitic infections-parasitic infections
-Traumatic biliary stricture -Traumatic biliary stricture
-Choledocal cyst -Choledocal cyst
-Pancreatitis -Pancreatitis
3-Clinical features due to Cholestasis include: 3-Clinical features due to Cholestasis include:

16. -Early features: jaundice, dark urine, pale stool -Early features: jaundice, dark urine, pale stool
& pruritis& pruritis
-Late features: Xanthama & Xanthelasma, -Late features: Xanthama & Xanthelasma,
malabsorption (steatorhoea, weight loss, malabsorption (steatorhoea, weight loss,
bleeding tendency & Osteomalacia) bleeding tendency & Osteomalacia)
4-Clinical features due to cholangitis include 4-Clinical features due to cholangitis include
fever, Rigors, pain & hepatic abscess fever, Rigors, pain & hepatic abscess
5-Investigations:5-Investigations:
-High ALP, G.GT, & prolong P.T-High ALP, G.GT, & prolong P.T
-Mainly conjugated bilirubin-Mainly conjugated bilirubin

17. -U/S, ERCP, CT & P.T.C, Serology & liver -U/S, ERCP, CT & P.T.C, Serology & liver
biopsybiopsy
Underlying cause of Cholestatic jaundice Underlying cause of Cholestatic jaundice
related to clinical featuresrelated to clinical features
1-Static or progressive jaundice = Carcinoma 1-Static or progressive jaundice = Carcinoma
2-Fluccuating jaundice = stone, stricture, 2-Fluccuating jaundice = stone, stricture,
Pancreatitis or Choledocal cystPancreatitis or Choledocal cyst
3-Abdominal pain = stone, Pancreatitis or 3-Abdominal pain = stone, Pancreatitis or
Choledocal cystCholedocal cyst
4-Cholangitis = stone, stricture or choledocal 4-Cholangitis = stone, stricture or choledocal
cystcyst

18. 5-Abdominal scar = stone , stricture5-Abdominal scar = stone , stricture
6-Irregular hard Hepatomegly = hepatic 6-Irregular hard Hepatomegly = hepatic
carcinoma carcinoma
7-Palpable G.B =Carcinoma below cystic duct 7-Palpable G.B =Carcinoma below cystic duct
e.g. Ca head of pancreas e.g. Ca head of pancreas
8-Abdominal mass = Ca, Pancreatitis (cyst) or 8-Abdominal mass = Ca, Pancreatitis (cyst) or
Choledochal cystCholedochal cyst
9-Occult blood in stools = Ampullary tumour9-Occult blood in stools = Ampullary tumour

19. Work out a case of jaundiceWork out a case of jaundice
OrOr
Abnormal liver function testsAbnormal liver function tests
1-Young patient : likely to have viral hepatitis. 1-Young patient : likely to have viral hepatitis.
Ask about history of drugs, alcohol & sexual Ask about history of drugs, alcohol & sexual
behaviour behaviour
2-Elderly patient with weight loss :- Ca2-Elderly patient with weight loss :- Ca
3-Country of origin (HBV) + travel (HAV)3-Country of origin (HBV) + travel (HAV)
4-Abdomial pain: biliary obstruction orhepatitis 4-Abdomial pain: biliary obstruction orhepatitis
5-Duration of illness: short history with 5-Duration of illness: short history with
prodrome suggest HAV as a recent outbreak of prodrome suggest HAV as a recent outbreak of
jaundicejaundice

20. 6-I.V. drugs abuse, tattooing, blood transfusion 6-I.V. drugs abuse, tattooing, blood transfusion
or plasma products (HBV,HCV)or plasma products (HBV,HCV)
7-Male homosexuality or female prostitution: 7-Male homosexuality or female prostitution:
HBVHBV
8-Alcohol consumption 8-Alcohol consumption
9-History of drug ingestion in the previous three 9-History of drug ingestion in the previous three
monthsmonths
10-Recent anaesth: Halothane 10-Recent anaesth: Halothane
11-Recent history of biliary surgery or Ca11-Recent history of biliary surgery or Ca
12-F.H: Gilbert, Wilson's 12-F.H: Gilbert, Wilson's
13-Pruritus: Cholestasis 13-Pruritus: Cholestasis

21. 14-Fever & chills: Cholangitis or liver abscess14-Fever & chills: Cholangitis or liver abscess
15-Smooth tender Hepatomegaly: hepatitis & 15-Smooth tender Hepatomegaly: hepatitis &
extra hepatic obstruction extra hepatic obstruction
16-Nodular hepatomegaly: malignancy 16-Nodular hepatomegaly: malignancy
17-Spleenomegaly: PHT17-Spleenomegaly: PHT
18-Acitis: Cirrhosis or PHT or Ca18-Acitis: Cirrhosis or PHT or Ca
19-Palpable G.B: Ca head of pancreas 19-Palpable G.B: Ca head of pancreas
20-Generalised L.N: Lymphoma 20-Generalised L.N: Lymphoma
21-Viral marker for high risk groups21-Viral marker for high risk groups

22. 22-U/S to exclude extra hepatic Cholestasis22-U/S to exclude extra hepatic Cholestasis
ــــــــــ dilated ductsdilated ducts
ــــــــــ level of obstructionlevel of obstruction
ــــــــــ cause of obstructioncause of obstruction
23-Liver biochemistry 23-Liver biochemistry
24-CBC & Retics count24-CBC & Retics count
25-Low serum alb. & prolonged PT: chronic 25-Low serum alb. & prolonged PT: chronic
liver diseaseliver disease
26-Leucocytosis suggest bacterial infection e.g. 26-Leucocytosis suggest bacterial infection e.g.
Cholangitis or hepatic abscess Cholangitis or hepatic abscess

23. 27-lucopenia with viral hepatitis 27-lucopenia with viral hepatitis
28-Abnormal lymphocyte: inf. Mono. 28-Abnormal lymphocyte: inf. Mono.
29-Serolgy & alphafoetoprotien29-Serolgy & alphafoetoprotien
30-ERCP & PTC30-ERCP & PTC
31-FNAC31-FNAC
32-Fine needle biopsy: more sensitive 32-Fine needle biopsy: more sensitive
33-Generally33-Generally
-Young patient -Young patient ــــــــــ viral markersviral markers
-If negative -If negative ــــــــــ U/SU/S
-If both U/S & viral markers are negative-If both U/S & viral markers are negative ــــــــ
serology serology

24. -U/S -U/S ــــــــــ obstruction obstruction ــــــــــ ERCP & PTCERCP & PTC
-U/S -U/S ــــــــــ Focal lesion Focal lesion ــــــــــ FNAC or biopsyFNAC or biopsy
-U/S -U/S ــــــــــ abnormal liver parenchyma abnormal liver parenchyma ــــــــــ liver liver
biopsybiopsy
-U/S -U/S ــــــــــ normal normal ــــــــــ viral markersviral markers
-U/S -U/S ــــــــــ portal or venous obstruction portal or venous obstruction ــــــــــ
Angiography Angiography