Jaundice

Jaundice are three Hemolytic, Hepatic and Obstructive Jaundice.

1. M.Prasad Naidu
MSc Medical Biochemistry,
Ph.D.Research Scholar

2. Clinical marker of defect in metabolism &/or
excretion of bilirubin.
ER task to initiate lab eval or imaging studies to
identify cause and determine admission or
outpt therapy.

3. Yellow discoloration of sclera, skin, mucous
membranes due to deposition of bile pigment
Clinically detected with serum bilirubin 2-
2.5mcg/dL or ­ (2 times nl)

4. The breakdown product of Hgb from injured
RBCs and other heme containing proteins.
Produced by reticuloendothelial system
Released to plasma bound to albumin
Hepatocytes conjugate it and extrete through
bile channels into small intest.

5. Overproduction by reticuloendothelial system
Failure of hepatocyte uptake
Failure to conjugate or excrete
Obstruction of biliary excretion into intestine

6. Unconjugated
­ production exceeds
ability of liver to
conjugate
Ex. Hemolytic anemias,
hemoglobinopathies, in-
born errors of metab.,
transfusion rxn.
Conjugated
Can produce but not
excrete
Metabolic defect
Intra- or extrahepatic
obstruction

7. Careful history and PE
Family history (Gilbert, Rotor, Crigler-Najjar,
Dubin-Johnson, Sickle Cell)
Healthy young person with fever, malaise,
myalgias = viral hepatitis (try to locate source)

8. Gradually develops symptoms = hepatic/bile
duct obstruction (consider ETOH liver
dz/cirrhosis)
Develops acutely with abd pain = acute
cholangitis 2° to choledocholithiasis

9. Painless jaundice in older person with
epigastric mass & weight loss = biliary
obstruction from malignancy
Hepatomegaly with pedal edema, JVD, and
gallop = CHF

10. Serum bilirubin level
(total and direct)
Liver aminotransferase
levels
Alk. Phos
U/A for bilirubin and
urobilogen
CBC
PT
Other labs pertinent to
history
Coombs test
Hgb electrophoresis
Viral hepatitis panel
U/S Gallbladder

11. Hemodynamically stable, new-onset jaundice,
no evidence of liver failure or acute biliary
obstruction ® discharge with follow up
If one of above violated ® admission with
surgery consult

12. Tintanalli Chapter 85
Pages 561-566

13. 1) Biliary Colic
2) Cholecystitis
3) Gallstone pancreatitis
4) Ascending cholangitis

14. Most gallstones are asymptomatic
Usually seen in obese females 20-40 yoa and
pregnancy (Remember fat, fertile, flatulent,
female, forty)
Associated with upper abdominal pain

15. Uncommon in children (seen with hemolytic d/o,
idiopathic, cystic fibrosis, obesity, ileal resection, long
term use of TPN)
Elderly
14-27% symptomatic gallstone dz.
More likely biliary sepsis/gangrenous GB
­ perioperative morbidity
Mortality rate 19%

16. Familial
Asian descent
Chronic biliary tract infections
Parasitic infections (ascaris lumbricoides)
Chronic liver dz (ETOH)
Chronic intravasular dz (Sickle Cell, Hereditary
Scherocytosis)
Hepatitis A, B, C, E
HIV
Herpesvirus

17. Bile
Manufactured & secreted from hepatocytes ®GB
storage in canaliculi, ductiles, & bile ducts ®bile
ducts enlarge ®form R and L hepatic ducts ®form
common hepatic duct ®joins cystic duct from GB to
form CBD ®Ampulla of Vater ®duodenum

18. Release of bile stimulated by cholecystokinin
secreted from small int. mucosal cells when
fats & AA enter duodenum

19. Symptomatic cholelithiasis = stone migration
from GB into biliary tract with eventual
obstruction ®obstruction of hollow viscus
®pain, nausea & vomiting ®acute
cholecystitis

20. E. coli/Klebsiella-70%
Enterococci-15%
Bacteroides-10%
Clostridium-10%
Group D Strep
Staphylococcal species

21. Overlap of s/s of PUD, gastritis, GERD,
nonspecific dyspepsia
RUQ pain
Upper abd/epigastric pain
Radiation to L upper back
Pain persisant lasting 2-6h

22. THANKING U