Jaundice clinical approach Dr Mokhtar.pptx

understanding and clinical approach to a case of jaundice

1. Jaundice ( Icterus ) 2015 DR A.A.MOKHTAR Professor of Internal Medicine Mansoura University

2. Definition : www.drsarma.in 2

3. Definition : Jaundice is yellow discoloration of the skin , mucus membranes and sclera of the eyes due to increase in the level of circulating bilirubin . Other causes of yellow skin ????? 3 Carotenemia . Xanthomatosis . Myxoedema . Drugs e,g Atebrine , Miracil D ( yellow skin ) Pecric acid yellow skin & mucus membrane ( more around the limbus ).

4. Clinical aspects : Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg% Jaundice is increased levels of SB > 1.0 mg% It becomes clinically evident at 2.0 -3.0 mg / dl. Factors affecting the depth of jaundice : Serum bilirubin level. Elastic fibers have more affinity ( sclera). Protein content of the tissue or body fluid ( exudates seems more icteric than transudates ). 4. With edema and dark skin – Jaundice is masked Where to detect : In fair skin...most noticeable on the face , trunk , and sclera. In dark skin on the hard palate , sublingual mucosa , and sclera. 4

5. Physiologic cycle of Bilirubin : 5

6. Bilirubin is the metabolic end product of Haeme metabolism 6 RBC life span in blood stream is 90-120 days Old RBCs are phagocytosed and/or lysed Lysis occurs extravascularly in the RE system subsequent to RBC phagocytosis Intravascular Hemolysis of young RBC This is due to hemolytic diseases of RBC

7. Pathway for RBC Scavanging Liver, Spleen & Bone marrow Hemoglobin Globin Amino acids Amino acid pool Heme Bilirubin Fe 2+ Excreted Phagocytosis & Lysis 7 Processed through the liver

8. Bilirubin in the RES ( production) : 8 300 mg daily in the RES

9. Bilirubin in the Liver Cell 9

10. ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile

11. ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT ALT AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP AlkP Blood Bile X

12. Bilirubin in blood Properties Unconjugated Conjugated Normal serum fraction 90% 10% Water solubility (polarity) (non polar) + (polar) Affinity to lipids ( Kernicterus ) +++  Renal excretion Nil + Vanden Berg Reaction Indirect Direct Temporary Albumin Binding +++ Irreversible Delta Bilirubin ++ 12 In late stages of cholestasis or hepatocellular J bilirubin is not detected in urine due to 3 rd type of bilirubin which is conjugated bilirubin covalently bound to albumen so not appear in urine.

13. Bilirubin in the Intestine www.drsarma.in 13

14. Bilirubin handling in Kidney www.drsarma.in 14

15. Bilirubin Metabolism - Summary 15

16. Jaundice – Classification Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg% Over production of Bilirubin (Hemolytic) From hemolysis of RBC Lysis of RBC precursors – Ineffective erythropoesis Impaired hepatic function (Hepatitic) Hepatocellular dysfunction in handling bilirubin Uptake, Metabolism and Excretion of bilirubin Obstruction to bile flow (Obstructive) Intrahepatic cholestasis Extrahepatic Obstruction (Surgical Jaundice) 16 www.drsarma.in

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22. How to clinically evaluate the patient ? What tests will help us in D.D ? What imaging modalities will be useful ? How to monitor the progress ? 22 Algorithmic approach for Jaundice www.drsarma.in

23. HISTORY TAKING www.drsarma.in 23

24. History taking : Personal History Age Childhood……..Hemolytic J. ……..Infective H (A) Middle age…………….. G.stones . Old age……………………Malignancy. Occupation : Contact with rats……… weil`s disease Medical personnel.…… Hcv , HBV Habits ……….Alcoholism & parentral drug addiction. Locality Egyptian HCV 24

25. Nausea , vomiting , flu like symptoms then fever subsides and jaundice appears ……….Viral hepatitis. Gradual , following long history of fat dyspepsia and associated with relatively fair general condition …… Calcular cholestatic jaundice ………….. with fever and rigors ……. Cholangitis due to stone or bile stricture, Rapid progressive with failure of health and weight loss ………….suggest malignancy. Complaint : 25

26. Qnset Acute ( infective & Drug ). Rapid Calcular & malignancy. Chronic Cirrhosis. Associated with : Surgery …..any surg ??? Halthane T. ? Hepatitis. ….. Surg for malig ???? Liver mets . … Biliary surgery ?? Missed stone ?? Stricture. Present History : 26

27. Regressive ……viral hepatitis. Intermittent ……. calcular or hemolytic. Progressive……….Malignancy or cirrhosis, Duration: Short Viral hepatitis. Chronic Cirrhosis. Course : www.drsarma.in 27

28. Associated with Fever - pain – stool colour – urine colour : Fever preceeds J . then disappear with J ?? V,hepatitis persists with J ????Weil`s disease , Brucellosis , Malaria , filaria , Amoebic hepatitis, Fever with J ……. Hemolytic crisis. Fever after J…….. 2ry infection on top of calc obst J Associated with : Pain Biliary ??????? Dull aching in the Rt Hpoch ……?????? Hepatitis. Bone aches???? Mets , hemolytic crisis , ?? osteomalacia Pruritus ……..due to bile salts in obstructive jaundice , ?? Hepatocellular J 28

29. Stool : Pale , clay with steatorrhoea ……..Obstructive J. Dark coloured …………………… Haemolytic J. Urine Pale ( acholuric J.) in hemolytic J as the indirect bilirubin is non filtrable Associated with drug intake :. 29 Drugs causing Cholestasi s . Hepatotoxic drugs.

30. Drugs causing Cholestasis www.drsarma.in 30 Anabolic steroids (testosterone, norethandrolone ) Antithyroid agents ( methimazole ) Azathioprine (Immunosuppressive drug) Chlorpromazine HCI ( Largactil ) Clofibrate , Erythromycin estolate Oral contraceptives (containing estrogens) Oral hypoglycemics (especially chlorpropamide )

31. Hepato toxic drugs 31 Conventional Drugs Natural Substances Acetaminophen, Alpha-methyldopa Vitamins, Hypervitaminosis A Amiodarone, Dantrolene, Diclofenac Niacin, Cocaine, Mushrooms Disulfiram, Fluconazole, Glipizide Aflatoxins , Herbal remedies Glyburide , Isoniazid , Ketaconazole Senecio , crotaliaria , Labetalol, Lovastatin, Nitrofurantoin Pennyroyal oil, Chapparral , Thiouracil , Troglitazone , Trazadone Germander, Senna , Herbal mix. www.drsarma.in

32. Causes of recurrent J. Obstructive multiple gall stones , ampullary carcinoma, pseudopancreatic cyst regressing with tt Hemolytic J. Liver cirrhosis complicated with sepsis or drugs Congenitaln hyperbilirubinemia . Family History : of similar conditions , hemolytic A, splenectomy , cholecystectomy ,,etc Past History : 32

33. PHYSICAL EXAMINATION www.drsarma.in 33

34. 34 General Examination:

35. I- Portal Hypertension : collaterals , venous hum , ascites . 2 – Organomegaly : Jaundice with hepatomegaly Huge liver Hard liver ……1ry HCC. Firm …………..Extra hepatic cholestasis.with palpable GB ( Cancer head of pancreas ) Impalpable GB Calcular Jaundice. Mild Hepatomegaly : Intrahepatic cholestasis except in 1ry BC there is also splenomegaly . Acute hepatitis. ABDOMINAL EXAMINATION : www.drsarma.in 35

36. Huge Liver : Secondaries ……….metastasis in both liver & spleen. 1ry HCC on top of cirrhosis, Primary biliary cirrhosis, Moderately ++ liver : Hepatitis group 20% of viral hepatitis is associated with splenomegaly . Hemolytic jaundice. Jaundice with Hepato-splenomegaly : www.drsarma.in 36

37. Jaudice + Splenomegaly + Lymphadenopathy 37

38. Palpable GB…… ? Cancer pancreas. Palpable other masses e.g : cancer stomach , colon , rectum,….etc. 3- Other palpable Abdominal masses 38

39. INVESTIGATIONS www.drsarma.in 39

40. First Step 40 www.drsarma.in

41. Second Step : If SB > 1.0 mg 41 www.drsarma.in

42. ↑ in U nconjugated Bilirubin 42 www.drsarma.in

43. Third Step : If CSB is increased 43 www.drsarma.in

44. Fourth Step : Hepatocellular 44 www.drsarma.in

45. What imaging we need Ultrasonography – 98% Sp, 90% Sen. For GB stones USG better than CT For duct stones –only 40% seen in USG PTC – Extrahepatic obstr. – drainage ERCP – Distal biliary obstruction Dx.Rx. MRCP – Most useful for duct stones www.drsarma.in 45

46. Acute Cholecystitis 46 GB wall is thickened and striated. Courtesy of Udo Schmiedl, M.D. www.drsarma.in

47. Retrograde Cholangiogram - ERCP Bile leak from the cystic duct after cholecystectomy Courtesy of Michael Kimmey, M.D.

48. Primary Sclerosing Cholangitis Normal Extra hepatic BD Narrowed abnormal intra-heptic bile ducts.

49. Conclusions Jaundice and liver injury are very common Careful history and physical examination are a must Acute hepatocellular diseases with jaundice Chronic hepatocellular jaundice (CLD) Cholestasis and obstructive jaundice LFT – SB, CB, – AST. ALT, AKP, 5’NS, GGT, Alb, PT Ultasonography, MRCP, ERCP, PTC Laparoscopy and liver biopsy Treatment as per the cause