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JAUNDICE

BIOCHEMISTRY

mprasadnaidu
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JAUNDICE

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

  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. Jaundice

  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) Pathophysiology

  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. What is bilirubin?

  5. Overproduction by reticuloendothelial system Failure of hepatocyte uptake Failure to conjugate or excrete Obstruction of biliary excretion into intestine What causes  bilirubin?

  6. Unconjugated vs. Conjugated • 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) Clinical Features

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

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

  10. Laboratory Tests • 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 Disposition

  12. Tintanalli Chapter 85 Pages 561-566 Cholecystitis and Biliary Colic

  13. 1) Biliary Colic 2) Cholecystitis 3) Gallstone pancreatitis 4) Ascending cholangitis Biliary Tract Emergencies Related to Gallstones

  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 Gallstones

  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% Gallstones

  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 Gallstone Risk Factors

  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 Pathophysiology

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

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

  20. E. coli/Klebsiella-70% Enterococci-15% Bacteroides-10% Clostridium-10% Group D Strep Staphylococcal species Pathogens Involved in AcuteCholecystitis

  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 Clinical Features

  22. THANKING U

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