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1. How to evaluate apatient with jaundice By
Dr. Ali Abdul Hussein Handoz
M.B.Ch.B F.I.C.M.S
2. Jaundice Definition:
Yellowish discoloration of skin and mucous membranes due to staining with bilirubin.
Normal bilirubin = 0.3 1.3 mg/dl.
Conjugated (direct) = 0.1 0.3 mg/dl.
unconjugated (indirect) = 0.2 0.7 mg/dl.
jaundice detected clinically at level of > 3 mg/dl.
6. Physiology of bilirubin -Break down of old RBCs in the RET releases HB .
-In liver: UB converted to conjugated (H2o soluble), this is mediated by bilirubin UDP glucuronyl transferase
-Conjugated bilirubin passes via biliary tree to duodenum
-In small bowel:
conjugated bilirubin is deconjugated by bacterial glucuronidase
unconjugated bilirubin is reduced to urobilinogen
7. Most of urobilinogen is excreted in faeces as stercobilinogen. Some is reabsorbed and partly excreted by liver (enterohepatic circulation) and rest is excreted by kidneys .
10. Causes of jaundice (Hyperbilirubinaemia) Hyperbilirubinaemia result from:
Over production of bilirubin (haemolysis) PREHEPATIC.
Impaired uptake, conjugation or excretion of bilirubin HEPATIC.
Regurgitation of unconjugated or conjugated bilirubin from damaged hepatocytes or bile ducts POSTHEPATIC.
11. Causes of unconjugated hyperbilirubinaemia:
Either overproduction (haemolysis)
Or impairment of uptake
Or impairment of conjugation
Causes of conjugated hyperbilirubinaemia:
Either decreased excretion into bile ductules
Or backward leakage of the pigment (bilirubin)
12. Hepatocellular conditions that may produce jaundice -viral hepatitis
hepatitis A,B,C,D and E
EBV
CMV
Herpes simplex
-Drug toxicity
Predictable, dose-dependent, e.g., acetaminophen
Unpredictable, idosyncratic, e.g., isoniazid
-alcohol
-Environmental toxins
vinyl chloride
Wild mushrooms amanita phalloides or verna
-Wilsons disease
-autoimmune hepatitis
13. Cholestatic conditions that may produce jaundice 1-INTRAHEPATIC
-viral hepatitis
fibrosing cholestatic hepatitis B and C
hepatitis
EBV
-Drug toxicity
pure cholestasis anabolic and contraceptive steroids
-alcoholic hepatitis
-vanishing bile duct syndrome
chronic rejection of liver transplants
sarcoidosis
drugs
-inherited
benign recurrent cholestasis
-total parenteral nutrition
-benign postoperative cholestasis
14.
2 EXTRAHEPATIC
A- Malignant
-cholangio ca.
-pancreatic ca.
-gall bladder ca.
-ampullary ca.
-malignant involvement of the porta hepatis lymph nodes
B- Benign
-CBD stone (choledocholithiasis) [the most common]
-1ry sclerosing cholangitis
-chronic pancreatitis
-AIDS cholangiopathy
-Hydatid cyst
15. Evaluation HISTORY TAKING
HPI:
-duration of the jaundice
-onset:
sudden: CBD stone, viral hepatitis
gradual: cirrhosis, pancreatic Ca.
-pattern:
-pain:
painful: CBD stone, pancreatic disease
painless: malignancy, viral hepatitis (although there is dragging subcostal pain)
-history of:
blood transfusion
anorexia
wt. loss malignancy
abdominal pain (RUQ)
fever
16. Past Hx:
Biliary surgery (stricture, residual stone)
Social Hx:
alcohol
Family Hx:
SCD & G6PD
spherocytosis
Drug Hx:
hx of any hepatotoxic drug
17. Physical Examination General appearance:
Cachexia (muscle wasting => in malignant disease)
General examination:
stigmata of chronic liver disease.
Abdominal examination:
heptomegaly
spleenomegaly
RUQ tenderness
Murphys (+ve)
18. INVESTIGATION 1- BLOOD
serum bilirubin:
conjugated or unconjugated
liver enzymes:
ALT
AST
ALP
CBC:
Hb in hemolytic jaundice
Reticulocytes
Leucopenia viral hepatitis esp. HBV aplastic anemia
Lymphocytes
coagulation profiles:
serum antigens (hepatitis profile):
-HBs Ag, HBe Ag ,..
19. LDH (lactate dehydrogenase):
found in muscles and RBCs.
Albumin.
immunological tests:
autoantibodies,
20. 2- URINE
urobilinogen
in hemolytic jaundice
or absent in obstructive jaundice (no more bile)
conjugated bilirubin
in obstructive (cholestatic) or hepatocellular jaundice
Hb urea: intravascular hemolysis
21. 3- STOOL
Pale stool in obstructive jaundice
stercobilinogen
in hemolytic jaundice
or absent in obstructive jaundice (pale stool)
occult blood
carcinoma of GI (metastasis to liver)
esophageal varices (2ry to liver cirrhosis)
22. 4- RADIOLOGICAL INVESTIGATION
US
Gall stones
Intrahepatic or extrahepatic biliary dilation (due to obstruction by stone, stricture, or tumor)
CT
assessing the head of pancreas (if there is Ca.)
identify stones in the distal CBD
ERCP
PTC
24.
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