ICTERUS

OR
JAUNDICE
Atan Baas Sinuhaji

Department of ChildHealth
School of Medicine,University Of Sumatera Utara
Medan

JAUNDICE
YELLOW APPEARANCE OF THE SKIN & MUCOUS MEMBRANES

BILIRUBIN

BODY FLUIDS

TISSUE

CHILDREN & ADULTS

: > 2-3 mg %
NEONATES : > 5 mg %
JAUNDICE CAROTENEMIA

YELLOWNESS OF THE SKIN/PALMS

FREE
FAT

UNCONJUGATED

ALBUMIN

BILIRUBIN

FREE
CONJUGATED

WATER
ALBUMIN
(DELTA)

Hb

RES

TRANSPORT

LIVER

ALBUMIN

UPTAKE

LIGANDIN
GLUCORONYL
TRANSFERASE

CONJUGATION

GLUCURONIC
ACID

SECRETION
GUT
ADULTS

INFANTS
B. Glucuronidase
DECONJUGATION

STOOLS

BILIRUBIN METABOLISM

Bacteria
Bilinogen
Urine

Stools

Urobilin

Stercobilin

UNCONJUGATED HYPERBILIRUBINEMIA
1. INCREASED PRODUCTION

G6 PD def
Infection

- Hemolysis

Antagonism
- Hematoma
- Drugs: Vit. K
2. DEFECT OF
TRANSPORT

ALBUMIN

Conc.
Capacity

: Premature
: Acidosis

Competitive : Sulfa,
Free Fatty Acid

3. DECREASED
UPTAKE

LIGANDIN
: GILBERTS SYNDR.
(Y Z PROTEIN
= GLUTHATHIONE S TRANSFERASE)

Conc.

- GLUCORONYL
TRANSFERASE
4. DEFECT OF
CONJUGATION

: Crigler Najjar Synd.

Block : Chloramphenicol

Activity

: Infection, dehydration

- GLUCURONIC ACID

5. ENTEROHEPATIC CIRCULATION :

- OBSTRUCTION
- ANTIBIOTICS
- BREAST MILK JAUNDICE

HUMAN MILK

Jaundice
Breast milk

Breast Feeding

Abnormality

Intake

CONSEQUENCES OF UNCONJUGATED
HYPERBILIRUBINEMIA
1. KERN ICTERUS = BILIRUBIN ENCEPHALOPATHY
2. CHOLESTASIS
3. UNDERLYNG - HEMOLYTIC
- CHOLESTASIS

CONJUGATED HYPERBILIRUBINEMIA

CHOLESTASIS

NON CHOLESTASIS

HEPATOCYTE
- ROTOR SYNDROME
- DUBIN JOHNSON SYND.

DUCTS =
OBSTRUCTIVE

INTRA
HEPATIC

EXTRA
HEPATIC

Hepatocyte
canaliculi
terminal bileduct

Intrahepatic

intralobular bileduct
interlobular bileduct
septal bileduct
right
hepatic
duct

left
hepatic
duct

Common hepatic duct

Extrahepatic

Cystic duct
Choledochal duct
Pancreatic duct

BILIARY TRACT

duodenum

CHOLESTASIS
STAGNATION/INTERFERENCE OF BILE FLOW

CONSEQUENCES

DEFECT OF
CANALICULAR
BILE SECRETION

ACCUMULATION

RETENTION
IN
THE BLOOD

Bile Salt bile acid cholesterol

Bilirubin Hb
electrolytes
BILE
phospholipid

protein
cholesterol

HEPATOCYTE CHOLESTASIS
INTERFERENCES OF:

1.
2.
3.

CHOLEPOEIESIS
SECRETION
CANALICULAR CONTRACTION

OBSTRUCTIVE CHOLESTASIS
= DUCTS

1.
2.
3.
4.

Ducts EHBA (Extrahepatic Biliary Atresia)

Inpissited bile
Intrabilier pressure
Interferences of bile delivery

INFECTION

NON INFECTION

INFLAMMATION

EMBRYOGENESIS

CHOLANGIOPATHIA
INFANTILE OBSTR.

BILE DUCT ABNORMALITY

1. ATRESIA EHBA
2. HYPOPLASIA
3. PAUCITY
4. CYSTS
5. FIBROSIS

OBSTRUCTION
PROXIMAL PRESS.

SECRETION

DAMAGE OF
HEPATOCYTE

SUPERSATURATION

ACCUMULATION
OF CHEMICAL
AGENT
ISCHEMIC OF
DUCTS WALL

HEPATITIS

OBSTRUCTION

CONSEQUENCES OF OBSTRUCTIVE
CHOLESTASIS

INFECTION

CHOLANGITIS

CHOLESTASIS

HEPATOCYTE

DUCTS

HEPATITIS

CHOLANGITIS
+
HEPATITIS

DIAGNOSIS CHOLESTASIS
- BILIRUBIN CONJ. > 2 mg %
OR
- BILIRUBIN CONJ. > 20% TOTAL BILIRUBIN
WITH
- SERUM ASAM EMPEDU > 10 gr / L a 2 X N

USBA
(URINARY SULFATED BILE ACID) > 55 mol/gr
creatinine

HEPATIC ARTERY

SINUSOID

Portal Vein

AN
TR

R
LA
U
LL
E
C

entero hepatic
circulation

Central Vein

PARACELLULAR

SPACE OF DISSE

HEPATOCYTE

DUCT

BILE ACID
CIRCULATION

BOWEL

HEPATOCYTE
BILE ACID
ENTEROHEPATIC CIRC 95%

BILE

ENTEROHEP. CIRC.
INPISSITED BILE

CHOLESTASIS
FAT MALABSORPTION
* STEATORRHOEA
* PCM
* DEF. VIT. A HEMERALOPIA
D RICKETS
E NEUROMUSC. DEG
K INTRACRANIAL
BLEEDING

RETENTION

CHOLESTEROL XANTHOMAS
BILE ACID BILIARY CIRRHOSIS
TRACE ELEMEN CUPRUM
CONJ. BILIRUBIN ICTERUS

CHOLESTASIS

NEONATES

- EHBA
- INTRAHEPATIC
CHOLESTASIS

CHILDREN

- VIRAL HEPATITIS
- MECHANICAL
OBSTR.
- INTRAHEPATIC
CHOLESTASIS

EHBA
OPERATIVE
CORRECTABLE

PARTIAL ATRESIA

UNCORRECTABLE

TOTAL ATRESIA
KASAI OPERATION

HEPATITIS
= INFLAMMATION OF HEPATOCYTE

ALT (ALANINE AMINOTRANSFERASE)

= SGPT (SERUM GLUTAMATE PYRUVATE TRANSAMINASE)
2xN

HEPATOTROPIC
VIRAL

INFECTION

BACTERIA

NON
HEPATOTROPIC

PARASITES

HEPATITIS

DRUGS

NONINFECTION

DRUG INDUCED HEP.

TOXIN
METABOLIC
INFARCT
Ag-Ab

HEPATOTROPIC VIRAL
A

HEP. INFEKSIOSA

HEP. B

HEP. C

HEP. DELTA

HEP. E

??

HEP.G

PRODROMAL

STADIUM

ICTERUS= FEVER(-)

RECOVERY

RECOVERY

ACUTE

VIRAL
HEPATITIS

FULMINANT HEPATIC
FAILURE

CHRONIC HEP.
(SGPT 6 MONTHS )

PROGRESSIVE
CHRONIC

HEPATIC
CIRRHOSIS

CARRIER

VIRAL HEPATITIS
SYMPTOMATIC

ICTERIC

ANICTERIC

FLU LIKE

ASYMPTOMATIC

SUBCLINICAL

BIOCHEMISTRY

INAPPARENT
INFECTION

SEROLOGY
eg. IgM ANTI HAV (+)

HEPATITIS. A

TREATMENT :
1.BED-REST
2.WATER & ELECTROLYTES :
PREVENTION OF
DEHYDRATION
3.DIET : FAT ISNT LIMITATED

HEPATIC CIRRHOSIS

- FIBROSIS(+)
- NODULE (+)
LIVER
DYSFUNCTION

HYPERSPLENISM
PORTAL
HYPERTENSION

HEPATIC FAILURE
= HEPATIC ENCEPHALOPATHY

CAUSES OF BLEEDING IN
CIRRHOSIS
1. VIT. K DEFICIENCY
2. DEFECT OF SYNTHESIS CLOTTING FACTORS
3. RUPTURE OF ESOPHAGEAL VARICES
4. GASTROPATHY
5. ABNORMAL TROMBOCYTES
6. COAGULATION INHIBITOR
7. DIC (DISSEMINATED INTRAVASCULAR
COAGULATION)

PORTAL
HYPERTENSION
= PORTA VENOUS PRESSURE 12 mmHg
HIGHER THAN THE PRESSURE IN THE
INFERIOR VENA CAVA

COLLATERAL VEINS

VARICES
ASCITES

SPLENOMEGALY

SUP. MESENTERIC V.

SPLENIC V.
PORTAL V.

CAPUT MEDUCAE
UMBILICAL V.
CORONARY V.

PANCREATICO
DUODENAL V.

RIGHT PORTAL V.

ESOPH. VARICES

LEFT PORTAL V.

HEPATIC VEIN

INFERIOR VENA CAVA

HEART

DIAGRAM
OF PORTAL
VENOUS

INTRAHEPATIC

PORTAL
HYPERTENSION

PRE HEP

THROMBOSIS
V.UMBILICALIS

EXTRAHEPATIC
(50-70%)

POST HEP.
BUDD CHIARY
SYNDR.

POST
SINUSOIDAL

TERMINAL
HEPATIC

VENO
OCCLUSIVE
DISEASE

VENULE

SINUSOIDAL

HEPATIC
CIRRHOSIS

INTRAHEPATIC

TERMINAL
PORTAL
PRE SINUSOIDAL

VENULE

SCHISTOSO
MIASIS

BLEEDING IN PORTAL
HYPERTENSION

INTRAHEPATIC

EXTRAHEPATIC

FREQUENCY

>

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SEVERITY

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LIFE EXPECTANCE

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ASCITES

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- JAUNDICE

- PALMAR ERYTHEMA

THE OTHER SIGNS

- VASCULAR SPIDER+
- LIVER DYSFUNCTION