By Dr. Ali Abdul Hussein Handoz M.B.Ch.B F.I.C.M.

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.

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

 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 .

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.

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)

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

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

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

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

 Past Hx:

Biliary surgery (stricture, residual stone) Social Hx: alcohol Family Hx: SCD & G6PD spherocytosis Drug Hx: hx of any hepatotoxic drug

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)

INVESTIGATION
1- BLOOD serum bilirubin: conjugated or unconjugated liver enzymes:
ALT AST ALP

CBC:

Hb in hemolytic jaundice Reticulocytes Leucopenia viral hepatitis esp. HBV Lymphocytes coagulation profiles: serum antigens (hepatitis profile): -HBs Ag, HBe Ag ,..

aplastic anemia

 LDH (lactate dehydrogenase):

found in muscles and RBCs. Albumin. immunological tests: autoantibodies,

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

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)

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

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