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KEHINDE Adeleke
Outline of Discussion
Definition
Epidemiology
Classification
Pathophysiology
Clinical evaluation
Management
Definition
Jaundice is the yellowish pigmentation of the skin,
the conjunctival membranes over the sclerae, and
other mucous membranes caused by
hyperbilirubinemia.
Total serum bilirubin values are normally 0.2-1.2
mg/dL. Jaundice may not be clinically
recognizable until levels are at least 3 mg/dL.
Jaundice is not a diagnosis.
Surgical jaundice is any jaundice amenable to
surgical treatment. Majority are due to
extrahepatic biliary obstruction.
Not all obstructive jaundice is surgical jaundice
e.g hepatitis and not all surgical jaundice is due
to obstruction e.g congenital spherocytosis
Epidemiology
RACE
The racial predilection depends on the
cause of the biliary obstruction.
Gallstones are the most common cause of
biliary obstruction.
Persons of Hispanic origin and Northern
Europeans have a higher risk of gallstones
compared to people from Asia and Africa.
Native Americans (particularly Pima
Indians)have a lifetime chance of
developing gallstones as high as 80%.
SEX
Women are much more likely to
develop gallstones than men.
This increased risk is likely caused by
the effect of estrogen on the liver,
causing it to remove more cholesterol
from the blood and diverting it into
the bile.
Pathophysiology
To better understand these disorders, a brief discussion
of the normal structure and function of the biliary tree is
needed.
Bile is the exocrine secretion of the liver and is produced
continuously by hepatocytes. It contains cholesterol and
waste products, such as bilirubin and bile salts, which aid
in the digestion of fats. Half the bile produced runs
directly from the liver into the duodenum via a system of
ducts, ultimately draining into the common bile duct
(CBD). The remaining 50% is stored in the gallbladder.
In response to a meal, this bile is released from the
gallbladder via the cystic duct, which joins the hepatic
ducts from the liver to form the CBD. The CBD courses
through the head of the pancreas for approximately 2 cm
before passing through the ampulla of Vater into the
duodenum
Biliary obstruction refers to the blockage of
any duct that carries bile from the liver to
the gallbladder(intrahepatic) or from the
gallbladder to the small
intestine(extrahepatic).
This can occur at various levels within the
biliary system.
The major signs and symptoms of biliary
obstruction result directly from the failure of
bile to reach its proper destination.
The failure of biliary flow may be due to
biliary obstruction by mechanical means or
by metabolic factors in the hepatic cells.
For the sake of simplicity, the primary
focus of this presentation is mechanical
causes of biliary obstruction, further
separating them into intrahepatic and
extrahepatic causes.
The discussion of intracellular/metabolic
causes of cholestasis is very complex,
the pathogenesis of which is not always
clearly defined. Therefore, these causes
are mentioned but are not discussed in
detail.
Intrahepatic cholestasis generally occurs at
the level of the hepatocyte or biliary
canalicular membrane. Causes include
hepatocellular disease (eg, viral hepatitis,
drug-induced hepatitis), drug-induced
cholestasis, biliary cirrhosis, and alcoholic
liver disease.
In hepatocellular disease, interference in
the 3 major steps of bilirubin metabolism,
ie, uptake, conjugation, and excretion,
usually occurs. Excretion is the rate-limiting
step and is usually impaired to the greatest
extent. As a result, conjugated bilirubin
predominates in the serum.
Extrahepatic obstruction to the flow of bile
may occur within the ducts or secondary to
external compression. Overall, gallstones
are the most common cause of biliary
obstruction. Other causes of blockage
within the ducts include malignancy,
infection, and biliary cirrhosis.
External compression of the ducts may
occur secondary to inflammation (eg,
pancreatitis) and malignancy. Regardless
of the cause, the physical obstruction
causes a predominantly conjugated
hyperbilirubinemia
The lack of bilirubin in the intestinal
tract is responsible for the pale stools
typically associated with biliary
obstruction.
The cause of itching (pruritus)
associated with biliary obstruction is
not clear. Some believe it may be
related to the accumulation of bile
acids in the skin. Others suggest it
may be related to the release of
endogenous opioids.
Causes