Download - Jaundice
Jaundice
Dr E M Said
objectives
• About jaundice
• History taking
• Discussion
definition• Jaundice (or icterus) is a term used to describe the yellow
pigmentation of a patient's skin and sclerae caused by excess bilirubin in the blood.
• Jaundice become visible at >35umole/L
• Jaundice is not itself a diagnosis and the cause should always be sought.
• Many diseases cause jaundice through a variety of different mechanisms.
Classification & causes
Pre-hepatic hepatic post-hepatic
haemoglobin bile duct
breakdown
Hepatocyte
Unconjugated
bilirubin conjugation
Liver uptake conjugated
bilirubin
Prehepatic jaundice:
excess production or failure of uptake into liver
• Haemolysis, eg G6PD deficiency
Autoimmune
• Congentital hyperbilirubinaemia eg Gilberts,
Crigler Najar
Pre-hepatic hepatic post-hepatic
haemolysis bile duct
haem breakdown Hepatocyte
Unconjugated
bilirubin conjugation
Liver uptake conjugated
bilirubin
Hepatocellular jaundice
Hepatocyte failure / damage (ALT>ALP)• Alcohol• Viral Hepatitis A, B and C, EBV• Cirrhosis• Drugs • Auto immune• Hepatoma• Metastases• Wilsons• Hepatic congestion from cardiac failure
Pre-hepatic hepatic post-hepatic
blood bile duct
haem Hepatocyte damage
Unconjugated
bilirubin conjugation
Liver uptake conjugated
bilirubin
Chronic liver disease• Alcohol & viral hepatitis are the most
common causes of chronic liver disease and cirrhosis.
• Develop when the functional capacity of the liver can no longer maintain normal physiological conditions
• Jaundice is a feature of chronic liver disease
Cholestatic jaundice
impaired excretion of bile (ALP>ALT)• Gallstones• Head of pancreas cancer• Porta hepatis lymph nodes• PBC• Sclerosisng Cholangitis
Pre-hepatic hepatic post-hepatic
blood bile duct
haem Hepatocyte
Unconjugated
Bilirubin conjugation
Liver uptake
obstruction
conjugated bilirubin
History
• When the patient first noticed it?• Was it gradually deepening?• Any prev episodes of jaundice?• Any family Hx of jaundice?• Pruritis?• Dark urine /pale stool?• Any abd pain and its nature?
History
• When the patient first noticed it?• Was it gradually deepening?• Any prev episodes of jaundice?• Any family Hx of jaundice?• Pruritis?• Dark urine /pale stool?• Any abd pain and its nature?
Painful jaundiceAlcoholic,infective,biliar
y colic,pancreatitis,cholecy
stitis,metastasis.
• When the patient first noticed it?• Was it gradually deepening?• Any prev episodes of jaundice?• Any family Hx of jaundice?• Pruritis?• Dark urine /pale stool?• Any abd pain and its nature?
History
Painless jaundiceHaemolysis,PBS
pancreatic/ biliary malignancy,cirrhosis
Heamochromatosis,
• Associated symptoms?
Continue history…
Continue history…
• Associated symptoms?•N/V
•Haematamesis
•Fatigue
•Malaise
•Fever
•Loss of apetite/Wt
•Rash/arthritis
•Abd swelling
•Confusion
•Sleep pattern
Continue history…
• Associated symptoms?
• Any cardiac/respiratory symptoms?
• Associated symptoms?
• Any cardiac/respiratory symptoms?
• Full alcohol Hx.
Continue history…
• Associated symptoms?
• Any cardiac/respiratory symptoms?
• Full alcohol Hx
Continue history…
•CAGE questionnaire
•Drinking at work
•Driving offences
•Psychological/social problems
• Associated symptoms?
• Any cardiac/respiratory symptoms?
• Full alcohol Hx
• Relevant PMHx
Continue history…
• Associated symptoms
• Any cardiac/respiratory symptoms
• Full alcohol Hx
• Relevant PMHx
Continue history…
Liver & gall stone disorder
Malignancy,recent anaesthesia,blood
transfusion,autoimmune
disorders
• Associated symptoms
• Any cardiac/respiratory symptoms
• Full alcohol Hx
• Relevant PMHx
• Full drug Hx
Continue history…
• Associated symptoms
• Any cardiac/respiratory symptoms
• Full alcohol Hx
• Relevant PMHx
• Full drug Hx
Continue history…
Antibiotics,antirhuematic,etc
• Associated symptoms
• Any cardiac/respiratory symptoms
• Full alcohol Hx
• Relevant PMHx
• Full drug Hx
• Risk factors for viral hepatitis
Continue history…
• Associated symptoms
• Any cardiac/respiratory symptoms
• Full alcohol Hx
• Relevant PMHx
• Full drug Hx
• Risk factors for viral hepatitis
Continue history…
examination
• Temp, pulse, BP
• Anaemia, lymph nodes
• Features of cirrhosis
• Encephalopathy
• Nutritional status
• Hepato / splenomegaly
• Tattoos
Investigations
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen
blood film, reticulocytes,
low haptoglobin,
high LDH, DCT
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen• Non Invasive Liver Screen
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen• Non Invasive Liver Screen
•Immunoglobulins, •Auto antibodies (smoth muscle, ANA, AMA, LKM) •Viral hepatitis serology •ferritin,•caeruloplasmin•alpha 1 anti-trypsin
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen• Non Invasive Liver Screen• Radiology USS
MRCP
Continue Investigations…
• Routine Bloods - LFT, GGT, UE, FBC• Haemolysis Screen• Non Invasive Liver Screen• Radiology USS
MRCP• Invasive Tests
ERCP
Liver biopsy
Treatment• Remove toxin • Antibiotics• Fluids• Relieve obstruction – ERCP, Percutaneous
drainage (PTC)• Ursodeoxycholic acid• Steroids / immunosupressants• Liver transplant
Any Question?