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?