ByDr. Ali Abdul

Hussein HandozM.B.Ch.B F.I.C.M.S

JaundiceDefinition: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• -Wilson’s 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 Murphy’s (+ve)

INVESTIGATION1- BLOOD• serum bilirubin: conjugated or unconjugated • liver enzymes:

– ALT– AST– ALP

• CBC: Hb in hemolytic jaundice Reticulocytes Leucopenia viral hepatitis esp. HBV aplastic

anemia Lymphocytes• coagulation profiles:• serum antigens (hepatitis profile): -HBs Ag, HBe Ag ,…..

LDH (lactate dehydrogenase): found in muscles and RBCs. Albumin.immunological tests: autoantibodies, 

2- URINEurobilinogen

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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