BY:VISHNU.R.NAIR,THIRD YEAR PHARM.D,NATIONAL COLLEGE OF PHARMACY,KERALA UNIVERSITY OF HEALTH SCIENCES(KUHS), KERALA STATE.

JAUNDICE – A DETAILED VIEW

To my parents, cousins, beloved brothers, sisters, cousins, loved ones, and of course, to the ALMIGHTY and all you viewers all over the world, who support me and make me what I am……without which, I am nothing………………………

GENERAL ACKNOWLEDGEMENT

JAUNDICE IN ADULTS NEONATAL JAUNDICE PATIENT COUNSELLING TIPS/ HOME REMEDIES FOR JAUNDICE

MAJOR DIVISIONS OF THIS PPT :

JAUNDICE IN ADULTS…………….

GENERAL INTRODUCTION EPIDEMIOLOGY ETIOLOGY(CAUSES) OF JAUNDICE PATHOPHYSIOLOGY OF JAUNDICE CLINICAL MANIFESTATIONS OF JAUNDICE COMPLICATIONS OF JAUNDICE RISK FACTORS FOR JAUNDICE DIAGNOSIS OF JAUNDICE MANAGEMENT OF JAUNDICE

INDEX/ CONTENTS OF JAUNDICE IN ADULTS :

- JAUNDICE is defined as “YELLOWISH DISCOLOURATION OF SKIN, MUCOUS MEMBRANES ,and of white of eyes, caused by elevated levels of chemical BILIRUBIN in blood (HYPERBILIRUBINEMIA)”

- Derived from French word “jaune” , meaning “yellow”- Typically seen, when bilirubin levels in blood exceeds 2.5-3 mg/dl of blood- Usually, it is indicative of an underlying disease process- Bilirubin : By-product of daily natural breakdown and destruction of RBC in the body- Hemoglobin molecules released into blood splitting occurs ‘Heme’ portion

undergoes chemical conversion to bilirubin- Normally, liver metabolizes and excretes bilirubin in the form of BILE- If there is a disruption in normal metabolism and/ or production of bilirubin

JAUNDICE occurs…………………………

GENERAL INTRODUCTION :

- Prevalence of Jaundice varies with age and sex- As per the writings based on Jerry.T.McKnight and Jerry.E.Jones regarding

jaundice, a study was performed among 88,000 patients, and it was found that:a. Newborns and older adults are the most affected b. Causes of jaundice vary with agec. Approximately 20% of newborns develop jaundice in the 1st week of life, mainly due to the immaturity of the HEPATIC CONJUGATION PROCESSd. Congenital abnormalities, hemolytic or bilirubin uptake disorders, and conjugation defects are also responsible for jaundice in infancy or childhoode. VIRAL HEPATITIS ‘A’ is the most frequent cause of jaundice among school-going children

EPIDEMIOLOGY :

f. Common duct stones, alcoholic liver disease, and neoplastic jaundice occur in middle-aged and older patientsg. Jaundice in men occur mainly due to CIRRHOSIS, CHRONIC HEPATITIS ‘B’, HEPATOMA, PANCREATIC CANCER, or SCLEROSING CHOLANGITISh. Jaundice in women occur mainly due to COMMON DUCT STONES, PRIMARY BILIARY CIRRHOSIS and CARCINOMA OF GALLBLADDER…………………………………….

Continued…………………………….

1. ALCOHOLIC LIVER DISEASE (EXCESS DRINKING)2. LIVER CIRRHOSIS3. METABOLIC DISORDERS (WILSON’S DISEASE)4. DRUGS :- Methyldopa- Isoniazid- Nitrofurantoin- Acetaminophen5. PRESENCE OF ANY UNDERLYING DISEASE CONDITION OR TUMORS …………………………

ETIOLOGY (CAUSES) OF JAUNDICE :

1. NORMAL BILIRUBIN PROCESSING :- Bilirubin is formed mostly from daily breakdown and destruction of RBCs in

bloodstream, which releases Hemoglobin as they rupture- Heme portion Converted into Bilirubin Transported in bloodstream to liver for

further metabolism and excretion- Inside liver Bilirubin is made conjugated (water-soluble) Excreted into gall-bladder

(where it is stored ) , and into intestine - Inside Intestine A portion of bilirubin is excreted via feces , whereas some is

metabolized by intestinal bacteria and excreted via urine2. JAUNDICE :- Jaundice occurs if there is a dysfunction in the normal metabolism and/ or excretion of bilirubin, which can occur at various stages………………………….

PATHOPHYSIOLOGY OF JAUNDICE :

3. TYPES(PATHOLOGICAL STAGES) OF JAUNDICE :I. PRE-HEPATIC JAUNDICE (PROBLEM ARISES BEFORE SECRETION TO LIVER) :- Due to various conditions Excessive destruction (hemolysis ) of RBCs occurs Causes

rapid increase of bilirubin levels in bloodstream Overcomes liver’s capacity to properly metabolize bilirubin Levels of UNCONJUGATED BILIRUBIN increases

- Conditions that are associated with PRE-HEPATIC JAUNDICE include :a. Malaria b. Sickle-cell disease c. Hereditary spherocytosis d. Thalassemiae. G6PD- deficiency f. Drugs /hepatotoxins g. Autoimmune disorders……………..

CONTINUED…………………………….

II. INTRA-HEPATIC JAUNDICE (PROBLEM OCCURS INSIDE LIVER ) :- Usually occurs due to abnormalities in the metabolism and/ or excretion of bilirubin- Leads to both increase in CONJUGATED and UNCONJUGATED BILIRUBIN levels- Causes of INTRA-HEPATIC JAUNDICE include:a. Acute/ chronic viral hepatitis b. Alcohol related hepatitis c. Liver cancer d. Cirrhosis 9due to various conditions) e. Drugs/ other toxins f. Gilbert’s disease g. Criggler-Najjar syndrome h. Autoimmune disorders………………………..

CONTINUED………………………………

III. POST-HEPATIC JAUNDICE (PROBLEM ARISES AFTER BILIRUBIN IS PROCESSED) :- Occurs due to disruption(obstruction) in normal drainage and excretion of

CONJUGATED BILIRUBIN in the form of BILE from LIVER into INTESTINE- Leads to increased levels of CONJUGATED BILIRUBIN in the bloodstream- Factors responsible for POST-HEPATIC JAUNDICE include:a. Gallstones b. Cancers of pancreas, gallbladder or bile duct c. Cholangitisd. Strictures of bile ducts e. Pancreatitis f. Parasites (e.g. : Liver flukes)………………………

Continued……………………………..

4. CONJUGATED VS UNCONJUGATED BILIRUBINEMIA :4- Bilirubin is a yellow colored pigment, responsible for the yellow colour of bruises and yellowish discoloration of urine- Old RBCs pass through spleen macrophages eat them up broken down into UNCONJUGATED BILIRUBIN (water-insoluble) sent to liver liver conjugates bilirubin with GLUCURONIC ACID renders it water-soluble (CONJUGATED BILIRUBIN) Most of this conjugated bilirubin goes into bile and out into the intestine……….- Some of the CONJUGATED BILIRUBIN Remains in Large intestine gets metabolized into UROBILINOGEN Then converted into STERCOBILINOGEN Gives feces its “Brown colour”

CONTINUED………………………………

- If you have an increase in serum bilirubin, it could be either because you are making too much bilirubin (due to increased hemolysis) , or because you are having a hard time properly removing the bilirubin from the system (either your bile ducts are blocked, or there is a liver problem, like cirrhosis, hepatitis, or an inherited problem with bilirubin processing )

- If you have lots of UNCONJUGATED BILIRUBIN in your blood It means that bilirubin hasn’t been through the liver yet So either you have got a situation, where you have got lots of HEME being broken down (exceeding the pace of liver conjugation) , or there is something wrong with liver’s conjugating capacity (for e.g. , in congenital disorders, where you are missing any requisite for conjugation- Like In Gilbert’s Syndrome)

- If you have lots of CONJUGATED BILIRUBIN in your blood It means that bilirubin has been through the conjugation process in liver But something is preventing the secretion of bilirubin into gallbladder (due to hepatic/ biliary obstruction) Thus, bilirubin gets backed up into blood………………………..

Continued…………………………………..

1. Pale colored stools 13. Confusion2. Dark- colored urine 14. Abdominal pain3. Skin itching 15. Headache4. Nausea 16. Swelling of legs5. Vomiting 17. Swelling and abdominal distention……..6. Rectal bleeding7. Diarrhea8. Fever9. Chills10. Weakness11. Weight loss12. Anorexia

CLINICAL MANIFESTATIONS OF JAUNDICE :

1. ELECTROLYTE ABNORMALITIES2. ANEMIA3. BLEEDING4. INFECTIONS/SEPSIS5. CHRONIC HEPATITIS6. CANCER7. LIVER FAILURE8. RENAL FAILURE9. HEPATIC ENCEPHALOPATHY (BRAIN DYSFUNCTION)10. DEATH………………………………..

COMPLICATIONS OF JAUNDICE :

1. HEREDITARY FACTORS :- Thalassemia- Hereditary spherocytosis2. Increased alcohol consumption3. Viral hepatitis4. Liver disease/ cancer5. Acetaminophen overdose………………………………………

RISK FACTORS OF JAUNDICE :

I. BLOOD TESTS:- CBC (Complete Blood Count)- LFTs (Liver Function Tests) To check BILIRUBIN levels- LIPASE/ AMYLASE levels to detect inflammation of pancreas

(PANCREATITIS)- Electrolytes panel- Additional tests, depending on initial results and history provided to the

practitioner/ physician………..

II. URINANALYSIS :- Urine is analyzed, which helps in the diagnosis of many underlying diseases…….

DIAGNOSIS OF JAUNDICE :

III. IMAGING STUDIES :Includes:A. ULTRASOUND SCANNING:- Safe, painless, imaging study- Usage of sound waves examines liver, gallbladder and pancreas- Useful to detect gallstones and dilated bile ducts- Can identify LIVER and PANCREATIC problemsB. CT (COMPUTED TOMOGRAPHY) SCAN:- Similar to X-RAY- Provides satisfactory details of all abdominal organs- Not as effective as Ultrasound in detecting gallstones- Helps in identification of other abnormalities of LIVER, PANCREAS, and ABDOMINAL

organs as well

Continued…………………………………….

C. CHOLESCINTIGRAPHY (HIDA SCAN) :- In HIDA scan Radioactive substance is used helps in evaluation of gallbladder

and liver ducts functioningD. MRI (MAGNETIC RESONANCE IMAGING ) SCAN :- In MRI Magnetic field is used examines organs of abdomen- Useful for DETAILED IMAGING OF BILE DUCTSE. ENDOSCOPIC RETTROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP):- In this procedure an ENDOSCOPE (a tube, with camera at ends ) introduced

through mouth and into small intestine dye is injected into bile ducts X-Rays are taken

- Useful to identify STONES, TUMORS, or BILE DUCTS NARROWING……..

CONTINUED…………………………………………

IV. LIVER BIOPSY :- In this procedure a needle is inserted into liver (after LOCAL ANESTHETIC

administration) guided by ULTRASOUND to facilitate needle placement small sample of liver tissue is taken sent to laboratory for examination by a PATHOLOGIST (Physician, who specializes in diagnosis of tissue samples )

- Useful to diagnose LIVER INFLAMMATION, CIRRHOSIS and CANCER………….

CONTINUED………………………………………………

INCLUDES:- GOALS OF THERAPY- GENERALIZED TREATMENT OF JAUNDICE- PREVENTION OF JAUNDICE

MANAGEMENT OF JAUNDICE :

- Management of underlying condition associated with JAUNDICE- Symptomatic relief- Supportive care implementation- Medication adherence- Prevention of progression into complications- To achieve recovery, as soon as possible- To prevent recurrence of the disease- To avoid hepatotoxins and counsel patients regarding the same- To implement prompt therapeutic measures, based on appropriate justifiable

diagnosis- To improve QOL (Quality Of Life)………………………….

1. GOALS OF THERAPY :

- Mainly depends on UNDERLYING CONDITIONS , leading to JAUNDICE/other POTENTIAL COMPLICATIONS

- SELF CARE AT HOME : Vital part of JAUNDICE MANAGEMENT- Supportive care assists in alleviation of JAUNDICE SYMPTOMS- Maintain ADEQUATE HYDRATION by drinking fluids- Focus on ADEQUATE REST- Take medications only as needed- Avoid medications, herbs / supplements, which may cause detrimental hepatic side

effects- PUT A BAN ON ALCOHOL CONSUMPTION (Especially for CIRRHOSIS,

ALCOHOLIC HEPATITIS and ACUTE PANCREATITIS patients)

2.. GENERALIZED TREATMENT OF JAUNDICE :

- MEDICAL TREATMENTS:• Depends on precipitating causes, which may include :a. SUPPORTIVE CAREb. I.V fluids : For DEHYDRATIONc. Medications for NAUSEA, VOMITING and PAINd. ANTIBIOTICS : For CHOLANGITISe. ANTI-VIRALS : For VIRAL involvements, including VIRAL HEPATITISf. BLOOD TRANSFUSIONSg. STEROIDS : For AUTOIMMUNE DISORDERSh. CHEMOTHERAPY/ RADIATION THERAPY : For HEPATIC CANCERSi. PHOTOTHERAPY : In NEONATAL JAUNDICE

CONTINUED………………………………………….

• For patients with diarrhea Give LACTULOSE • BLOOD TRANSFUSIONS Applicable for individuals with ANEMIA from

HEMOLYSIS / as a result of BLEEDING• For individuals with CANCER leading to JAUNDICE recommend

ONCOLOGIST CONSULTATION Treatment varies, depending upon the STAGING OF CANCER

- SURGERY :• Required for certain patients• Certain patients with GALLSTONES may require surgery• Other individuals with LIVER FAILURE / CIRRHOSIS may require a LIVER

TRANSPLANT

CONTINUED………………………………………..

URSODEOXYCHOLIC ACID (LIVOKIND):- Hepatoprotective drug- Also finds application in solubilizing gallstones- ADR:a. Increased liver enzyme valuesb. Calcification of cholesterol stones- CONTRAINDICATION:a. Intestinal disorders b. Chronic liver disease- DOSE:ADULT: 10-15 mg/kg/day , in 2-4 divided doses…………………….

CONTINUED……………………………………….

1. MEDICATION ADHERENCE is important prevents potential LIVER DAMAGE and / or UNINTENTIONAL OVERDOSE

2. For individuals with G6PD or CIRRHOSIS Discuss with physician before taking medications

3. Avoid HIGH RISK BEHAVIOURS like:- Unprotected sexual intercourse- i.v drug abuse4. Implement UNIVERSAL PRECAUTIONS, when working with BLOOD PRODUCTS and NEEDLES Decreases risk of HEPATITIS ‘B’ and ‘C’5. Avoid potentially contaminated food products / unsanitary water Decreases rrisk of HEPATITIS ‘A’

3. PREVENTION OF JAUNDICE :

6. When travelling to areas, where MALARIA is endemic take recommended precautions and prophylactic medications Decreases risk of contracting MALARIA

7. MODERATE to NEGLIGIBLE ALCOHOL CONSUMPTION is warranted8. Avoid SMOKING MAJOR RISK FACTOR FOR DEVELOPMENT OF

PANCREATIC CANCER and ASSOCIATED MALIGNANCIES9. Vaccinations for HEPATITIS ‘A’ and ‘B’ will also help prevent the same10. Avoid PARACETAMOL OVERCONSUMPTION. FOR PARACETAMOL

TOXICITY/ OVERDOSE Focus on N-ACETYL CYSTEINE (625 mg)………………….

Continued……………………………………

NEONATAL JAUNDICE – A DETAILED INSIGHT

GENERAL INTRODUCTION EPIDEMIOLOGY ETIOPATHOGENESIS SIGNS AND SYMPTOMS MANAGEMENT

CONTENTS OF NEONATAL JAUNDICE:

- Caused by several different conditions- Normal physiological consequence of NEWBORN’S IMMATURE LIVER- Even though NEONATAL JAUNDICE is usually harmless under these

circumstances Newborns, with excessively elevated levels of bilirubin from other medical conditions (pathological jaundice)/ SULPHONAMIDE TOXICITY May suffer devastating effects ,with respect to brain damage( KERNICTERUS), if the underlying cause is not properly diagnosed

- Common happening among NEONATES……………………………………

GENERAL INTRODUCTION :

1. 50% of TERM and 80% of PRETERM infants develop jaundice, typically 2-4 days after birth

2. In a 2003 study in the UNITED STATES 4.3% of 47,801 infants had high total serum bilirubin levels, as per 1994 AAP (American Academy of Pediatrics ) guidelines

3. Incidences are higher in those living at high altitudes4. In Denmark, 9 in 1,00,000 infants developed ACUTE BILIRUBIN

ENCEPHALOPATHY5. Increased incidence observed in EAST ASIAN, AMERICAN

INDIANS, and GREEK DESCENDANTS…………………

EPIDEMIOLOGY OF NEONATAL JAUNDICE :

Can be caused by the following reasons :I. PHYSIOLOGICAL JAUNDICE :- Evident on 2nd and 3rd days of life- Most common form- Usually TRANSIENT and HARMLESS- Caused by INABILITY of NEWBORN’S IMMATURE LIVER to PROCESS

BILIRUBIN from ACCELERATED RBC BREAKDOWN that occurs at this age- As newborn’s liver matures jaundice eventually disappears……………

ETIOPATHOGENESIS OF NEONATAL JAUNDICE :

II. MATERNAL-FETAL BLOOD GROUP INCOMPATIBILITY (Rh, ABO):- Incompatibility between blood types of mother and fetus increased breakdown of fetus

RBCs (hemolysis) increased bilirubin levels

III. BREAST MILK JAUNDICE :- Occurs in breastfed newborns- Appears at 1st week of life- Occurs due to certain chemicals in breastmilk- Harmless condition- Resolves spontaneously- Mothers do not have to discontinue breastfeeding…………………….

Continued…………………………….

IV. BREAST-FEEDING JAUNDICE :- Occurs when breastfed newborn does not receive sufficient breast milk- Delayed / insufficient milk production by mother / poor feeding by newborn

dehydration and fewer bowel movements occurs decreased excretion of bilirubin from body

V. SULPHONAMIDE TOXICITY:- SULPHONAMIDES (sulphasalazine, sulphamethoxazole, etc) increase

hemolysis KERNICTERUS occurs precipitates NEONATAL JAUNDICE- Thus, SULPHONAMIDES are not preferred for NEONATES or

INFANTS……………….

Continued……………………………..

VI. CEPHALOHEMATOMA :- Phenomenon of “collection of blood under scalp”- During birth process (parturition) newborn may sustain bruises / injury to head

blood collection / blood clots under scalp As this blood is naturally broken down Sudden increased levels of BILIRUBIN occurs overwhelms processing capacity of newborn’s immature liver NEONATAL JAUNDICE occurs………………………..

CONTINUED……………………………….

POOR FEEDING LETHARGY CHANGES IN MUSCLE TONE HIGH-PITCHED CRYING SEIZURES……………………………

Signs and symptoms of NEONATAL JAUNDICE :

I. PHOTOTHERAPY:- Take baby expose to UV light for 30 minutes- 1 hour INSOLUBLE BILIRUBIN is

converted into SOLUBLE LUMIRUBIN Excreted via URINE

II. ADEQUATE MILK INTAKE (IN CASES OF BREAST-FEEDING JAUNDICE )III. SODIUM PHENOBARBITAL :- More preferred than orally given L-TRIIODOTHYRONINE (0.05-0.1 mg/day) , i.m HUMAN

GROWTH HORMONE (1 mg/day) , or TESTOSTERONE PROPIONATE (0.1 mg/day)- Drug Potent ENZYME INDUCER Induces enzymes that increase LIVER METABOLISM

Decreases BILIRUBIN LEVELS in blood- Dose : 5 mg/kg orally- For PROPHYLAXIS : 10 mg/kg (within 1st 6 hours of life ) follow with 5 mg/kg till day ‘5’

of life

MANAGEMENT OF NEONATAL JAUNDICE :

IV. I.V IMMUNEGLOBULIN :- Given at 500 mg/kg- Shown to significantly reduce need for exchange transfusion

in infants, with ISOIMMUNE HEMOLYTIC DISEASE……………………………..

CONTINUED…………………………………………

1. FOCUS ON ALCOHOL CESSATION2. FOCUS ON SMOKING CESSATION3. AVOID ACETAMINOPHEN OR HEPATOTOXIC DRUGS OVERDOSE4. RADISH LEAVES:- Take 1 cup of radish juice add 1 tsp paste of basil leaves have this juice twice a day for

15-20 days5. SUGARCANE JUICE :- Take 1 glass of pure sugarcane juice mix with half lime juice consume twice a day6. BARLEY :- Add 1 tsp of roasted barley powder to 1 cup of water add 1 tsp honey to it consume twice a day

PATIENT COUNSELLING TIPS/ HOME REMEDIES FOR JAUNDICE :

7. LEMONS:- Beneficial in jaundice treatment- Take 20 ml of lemon juice mix with water drink several times a day- Protects damaged liver cells8. SNAKE GOURD :- Leaves of snake gourd are effective in JAUNDICE- Drink tea made with the leaves of snake gourd twice a day to ease jaundice9. TOMATO :- Take 1 glass of fresh tomato juice add a pinch of salt and pepper consume every early

morning10. JAUNDICE BERRY:- Herb, commonly known as ‘BERBERIS VULTARIS’ Take powdered bark of it, in forms of 1/4th of a tsp of 2-4 ml fluid extract EXCELLENT FOR JAUNDICE……….!!!!

CONTINUED…………………………………….

WWW.MEDICALNEWSTODAY.COM WWW.EMEDICINE.NET PHARMACOTHERAPY:A PATHOPHYSIOLOGIC APPROACH , BY

JOSEPH.T.DIPIRO and BARBARA.T.WELLS JAUNDICE: By JERRY.T.McKNIGHT and JERRY.E.WELLS

BIBLIOGRAPHY :

THANK YOU !!!

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