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Hemolytic Jaundice
Hepatic Jaundice
Obstructive
Jaundice(Cholestasis)
Congenital Jaundice
Jaundice classification
predominantly unconjugated
hyperbilirubinaemia
predominantly conjugated
hyperbilirubinaemia
Causes:
1. Increased bilirubin
production
Lead to increases in
2. Reduced bilirubin uptake
free (unconj.) bilirubin
by hepatic cells
3. Disrupted intracellular
conjugation
4. Disrupted secretion of
bilirubin into bile
canaliculi Result in rise in conj.
5. Intra/extra-hepatic bile bilirubin levels
duct obstruction
Causes of Jaundice
Pre-hepatic unconjugated hyperbilirubinaemia
Haemolysis
Congenital defects:
Gilbert’s syndrome (uptake/conjugation
defect)
Crigler-Najar (conjugation defect)
Isolated elevation of serum Bilirubin
Unconjugated Hyperbilirubinaemia
* Increase bil. production (e.g. haemolysis,
resorptionof haematoma)
* Decrease hepatocellular uptake (e.g.
rifampcin)
* Decrease conjugation (Gilbert S, Crig. Nagar S)
Conjugated Hyperbilirubinemia
* Dubin-Junson syndrome
* Roter syndrome
Causes of Jaundice
Hepatocellular
Acute Chronic
Cholestatic
Extra-hepatic Intra-hepatic
Gallstones Drugs
Carcinoma of head of Primary biliary
pancreas cirrhosis
Benign stricture Cholestatic phase of
Congenital
viral hepatitis
Traumatic
Alcoholic hepatitis
iatrogenic
Primary or secondary
Carcinoma of ampulla cancer
of Vater or bile ducts
Sclerosing Cholangitis Lymphoma
pancreatitis Pregnancy
Clinical symptoms and signs
History:
- The onset of Jaundice in viral hepatitis is
associated with a prodrome of ANV, malaise &
myalgia.
- The onset of cholestasis is insidious, it is
associated with pruritus.
- A history of fever with rigors, Rt upper abd. pain
or a past history of biliary surgery suggest
cholangitis.
- Dark urine & pale stool exclude the possibility of
haemolytic jaundice.(related autoimun).
- A history of multiple sex partners, travel, ethanol
intake, drugs, bl. transfusion, needlestick
exposure & tattooing is also important.
- Recent surgery with subsequent jaundice after one
week may suggest halothane toxicity.
- Previous biliary surgery with subsequent jaundice may
suggest stricture, residual stones or hepatitis.
- A family history of jaundice or liver disease suggests
the possibility of hereditary hyperbilirubinaemia or
genetic disorder such as Wilson disease.
- Painless jaundice in older person with epigastric mass &
weight loss = biliary obstruction from malignancy
The clinical assessment & basic biochemical
parameters lead to three broad subgroups of
patients:
1- Isolated elevation of s. bilirubin: when AST,
ALT & ALP levels are normal.
2- Hepatocellular jaundice: when the AST & ALT
levels are elevated out of proportion to the ALP
levels.
3- Cholestatic jaundice: when the ALP level is
elevated out of proportion to the AST & ALT
levels.
Examination
Pale yellow vs. deep yellow
Signs of cirrhosis,Sp.Nevy,Caput
Medusa,Gynecomasty,ascites,Palmar Erytema,.
Liver – tender, enlarged, firm, shrunken,
irregular
Gallbladder – tender (Murphy’s sign), palpable
splenomegaly
Stigmata of Chronic Liver Disease
ULTRASONOGRAPY :
EUS:ENDOS-ULTRASONO
ENDOSKOPY: GASTROSKOPY,ERCP
CT-ABDOMEN/MRI/MRCT
BIOPSI
Imaging Procedures:
ENLARGE LIVER
NORMAL
HEPATIC PARENCHYMAL
ECHODENSITY DECREASED.
ERCP / PTC
Remove stones
Stent or dilate stricture
Surgery
Cholecystectomy with bile duct exploration
Whipple’s procedure