{ Jaundice Clinical round By Dr. Ehab M. Oraby. Yellowish discoloration of: Tissues ex. Sclera...

{Jaundice

Clinical roundByDr. Ehab M. Oraby

2Dr. Ehab M. Oraby

Yellowish discoloration of: Tissues ex. Sclera and palate except

brain. Body fluids urine and stool except CSF,

tears and saliva.

Definition

3Dr. Ehab M. Oraby

Destruction of RBCs release of HB Haeme + Globin

Haeme iron + bilirubin (in unconjugated form = water insoluble).

Conjugation occurs in liver (bilirubin becomes water soluble).

Pathophysiology:

4Dr. Ehab M. Oraby

Secretion of conjugated form of bilirubin to biliary tract then to GIT stool coloration.

Some of conjugated bilirubin absorbed from GIT to circulation renal excretion.

Pathophysiology:

5Dr. Ehab M. Oraby

Hemolytic Anemia: Young age. Congenital or Acquired. Attacks of “crisis” ++ Hemolysis ++

unconjugated bilirubin, ++ conjugation, ++ conjugated bilirubin dark stool & normal urine.

Pathophysiology:

6Dr. Ehab M. Oraby

Hemolytic Jaundice: Anemia (chronic with periodic

exacerbations). During attacks diffuse abdominal pain +

bony pains + fever with rigors. Splenomegaly. Gall stones “pigment stones”. Leg ulcers.

Pathophysiology:

7Dr. Ehab M. Oraby

Hepatocellular Jaundice: Any age. Mostly viral hepatitis cirrhosis. Others:

drug induced hepatitis.

Pathophysiology:

8Dr. Ehab M. Oraby

Hepatocellular Jaundice: Liver fail to conjugate bilirubin + fail to

properly secrete conjugated fraction to biliary tree ++ blood level of conjugated bilirubin and bile salts.

Conjugated bilirubin jaundice + excreted in urine dark urine.

Bile salts in blood pruritus. Stool is normal.

Pathophysiology:

9Dr. Ehab M. Oraby

Hepatocellular Jaundice: Other stigmata of LCF: gynecomastia,

spider naevi, palmar erythema, ascites and lower limb edema

Pathophysiology:

10Dr. Ehab M. Oraby

Obstructive Jaundice: Failure of bile drainage ++ blood level

of conjugated bilirubin and bile salts jaundice, dark urine, pale clay stool and pruritus.

Obstruction is either calcular or malignant.

Pathophysiology:

11Dr. Ehab M. Oraby

Calcular obstruction: Females, Middle age. By gall stone impacted in ampulla of vater.

Pathophysiology:

12Dr. Ehab M. Oraby

Calcular obstruction: Intermittent jaundice + pain “biliary” +

fever.

Pathophysiology:

13Dr. Ehab M. Oraby

Calcular obstruction: Gall Bladder is non-palpable except in cases with:

double impaction or strategic impaction.

Pathophysiology:

14Dr. Ehab M. Oraby

Re Calcular obstruction: Females, Middle age. By gall stone impacted in ampulla of vater. Intermittent jaundice + pain “biliary” + fever. Gall Bladder is non-palpable except in cases with double impaction or

strategic impaction.

Pathophysiology:

15Dr. Ehab M. Oraby

Malignant Obstruction: Males, old age. By:

Pancreatic head tumors Malignant LN in porta hepatis Bile duct cancer”cholangiocarcinoma”.

Pathophysiology:

16Dr. Ehab M. Oraby

Malignant Obstruction: Painless except late. Epigastric pain referred to back patient

position is leaning forward.

Pathophysiology:

17Dr. Ehab M. Oraby

Malignant Obstruction: Jaundice is progressive except:

in cases with peri-ampullary carcinoma.

Pathophysiology:

18Dr. Ehab M. Oraby

Malignant Obstruction: Gall Bladder is palpable “courvoiser law”

except in cases with: double pathology “cancer + gall stone” or malignant LN ???coming from cancer Gall

Bladder.

Pathophysiology:

19Dr. Ehab M. Oraby

ReMalignant Obstruction: Males, old age. By:

Pancreatic head tumors Malignant LN in porta hepatis Bile duct cancer”cholangiocarcinoma”.

Painless except late. Epigastric pain referred to back patient position is leaning forward.

Jaundice is progressive except in cases with peri-ampullary carcinoma.

Gall Bladder is palpable “courvoiser law” except in cases with double pathology “cancer + gall stone” or malignant LN ??? coming from cancer Gall Bladder.

Pathophysiology:

20Dr. Ehab M. Oraby

21Dr. Ehab M. Oraby

General examination Look Fascies Complexion Body built and position Vital signs Regional survey

Examination

22Dr. Ehab M. Oraby

Local abdominal examination: Inspection:

General look: Movement with respiration Contour Scars Dilated veins Pigmentation

Specific look: Subcostal angle Linea alba Umbilicus Hair distribution Hernial orifices

Examination

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Palpation: Superficial palpation Deep palpation:

Liver Gall Bladder Spleen Lymph Nodes swelling

Examination

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Percussion: Liver Gall Bladder Spleen Ascites Swelling

Auscultation: Venous hum with portal hypertension

Examination

25Dr. Ehab M. Oraby

Anatomical Pathophysilogical Functional

Diagnosis