Hepatic And Post-hepatic Jaundice

Sonal PruthiRoll Number - 82

• Defective Hepatic Uptake• Abnormal Conjugation• Hepatocellular Damage

•Gilbert’s Syndrome•Drugs

•Rifampicin•Novobiocin•Probenecid

Viral HepatitisAlcoholic Hepatitis

Drug Induced HepatitisAutoimmune hepatitis

Toxic Hepatitis

•Criggler Najjar Syndrome•Viral Hepatitis•Drugs

•Primaquine•Novobiocin•Pregnanediol•Chloramphenicol

Hepatic Jaundice

Viral Hepatitis

Hepatitis A

HBsAg

HBeAg

Total Anti-HBc

IgM Anti-HBcAnti-HBe

Anti-HBs

HBV DNA

Hepatitis B

HBV DNA

HBsAg

HBeAg

Total Anti - HBc

IgM-Anti HBc

Hepatitis C

Clinical Features- Hepatic Jaundice• Icterus• Spider telangiectasia• Asterixis• Palmar erythema• Fetor hepaticus• Gynaecomastia• Testicular atrophy• Ascites

Obstructive Jaundice

• Intrahepatic Cholestasis

• Extrahepatic Cholestasis

•Primiary Biliary Cirrhosis•Primary Sclerosing Cholangitis•Dubin Johnson Syndrome•Rotor’s Syndrome•BRIC•PFIC•Drugs - phenothiazines

•Bile duct strictures•Common duct stone.•Periampullary carcinoma

Gall bladder Stone

The majority of cases (approximately 80%)are

asymptomatic (silent) gall stones , discovered accidentally

by abdominal sonar .

Obstruction of common bile duct leading to pain &

jaundice

Periampullary Carcinoma

• CBD• Duodenum• Ampulla• Pancreas

Clinical features - Obstructive• Pain due to gallbladder disease, malignancy or

stretching of the liver capsule

• Fever due to ascending cholangitis

• Palpable and / or tender gallbladder• • Enlarged liver usually smooth

Investigations

Hepatic Post-hepaticTotal Bilirubin Increased IncreasedConjugated Bilirubin

Increased Increased

Unconjugated Bilirubin

Increased Normal

Urobilinogen Increased Decreased/ absent

Stercobilin Normal Reduced/absent

ALT and AST – RaisedALT specific for liver injury ALT>1000 IU/L - suggestive of Hepatocellular

injury

AST:ALT > 2:1 Suggestive of ALD

AST:ALT < 1Suggestive of viral hepatitis

Enzymes that reflect damage to hepatocytes

Enzymes that reflect Cholestasis

Alkaline Phosphatase – Raised large bile duct obstruction Intrahepatic cholestasis

Gamma Glutamyl transferase more sensitive marker for cholestasis as compared to

ALT

Investigations

Prothrombin Time might be increased in cases of hepatic jaundice. Disorders that lead to Vitamin K deficiency

Serum ANA and Anti Smooth Muscle Antibody positive in patients with PBC

Clinical VignetteMatch the clinical description with the most

likely disease process.• a. Primary biliary cirrhosis• b. Sclerosing cholangitis• c. Anaerobic liver abscess• d. Hepatoma• e. Hepatitis C• f. Hepatitis D• g. Hemochromatosis

• A 40-year-old white female complains of pruritus.

• She has an elevated alkaline phosphatase and positive antimitochondrial antibody test.

CHOOSE 1 DISEASE PROCESS

• A 70-year-old male with a long history of diverticulitis has low-grade

• fever, elevated alkaline phosphatase, and right upper quadrant pain.CHOOSE 1 DISEASE PROCESS

A 30-year-old male with ulcerative colitis develops jaundice, pruritus,and right upper quadrant pain.

Liver biopsy shows an inflammatory obliterative process affecting intrahepatic and extrahepatic bile ducts.

CHOOSE 1 DISEASE PROCESS

• A 40-year-old white male complains of weakness, weight loss, and abdominal pain.

• On examination, the patient has diffuse hyperpigmentation, icterus and a palpable liver edge. Polyarthritis of the wrists and hips is also noted. Fasting blood sugar is 185 mg/dL. The most likely diagnosis is

• a. Insulin-dependent diabetes mellitus• b. Pancreatic carcinoma• c. Addison’s disease• d. Hemochromatosis

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