Jaundice 　

Aims and DemandsAims and Demands 1. Grasp the concept of jaundice, clinical manifestation 1. Grasp the concept of jaundice, clinical manifestation

and points of inquisitionand points of inquisition 2. Familiar the etiology and mechanism of jaundice2. Familiar the etiology and mechanism of jaundice 3. Realize normal bilirubin metabolism3. Realize normal bilirubin metabolism

DefinitionDefinition：： jaundice,or icterus refers to the yellow appeajaundice,or icterus refers to the yellow appea

rance of the skin,scleral and mucous membranes resulting rance of the skin,scleral and mucous membranes resulting

from an increased bilirubin concentration in the body fluidfrom an increased bilirubin concentration in the body fluid

s. s. Total bilirubin: 1.7-17.1μmol/LTotal bilirubin: 1.7-17.1μmol/L Conjugated bilirubin:0-3.42μmol/lConjugated bilirubin:0-3.42μmol/l ，， Unconjugated bilirubin:1.7-13.68μmol/l.Unconjugated bilirubin:1.7-13.68μmol/l.

Liver

AlbuninHeme

Ferroheme

transferase

Bilirubin

Conjugated bilirubinKidney

Urobilin

Stercobilinogen

Urobilinogen

Intestines

Albumin

Bilirubin

reductase Heme

Globin

Hemoglobin

oxidase

Biliverdin

Marrow

Infantility ErythrocyteFerroheme Enzyme

15%~20%

Bilirubin |Albumin

Erythrocyte80%~85%

UDP UDPGA

Bilirubin glucuronolactone

urobilinogen

Enterohepatic circulation

Y/Z protein

cathepsin

Erythrocyte

Normal bilirubin

metabolism

Normal bilirubin metabolism

ClassificationClassification

1. Depending on Etiology1. Depending on Etiology Hemolytic JaundiceHemolytic Jaundice Hepatocellular JaundiceHepatocellular Jaundice Cholestatic JaundiceCholestatic Jaundice Congenital jaundiceCongenital jaundice

2. Depending on bilirubin Unconjungated bilirubing

increased jaundice Conjungated bilirubing in

creased jaundice

EtiologyEtiology 1.Congenital hemolytic anemia (1.Congenital hemolytic anemia (thalassemiathalassemia,,hereditary spherocyhereditary spherocy

tosis).tosis). 2.P2.Posteriority acquired hemolytic anemia (autoimmunity hemolyosteriority acquired hemolytic anemia (autoimmunity hemoly

tic anemia, hemolytic disease of newborn,tic anemia, hemolytic disease of newborn, posttransfusion hemolposttransfusion hemol

ytic, Favism)ytic, Favism).. MechanismMechanism A large number of erythrocyte destroyed rapidlyA large number of erythrocyte destroyed rapidly Anemia,hypoxia and toxity of erythocyte metabolism productsAnemia,hypoxia and toxity of erythocyte metabolism products

1.Hemolytic Jaundice

Haemolytic Jaundice mechanis

m

Clinical ManifestationClinical Manifestation Mild jaundice,light lemon,no skin itch.Mild jaundice,light lemon,no skin itch. Acute hemolytis: fever,chill,headache,vomit,backache,anemia, Acute hemolytis: fever,chill,headache,vomit,backache,anemia,

hemoglobinuria( dark sauce or tea), acute renal failure.hemoglobinuria( dark sauce or tea), acute renal failure. Chronic hemolysis:anemia and splenomegaly.Chronic hemolysis:anemia and splenomegaly.

Laboratory ExaminationLaboratory Examination 1.Serum TB↑,UCB↑,CB normal.1.Serum TB↑,UCB↑,CB normal. 2.UCB↑→intestinal CB↑→faecal color deepen.2.UCB↑→intestinal CB↑→faecal color deepen. 3.Intestinal Urobilinogen↑→urinary Urobilinogen↑.3.Intestinal Urobilinogen↑→urinary Urobilinogen↑. 4.Acute hemolytis, occult blood test (+).4.Acute hemolytis, occult blood test (+). 5.Blood test:anemia, reticulocyte↑,erythacyte proliferation↑. 5.Blood test:anemia, reticulocyte↑,erythacyte proliferation↑.

2.Hepatocellular Jaundice2.Hepatocellular Jaundice

EtiologyEtiology Hepatocyte damage.Hepatocyte damage. MechanismMechanism Impair hepatocyte uptakeing,conjugating and excreting biImpair hepatocyte uptakeing,conjugating and excreting bi

lirubin, UCB↑lirubin, UCB↑ CB reflux into blood, serum CB↑→jaundice.CB reflux into blood, serum CB↑→jaundice.

Hepatocellular Jaundice mechani

sm

Clinical ManifestationClinical Manifestation Skin and mucosa:light to deep yellow, mild skin itchSkin and mucosa:light to deep yellow, mild skin itch Tired,loss of appetiteTired,loss of appetite hemorrhagic tendency,ascites,coma.hemorrhagic tendency,ascites,coma. Primary disease manifestationPrimary disease manifestation

Laboratory ExaminationLaboratory Examination

1.1. CB↑, UCB↑CB↑, UCB↑

2.2. Icteric hepatitis:CB↑ ↑ UCB ↑Icteric hepatitis:CB↑ ↑ UCB ↑

3.3. Urine:CB(+),urobilinogen ↑Urine:CB(+),urobilinogen ↑

4.4. Blood test:liver demaged Blood test:liver demaged

3.Cholestatic Jaundice3.Cholestatic Jaundice EtiologyEtiology Obstruction in liver:virus hepatitis,drug caused,drug hepatitis, primary biliary cirrhosiObstruction in liver:virus hepatitis,drug caused,drug hepatitis, primary biliary cirrhosi

s.s. Obstruction of Extrahepatic bile duct:narrow, obstruction,stone, inflammtory,tumor.Obstruction of Extrahepatic bile duct:narrow, obstruction,stone, inflammtory,tumor. MechanismMechanism Obstruction causes small bile duct and bile capillary broken, conjugated bilirubin refluObstruction causes small bile duct and bile capillary broken, conjugated bilirubin reflu

x to blood.x to blood. Failure of hepatocyte excreting CB,bilirubin deposit and bile thrombus formation.Failure of hepatocyte excreting CB,bilirubin deposit and bile thrombus formation.

Cholestatic Jaundice mechanism

Clinical featuresClinical features Skin dark yellow,yellow green.Skin dark yellow,yellow green. Skin itch, bradycardia,dark yellow of urine,facaSkin itch, bradycardia,dark yellow of urine,faca

l light yellow or clay color. l light yellow or clay color. Courvoisier’s sign.Courvoisier’s sign.

Laboratory ExaminationLaboratory Examination Serum CB↑Serum CB↑ Urine bilirubin (+)Urine bilirubin (+) Urobilinogen , stercobilin ↓or absenceUrobilinogen , stercobilin ↓or absence Serum alkaline phosphatase and CholesteSerum alkaline phosphatase and Choleste

rol↑rol↑

Three kinds of jaundice laborotory examination indentifiThree kinds of jaundice laborotory examination indentificationcation

Class Haemolytic Hepatocellular CholestaticClass Haemolytic Hepatocellular Cholestatic

TB increasedTB increased(UCB(UCB) increased increased) increased increased

CB normal increased markedly increased CB normal increased markedly increased

CB/TB CB/TB ＜＜ 1515 ％一％一 2020 ％ ＞％ ＞ 3030 ％一％一 4040 ％ ＞％ ＞ 5050 ％一％一 6060 ％％ urine bilirubin — urine bilirubin — 十 十十十 十十 urobilinogen increased slight increased decreased or absenceurobilinogen increased slight increased decreased or absence

ALTALT 、、 AST normal markedly increased may increasedAST normal markedly increased may increased

ALP normal increased markedly increased ALP normal increased markedly increased

r-GT normal increased markedly increasedr-GT normal increased markedly increased

PT normal delayed delayedPT normal delayed delayed

Vit K respond no poor goodVit K respond no poor good

Cholesterol normal slight increased or decreased markedly increasedCholesterol normal slight increased or decreased markedly increased

Serum protein normal Alb decreased,Glob increased normalSerum protein normal Alb decreased,Glob increased normal

4.Congenital Nonhemolytic Jaundice 4.Congenital Nonhemolytic Jaundice

Due to the deficiency of the hepatocyte in uptakeiDue to the deficiency of the hepatocyte in uptakei

ng,conjugating and excreting bilirubinng,conjugating and excreting bilirubin UncommonUncommon

1.Gilber syndrome:hepatocyte uptaking UCB abnormal, def1.Gilber syndrome:hepatocyte uptaking UCB abnormal, def

iciency of glucuronyl transferase, →UCB↑ →jaundice (no iciency of glucuronyl transferase, →UCB↑ →jaundice (no

symptom,liver function normal).symptom,liver function normal). 2.Dubin-Johnson’s syndrome:abnormal of Hepatocyte excr2.Dubin-Johnson’s syndrome:abnormal of Hepatocyte excr

eting CB and some anion to bile capillary →CB↑ →jaundiceting CB and some anion to bile capillary →CB↑ →jaundic

e.e. 3.Crigler-Najjar’s syndrome:absence of glucuronyl transfer3.Crigler-Najjar’s syndrome:absence of glucuronyl transfer

ase in hepatocyte, UCB can’t be transfered to CBase in hepatocyte, UCB can’t be transfered to CB ，， serum serum

UCB↑→jaundice,UCB↑↑↑→nuclear jaundic, newborn,poor UCB↑→jaundice,UCB↑↑↑→nuclear jaundic, newborn,poor

prediction.prediction. 4.Rotor’s syndrome:deficiency of Hepatocyte uptaking UC4.Rotor’s syndrome:deficiency of Hepatocyte uptaking UC

B and excreting CB,→bilirubin↑→jaundice.B and excreting CB,→bilirubin↑→jaundice.

Accessory Examination Accessory Examination

1.Ultrosound1.Ultrosound 2.X ray2.X ray 3.ERCP3.ERCP(Endoscopic retrograde cholangiopancreatography) 4.PTC4.PTC(Percutaneous transheptic cholangiography) 5.CT5.CT(Computed tomography)) 6.MRI6.MRI(Magnetic resonance cholangiopancreatography) 7.Radio Nuclide Examination7.Radio Nuclide Examination 8.Liver Biopsy and LC8.Liver Biopsy and LC(Laparoscopy)

Accompanying Symptoms Accompanying Symptoms

1.1. Fever:acute cholangitis,liver abscess, leptospirosis, septicFever:acute cholangitis,liver abscess, leptospirosis, septic

emia, lobar pneumonia.Fever then jaundice:virus hepatitemia, lobar pneumonia.Fever then jaundice:virus hepatit

is,acute hemolysis.is,acute hemolysis.

2.2. Upper abdominal sharp pain:biliary calculi,liver abscess, Upper abdominal sharp pain:biliary calculi,liver abscess,

biliary ascariasis,biliary ascariasis,

Right upper abdom sharp pain,chill, high fever,jaundice, Right upper abdom sharp pain,chill, high fever,jaundice,

Charcot triad sign:acute pyogenic cholangitis,Charcot triad sign:acute pyogenic cholangitis,

Sustained right upper abdominal blur or swell pain:virus Sustained right upper abdominal blur or swell pain:virus

hepatitis,liver abscess,primary carcinoma of liverhepatitis,liver abscess,primary carcinoma of liver

3.3. HepatomegalyHepatomegaly

① ①Mild or moderate,soft or moderate hard,smooth surfMild or moderate,soft or moderate hard,smooth surf

ace:Virus hepatitis,acute infection of biliary tract.obstrace:Virus hepatitis,acute infection of biliary tract.obstr

uction of biliary tractuction of biliary tract

② ②Obvious enlargement, hard, ragged surface:primary Obvious enlargement, hard, ragged surface:primary

or secondary carcinoma of liver.or secondary carcinoma of liver.

③ ③Not obvious enlargement,hard,edge not tidy,nodule Not obvious enlargement,hard,edge not tidy,nodule

on the surface:cirrosis.on the surface:cirrosis.

4.4. Gallbladder enlargement:common bile duct obstructioGallbladder enlargement:common bile duct obstructio

n, n,

pancrease head carcinoma,common bile duct carcinoma,pancrease head carcinoma,common bile duct carcinoma,

carcinoma of ampulla.carcinoma of ampulla.

5.5. Splenomegaly:virus hepatitis,leptospirosis, septicemia, Splenomegaly:virus hepatitis,leptospirosis, septicemia,

Malaria,biliary cirrhosis,hemolytic anemia,lymphoma.Malaria,biliary cirrhosis,hemolytic anemia,lymphoma.

6.6. Acite:serious hepatitis,decompensation of cirrosis, Acite:serious hepatitis,decompensation of cirrosis,

carcinoma of liver.carcinoma of liver.

Interrogatoire Interrogatoire Points Points

1.Assure jaundice1.Assure jaundice 2.Etiology and onset 2.Etiology and onset 3.Accompany syndrome3.Accompany syndrome 4.Time and fluctuation of jaundice4.Time and fluctuation of jaundice 5.Influnce to the overall health5.Influnce to the overall health In one word: make sure the type of jaundice then fiIn one word: make sure the type of jaundice then fi

nd the pathogenynd the pathogeny

Recognise jaundiceRecognise jaundice

PositionPosition：： sclera,skin and sclera,skin and tongue sleevestongue sleeves

Pseudojaundice:Pseudojaundice:eat eat Carotene food(Carotene,pumpkinCarotene food(Carotene,pumpkin, tomat, tomat

o,orange)also can cause skin stained yellow,but bilirubin is o,orange)also can cause skin stained yellow,but bilirubin is

not increased. not increased.

Old people fat Old people fat accumulation at bulbar conjunctivaaccumulation at bulbar conjunctiva ，， yelloyello

w,w,uneven distributionuneven distribution

Jaundice is a common symptom and sign in clinical work,

get to know the mechanism can help us identify different kin

ds of jaundices. hemolytic jaundice is due to the rapidly destr

oyed erythocyte, so the UCB increased. hepatocellular jaundi

ce refers to uptakeing,conjugating and excreting bilirubin, so

both CB and UCB increased. Cholestatic jaundice due to the

obstruction of bile track, so the CB increased and urine biliru

bin positive.

Summary

1.A 13 years old male, chief complaints “Finding skin and

sclera yellow and feeling right upper abdomen swell pain for

1 week”

What are the possible diagnoses and your suggested

examinations.

Question

Reference booksReference books

Cecil mecidine 23Cecil mecidine 23rdrd edition. edition.

Davidson’ principles and practice of medicine.Davidson’ principles and practice of medicine.

Harrison's principles of internal medicine.16Harrison's principles of internal medicine.16thth edition. edition.