JAUNDICEBYDr

HAYDER M. ABDULNABICABS

Jaundice – Classification

Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg%

Jaundice is increased levels of SB > 1.0 mg%

Over production of Bilirubin (Hemolytic)

From hemolysis of RBC

Impaired hepatic function (Hepatitic)

Hepatocellular dysfunction in handling bilirubin

Uptake, Metabolism and Excretion of bilirubin

Obstruction to bile flow (Obstructive)

Intrahepatic cholestasis

Extrahepatic Obstruction (Surgical Jaundice)

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Clinical Aspects of Jaundice

Clinically detectable if SB is >3 mg%

With edema and dark skin – Jaundice is masked

What is special about the sclera ? – Rich Elastin

Darkening of the urine – Differential Diagnosis

Skin discoloration – Yellowish, - Carotinemia – Eyes N

Mucosa – hard palate (in dark skinned)

Greenish hue of skin and sclera - due Biliverdin – indicates

long standing jaundice ( CA head pancreas )

Generalized Pruritus – Obstructive Jaundice – Why ?

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Clinical History – Imp cluesDuration of jaundice – Acute / ChronicAbdominal pain v/s painless jaundiceFever – Viral / bacteria /sepsisScraches-Pruritus - obstructiveAppetite – Hepatocellular / MalignancyWeight loss – Malignancy Colour of stools –chalky white –obstructiveFamily history – Hemolytic – Inherited dis.H/o transfusionAlcohol abuse, Medications – INH, EM, Largactil

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Coloured Urine – Differ. Diagnosis

Bilirubin in urine due to Jaundice (CB)Concentrated urine in dehydration Sulfasalazine use – for Ulcerative colitisRifampicin, Pyridium and Thiamine useRed urine – Porphyria, Hemoglobin & Myoglobinuria, HematuriaMelanin excretion from Melanoma-blackfood

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Fate of RBC

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• RBC life span in blood stream is 90-120 days

• Old RBCs are phagocytosed and/or lysed

• Lysis occurs extravascularly in the RE system subsequent to RBC phagocytosis

• Intravascular Hemolysis of young RBC

• This is due to hemolytic diseases of RBC

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E V Pathway for RBC Scavanging

Liver, Spleen & Bone marrow

Hemoglobin

Globin

Amino acids

Amino acid pool

Heme Bilirubin

Fe2+

Excreted

Phagocytosis & Lysis

Through Liver

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Bilirubin Metabolism - Summary

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Bilirubin handling in Kidney

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How to clinically evaluate the patient ?

What tests will help us in D.D ?

What imaging modalities will be useful ?

How to monitor the progress ?

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ALGORITHMIC APPROACH FOR JAUNDICE

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First Step

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Second Step : If SB > 1.0 mg

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Third Step : If CSB is increased

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Fourth Step : Hepatocellular

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What imaging we need

• Ultrasonography – 98% Sp, 90% Sen.

• For GB stones USG better than CT

• For duct stones –only 40% seen in USG

• PTC – Extrahepatic obstr. – drainage

• ERCP – Distal biliary obstruction Dx.Rx.

• MRCP – Most useful for duct stoneswww.drsarma.in 15

Post hepatic Obstructive Jaundice• Painful v/s painless

• Obstruction can be

– Intra Luminal -(stone), hydatit cysts worms

– Luminal- Stricture (benign v/s

cholangiocarcinoma), periampulary ca

– Klatskin tumor

– Extra luminal pancreatic cancer,. lymph nodes,

choledocal cyst

• Investigate & treat with

– Radiology (US, CT, MRCP)

– ERCP / PTC

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• A Klatskin tumor (or hilar cholangiocarcinoma) is a cholangiocarcinoma (cancer of the biliary tree) occurring at the confluence of the right and left hepatic bile ducts. It is named after Dr. Gerald Klatskin, an American physician working at Yale.

Acute Cholecystitis

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GB wall is thickened and striated.Courtesy of Udo Schmiedl, M.D.

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Magnetic Resonance Cholangio-Pancreatography

(MRCP)

Two stones in the common bile ductTwo stones in the common bile duct

Courtesy of Udo Schmiedl, M.D.Courtesy of Udo Schmiedl, M.D.

Retrograde Cholangiogram - ERCP

Bile leak from the cystic duct after cholecystectomy Courtesy of Michael

Kimmey, M.D.

Primary sclerosing cholangitis (PSC) with stricture due to cholangiocarcinoma. Courtesy of Robert L.

Carithers, Jr., M.D.

Retrograde Cholangiogram - ERCP

Irregular dilation of intrahepatic and extrahepatic ducts.Courtesy of Charles Rohrmann, M.D.

Retrograde Cholangiogram - ERCP

Primary Sclerosing Cholangitis

Normal Extra hepatic BD

Narrowed abnormal intra-heptic bile ducts.

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PRE-OPERATIVE MANAGEMENT OF OBSTRUCTIVE JAUNDICE

1. HIGH INTAKE OF GLUCOSE (BUILD UP LIVER GLYCOGEN STORE)2. VITAMIN K (FAT SOLUBLE), 10mg IV OR IM3. ANTIBIOTICS (BROAD SPECTURUM)4. HYDRATION (PREVENT RENAL FAILURE) (5% DEXTROSE TO ENSURE 30 ml/HOUR URINE FLOW)5. DIURESIS – MANNITOL- 200ML REGIMEN

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SURGICAL PROCDURES1. ENDOSCOPIC PAPILLOTOMY (DORMIA BASKET, BALLOON CATHETER)(STENT TO RELIEVE SYMPTOMS)2. PERCUTANEOUS REMOVAL OF STONES BY BURHENNE METHOD (T- TUBE LEFT FOR SIX WEEKS AND THEN REMOVED, DILATION OF THE MATURE TRACT, STEERABLE CATHETER, AND THEN STONE BASKET)3. PERCUTANEOUS BILIARY DRAINAGE (PTC), IN THE VERY ILL4. SUPRADUODENAL CHOLEDOCHOTOMY WITH OR WITH OUT TRANSDUODENAL SPHINCTEROTOMY OR CHOLEDOCHODUODENOSTOMY5. STENTING

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EXPLORATION OF THE CBD

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DORMIA BASKET

ERCP

DILATED CBD

Ascending cholangitis

• Physical examination findings typically include jaundice and right upper quadrant tenderness.

• Charcot's triad is a set of three common findings in cholangitis: abdominal pain, jaundice, and fever.

Causes•OBSTRUCTION

•GALL STONES 10-30% of cases•CA•TRAUMATIC-- ERCP

• TESTS

• MANAGEMENT