Jaundice By Dr. Kenny
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Transcript of Jaundice By Dr. Kenny
JAUNDICEJAUNDICE
Definition• Is a yellowish
pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood).
Pathophysiology
Pre-hepatic
Hepatic
Post-hepatic
Entero-hepatic Circulation
Etiology1.Unconjugated hyperbilirubinaemia• Pre-hepatic- increases the load of bilirubin to be metabolized by the liv
er 2.Conjugated hyperbilirubinaemia• Hepatocellular-damages or reduces the activity of the transferase enzyme
or hepatocyte • Post-hepatic-also called obstructive jaundice, is caused by an interrupti
on to the drainage of bile in the biliary system
Etiology• Pre-hepaticHemolytic anemias;Polycythemia; Shortened red cell life as a result of immaturity
or transfused cells ;Drug induced (antimalarias);G-6PD;etc.• HepatocellularViruses:Hepatitis(A,B,C,D,E);CMV,EBV;Drugs;Autoimmune Hepatitis;Wilson's Dise
ase;Right Heart Failure;Drug induced(Paracetamol, Isoniazid,rifampicin,pyrazinamide); etc.
• Post-hepaticExtrinsic obstruction of the bile duct ;Biliary atresia;Common bile duct gallstones;
Drugs induced (steroids,flucloxacilin);etc.
Common Causes In Older Children• Infection-eg. Viral (Hepatitis
A,B,C,D,E),EB,Malaria,Leptospira• Autoimmune eg. SLE,Kawasaki• Infiltrative eg.Malignancy• Metabolic eg. Wilson,CF• Narrow or obstructed bile ducts• Toxin & drugs eg.Acetaminophan
I MET 3
History Taking• ID/CC: Age, sex, symptom• HoPI:-Elaborate the symptoms1. Onset (sudden or progressively)?• sudden (Infection .)• proggressive ( Obstrustion above hepatobiliary duct, chornic hem
olysis eg.Thalassaemia ,chronic hepatitis etc.)2. Asso: symptoms- Fever, LOA, Pallor, Stool & urine
colour,vomiting,abdo;pain, rash, arthralgia3. if there is any aggravating factor (bloods transfusion, intake of food
/ drugs).4. Exposures to epidemic areas?
History Taking cont:
Sleep—quantity, quality, disturbances (restlessness),
History Taking• PMH:• Pregnancy—gravida/para status, maternal age, duration, exposures
(medications,alcohol, tobacco, drugs, infections, radiation); complications (bleeding,
gestational diabetes, hypertension, etc.), problems with past pregnancies• Labor and delivery—length of labor, rupture of membranes, fetal
movement, medications, presentation/delivery,mode of delivery, assistance (forceps, vacuum), complications, Apgars
• Neonatal—birth height/weight, abnormalities/injuries, length of hospital stay, complications (respiratory distress,cyanosis, anemia, jaundice, seizures, anomalies, infections), behavior
• Infancy—temperament, feeding, family reactions to infant• Illnesses/hospitalizations/surgeries/accidents/injuries—dates,
medications/interventions, impact on child/family• Past medical illness • Medicatioion/Drug H/O—past (antibiotics, especially), present, reactions• Allergies—include reaction• Immunizations—up to date, reactions• Family history—relatives, ages, health problems, deaths (age/cause),
miscarriages/stillbirths/deaths of infantsor children• Social history—parents’ education and occupation, living arrangements,
pets, water (city or well), lead exposure(old house, paint), smoke exposure, , risk-taking behaviors,school/daycare
Physical Examination
Physical Examination
• General— Lethargic, Tired, Hydration status,Malnutrition,Jaundice,Concious level,Weight,Height
• Hand-Pallor,Cyanosis,Leuconychia(hypoalbuminaemia?),Clubbing,Liver palms,Aneamia,Hepatic Flap
• Skin—Bruising,Scratch marks, Spider Naevi • Eyes—Jaundice,Pallor• Nose— Flaring nostrils
• Mouth—Cyanosis,Ulcer• Throat—Oropharynx (red, moist, injection, exudate)
• Lymph—Lympoedema(Cervical, axillary, inguinal)• Legs-Edema(Pretibial/Medial malleolus)
Physical Examination• Abdomen1. Inspection-Distention,Scar,Prominent veins 2. Palpation-Hepatomegaly(Hepatitis,Cirrhosis?),Spleenomegaly(H
emolysis?),Tenderness,Gallbladder(Murphy?),Kidneys.3. Percussion-Liver,Spleen,Shifting dullness(Ascites?)4. Ausculation- Bowel sounds.
For extra Eamination• Respiratory( Pulmonary Edema?)—Rate, Grunting,Basal Crac
kles? Sputum?• Cardiovascular(Heart Failure?)—Heart rate,Gallop Rhythnm?
Investigation• Full blood count (RBC,Retic )• Liver function tests(ALT, AST,GGT, AKP,T&DP,TB,UCB,CB)1. TB+UCB = pre-hepatic2. TB+UCB+CB =hepatic3. TB+CB = post-hepatcic• Coagulation profile –PT,INR• Ultrasound (In adavanced MRCP,ERCP)• Urine FEME,• Urine for leptospiral Ag• Renal function test• Stool test • Genetic Test (G-6PD ,Thalasseamia)• Serology Test for viruses(Hepatitis A,B,C,D,E)• Serology Test for Autoimmune• Coomb's test• Liver biopsy
Table of Diagnosis TestFunction test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic Jaundice
Total bilirubin Normal / Increased Increased Increased
Conjugated bilirubin Normal Increased Increased
Unconjugated bilirubin
Normal / Increased Increased Normal
Urobilinogen Normal / Increased Increased Decreased / Negative
Urine Color Normal Dark (urobilinogen + conjugated bilirubin)
Dark (conjugated bilirubin)
Stool Color Normal Normal/Pale Pale
Alkaline phosphatase levels
Normal Increased Increased
Alanine transferase and Aspartate transferase levels
Normal Increased Increased
Conjugated Bilirubin in Urine
Not Present Present Present
References• Goljan, Edward F., Rapid Review
Pathology 2nd edition. Pg. 368–369. 2007.
• First Aid For The Pediatric Clerkship Pg.9-10• Oxford Handbook Of Clinical Medicine Pg.2
50-251• Nelson's Pediatrics 18th edition• Essential Nelson• Current Paed: