JAUNDICE Internal Medicine Presentation
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Transcript of JAUNDICE Internal Medicine Presentation
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HYPERBILIRUBINEMIAJAUNDICE
(Icterus)
Presenter: Abdul Mushib Ibrahim
MBBS Year 4
UPSM
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Definition
Refers to YELLOWISH pigmentation of:
SKIN
SCLERAEMUCOSA
-Due to increased levels of bilirubin in the blood.
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VALUES
NORMAL PLASMA Bilirubin:
0.5mg/dl
ABNORMAL PLASMA Bilirubin:
> 1.5mg/dl or > 35micromoles/L
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Classification of Jaundice
Jaundice is classified by1-Type of Circulating Bilirubin:
a)Conjugated
b)Unconjugated
2-Site of Problem:
a)Pre-Hepaticb)Hepatic
c)Post Hepatic/Cholestatic/Obstructive
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RBC BREAK DOWNGLOBIN
HEME
biliverdin
(greencolor)
Unconjugated-
bilirubin-yellow
BLOOD STREAM
LIVERConjugated
Bilirubin
UDP-glucuronyl
transferase
Bilary Tree &
Cystic Duct->
BILE
Intestinal Bactria
Urobilinogen
stercobilin urobilin
ALBUMIN
YELLOW
DISCOLOURATION
OF SKIN
1-Gilberts
Syndrome
2-Crigler Najjar
Syndrome
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Uncongugated Bilirubin
-Is water insoluble.
-It does not enter urine.-Bound to plasma Albumin-> travels to Liver->to
form congugated Bilirubin.
-Results in ACHOLURIC Hyperbilirubinaemia.
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Classification of Jaundice
Jaundice is classified by1-Type of Circulating Bilirubin:
a)Unconjugated
b)Conjugated
2-Site of Problem:
a)Pre-Hepaticb)Hepatic
c)Post Hepatic/Cholestatic/Obstructive
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Pre-Hepatic-Uncongugated
The pathology is occurring prior to the liver
caused by anything which causes an increasedrate of breakdown of red blood cells
ISOLATED raised Bilirubin levels-(Uncongugated)
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Hemolytic Jaundice:
Genetic diseases, such as:
1-sickle cell anemia2-spherocytosis
3-thalassemia
4 glucose 6-phosphate dehydrogenasedeficiency
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Infective Causes:
5-Malaria-In tropical countries
6-Leptospirosis.
Congenital Causes:
7-Gilberts Syndrome8-Cringler Najjar Syndrome
TYPE I
TYPE II
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Classification of Jaundice
1-Type of Circulating Bilirubin:
a)Unconjugated
b)Conjugated
2-Site of Problem:
a)Pre-Hepaticb)Hepatic
c)Post Hepatic/Cholestatic/Obstructive
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Hepatic Jaundice-Congugated
DEFINITION
Results from the inability of the liver totransport bilirubin across the hepatocyte into
the bile duct, occuring as a consequence of
parenchymal liver disease.
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Bilirubin transport is impaired because of:Uptake of Uncongugated Bilirubin into the cells
Transport of Congugated Bilirubin into the Canaliculi.
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In Hepatic Jaundice, concentrations of bothcongugated and Uncongugated Bilirubin
increase.
CARACTERISTICS OF HEPATIC JAUNDICE
Increase in Transaminases AST (Aspartate Transaminase-5-35 iu/L)
ALT (Alanine Aminotransferase-5-35iu/L)
NOTE: Increase in other LFTS suggest other specificaetiologies.
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Acute Jaundice in presence of AST > 1000U/L
is HIGHLY SUGGESTIVE of:
1. An Infectious Cause Hepatitis A, B,C, Alcoholic,
CMV
EBV
2. Hepatic Ischaemia
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3. Drugs
Paracetamol Overdose
Isoniazid, Rifampicin, Pyrazinamide
Monoamine Oxidase Inhibitors
Sodium Valproate
Halothane
Statins
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Other Causes of Hepatic Jaundice
4. Failure to excrete Congugated Bilirubin
Dubin Johnson Syndrome
Rotor Syndrome
5-Sepsis ,hypoperfusion states
6-Toxins
Fungi-Amanita Phalloides
Carbon Tetrachloride
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DIAGNOSING HEPATIC JAUNDICE
Blood Test-LFTS
Imaging-essential to identify features
suggestive of cirrhosis. Irregular liver outline
Splenomegaly
Define Patency of Hepatic Arteries, Veins, Portal
Vein.
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Liver Biopsy-to define the cause of Hepatic
Jaundice.
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Classification of Jaundice
1-Type of Circulating Bilirubin:
a)Unconjugated
b)Conjugated
2-Site of Problem:
a)Pre-Hepaticb)Hepatic
c)Post Hepatic/Cholestatic/Obstructive
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POSTHEPATIC-Obstructive
(Cholestatic) JaundiceCaused by:-Failure of hepatocytes to initiate bile flow.
-Obstruction of Bile flow in bile ducts
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Disease States
Obstructive Jaundice extrahepatic cholestasis
Choledocholithiasis (CBD stone)
Cancer (peri-ampullary or cholangio CA)
Strictures after invasive procedures Acute and chronic pancreatitis
Primary sclerosing cholangitis (PSC)
Parasitic infections Ascaris lumbricoides, liver flukes
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Drug induced CholestatsisFlucloxacillin
Augmentin
Nitrofurantonin
Steroids (Pill)
Sulfonylureas
Prochlorperazine
Chlorpromazine.
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Congugated BilirubinDark UrineBut less
Congugated Bilirubin enters the gut thusfeaces is pale.
When severeassociated with pruritis RX-
relief of obstruction.
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Cholestatic Jaundice is CHARACTERISED by:
INCREASED: ALP -Alkaline Phosphatase-30-150
GGT(-g- Glutamyl transpeptidaseU/S is indicated to determine mechnical
obstruction & Dilatation of bilary tree.
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EVALUATION
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Initial Evaluation: History
Jaundice, pale stool, tea-colored urine Fever/chills, RUQ pain (cholangitis)
Could lead to life-threatening septic shock
Reasons to have hepatitis or cirrhosis? Alcohol, Viral, risk factors for viral hepatitis
Exposure to toxins or offending drugs
Inherited disorders or hemolytic conditions Recent blood transfusions or blood loss?
Is patient septic?
Recent gallbladder surgery? (CBD injury)
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Initial Evaluation: Physical Exam
Signs of end stage liver disease (cirrhosis)
Ascites, splenomegaly, spider angiomata, and
gynecomastia
Jaundice evident first underneath the tongue,
also evident in sclerae or skin
Courvoisiers sign = painless, but palpable or
distended gallbladder on exam
Could indicate malignant obstruction (e.g
Pancretic Cancer)
Unlikely to be caused by gallstone obstruction.
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Screening Labs
URINE TEST-Bilirubin is absent in pre-hepatic cause.
-Urobilinogen is absent in obstrcutive cause.
HAEMATOLOGY
-FBC
-Clotting
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BIOCHEMISTRY
-U&E LFT (Bilirubin,ALT,AST, ALK PHOS, GGT,
Total Protein, Albumin)
Alk Phos moreso than AST/ALT implies
cholestasis (intrahepatic vs obstruction)
Alk Phos also seen in sarcoid, TB, bone
In this case, GGT is specific for biliary origin
PredominantAST/ALT implies intrinsic
hepatocellular disease AST/ALT ratio > 2 in alcoholic hepatitis
albumin orINR c/w advanced liver dz
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Imaging for Obstructive Jaundice
RUQ Ultrasound See stones, CBD diameter->6mmobstruction.
ERCP
Direct visualization of biliary tree/panc ducts Procedure of choice for choledocholithiasis
Diagnostic AND- therapeutic
Endoscopic Ultrasound CT scan
Identify both type & level of obstruction
If abdominal malignancy is suspected
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Treatment
If Medical, then treat the etiology If Obstructive Jaundice:
Ascending cholangitis For cholangitis: IVF, IV Antibiotics, Decompression
Stones (remove stones vs stent vs drainage) Done via ERCP or open (surgery)
Benign stricture (stent vs drainage catheter)
Cancer (Stent vs drainage +/- resect the CA)
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THE END
REFERANCE
-DAVIDSONS-PRINCIPLES & PRACTICE OFMEDICINE
-OXFORD HAND BOOK OF CLINICAL MEDICINE
-WIKIPEDIA