JAUNDICEBY

PROF/GOUDA ELLABBAN

DEFINITION OF JAUNDICE:

Jaundice ( icterus ) is a yellow discoloration of the sclerae and skin as a result of a raised serum bilirubin .

YELLOW SKIN AND SCLERAE APPEAR WHENEVER BILIRUBIN REACHES 3.0 mg/mL .

Grades of jaundice

Mild: pale lemon yellow.

Moderate: yellow orange.

Sever: brown.

Two form of bilirubin:

1.Unconjugated, insoluble and not excreted in the urine.

2. Conjugated, soluble and excreted in the urine.

Causes of jaundice

1. Pre hepatic

2. Hepatic

3. Post hepatic

1. Pre hepatic

Increase breakdown of red cells leads to increased production of bilirubin.

It is due to hemolytic anemia as:-SCD.-G6PD def.-H. spherocytosis.

2. Hepatic

It is due to:

- Hepatitis.

- Cirrhosis.

- Drugs.

- Venous Obstuction.

3. Post hepatic

It is due to:1. Extrahepatic obstruction (obstructive jaundice):- Gallstone obstruction of biliary tree.- Carcinoma of head of pancreas, extrahepatic bile

duct, ampulla of vater and duodenum .- Extrahepatic biliary atresia.- Biliary strictures and choledochal cysts.- Biliary sclerosing cholangitis (extrahepatic).- Liver fluk infestation.

Impairment of bile flow subsequent to secretion by the hepatocyte

2. Intrahepatic cholestasis as in:

- Drugs.

- Recurrent juandice of pregnancy.

LAB DIFFERENTIATION

Pre hepatic J. Hepatic J. Post hepatic J.

color Achaluric (colorless)

As usual Dark

Conjugated bilirubin

NL0 mg

NL or

Urobilinogen NL or 0-4 mg/D

Absent or

Color Dark As usual Pale

stercobilingen NL40-280mg

URINE

STOOL

To differentiate between obstructive jaundice from hepatic and pre hepatic jaundice :

History of dyspepsia , pain or biliary colic .

No pre monitary period of malaise and loss of appetite .

A sudden onset

Simultaneous appearance of pale feces and dark urine

Itching of the skin

If the pain is sudden and regressive it is due to stone

If the pain is progressive it is due to tumor

In young age mostly due to stone

In old age mostly due to tumor

Surgical anatomy :

The cystic duct joined common hepatic duct to form common bile duct .

The bile duct (common bile duct) is about 3 inches (8 cm) long . In the third part of its caurse it lies in the in a groove on the posterior surface of the head of the pancreas . Here , the bile duct comes into contact with the main pancreatic duct and they open into ampulla of vater in the second part of the duodenum.

Commonest Causes Of Obstructive Jaundice

Choledocholithiasis (stones within the bile duct)

The goal of treatment is to relieve the obstruction in the common bile duct. Surgical removal of the gallbladder and the stones (via either an open procedure or a laparoscopic procedure) is one option.

Another possibility is removal of the stones by ERCP and sphinterotomy (an incision into the sphinter muscle of the duct).

Jaundice must be treated to prevent coagulation disorders and hepatorenal syndrome

TUMORS OF THE PANCREAS

If the tumer has no metastesis and no inviding the surround vessels it is operable

If the tumor has metastisis and inviding the surround vessels it is inoperable and treated by radiochemotherapy

Pancreatoduodenectomy(Whipple Procedure)

By remove of

Head of pancreas

Entire duodenum

Portion of jejunun

Distal third of the stomach

Lower half of the commom bile duct

Reestablishment of continuity of the biliary, pancreatic, and GI tract system

Investigation

Routine :CBCRFTcreatine & electrolyte & BUNFBS RBSURINE ANALYSISCHEST X-RAY AND ECG if he is above 40

yearsPT & PTT

SPECIFIC INVESTIGATION :

ERCP (endoscopic retrograde cholangiography)

MRCP (magnetic resonance cholangiopancreatography)

Abdominal CT scan

Abdominal ultrasound

Percutaneous transhepatic cholangiogram (PTCA)

Liver function test:

serum enzymes: normally

alkaline phosphatase 13-39U/ml

aspartate aminotransferase 5-40U/ml

alanine aminotransferase 5-35U/ml

lactate dehydrogenase 200-500U/ml

5-nucleotidase 2-11U/ml

Gamma-glutamyltranspeptidase men:80-200U/L women 45yr:5-27U/L

BILIRUBIN METABOLISM:Serum bilirubin: Indirect(uncojugated) 0.8mg/dl Direct(conjugated) 0.2-0.4mg/dlTotal 1mg/dlUrine bilirubin 0(bilirubin in the urine may be seen with hepatic disease or

biliary obstruction; only conjugated bilirubin spills into the urine because the unconjugated bilirubin is bound to albumin in the serum and thus cannot pass the glomerular membrane)

Urine urobilinogen 0-4mg/24hFecal urobilinogen 40-280mg/24h

AMMONIA adult 15-110/dl

SERUM PROTEINSAlbumin 3.5-5.5g/dlGlobulin 2.5-3.5g/dlTotal 6-7g/dlAlbumin/globulin(A/G) ratio1.5/1 to 2.5/1Transferring 250-300 mg/dl

BLOOD-CLOTTING FUNCTIONS

Prothrombin time(PT) 11.5-14 sec or 90% of control

Partial thromboplastin time (PTT) 25-40 sec

TESTS OF PANCREATIC FUNCTIONS:

Serum amylase 60-180 somogyi unit/ml

Serum lipase 1.5 somogyi unit/ml

Urine amylase 35-260 somogyi units/ml

Secretin test volume 1.8 ml/kg/h