JAUNDICE

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Jaundice
M.Prasad Naidu MSc Medical Biochemistry, Ph.D.Rese
arch Scholar
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Jaundice

• Clinical marker of defect in metabolism /or
  excretion of bilirubin.
• ER task to initiate lab eval or imaging studies
  to identify cause and determine admission or
  outpt therapy.

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Pathophysiology

• Yellow discoloration of sclera, skin, mucous
  membranes due to deposition of bile pigment
• Clinically detected with serum bilirubin
  2-2.5mcg/dL or ? (2 times nl)

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What is bilirubin?

• The breakdown product of Hgb from injured RBCs
  and other heme containing proteins.
• Produced by reticuloendothelial system
• Released to plasma bound to albumin
• Hepatocytes conjugate it and extrete through bile
  channels into small intest.

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What causes ? bilirubin?

• Overproduction by reticuloendothelial system
• Failure of hepatocyte uptake
• Failure to conjugate or excrete
• Obstruction of biliary excretion into intestine

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Unconjugated vs. Conjugated

• Unconjugated
• ? production exceeds ability of liver to
  conjugate
• Ex. Hemolytic anemias, hemoglobinopathies,
  in-born errors of metab., transfusion rxn.

• Conjugated
• Can produce but not excrete
• Metabolic defect
• Intra- or extrahepatic obstruction

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Clinical Features

• Careful history and PE
• Family history (Gilbert, Rotor, Crigler-Najjar,
  Dubin-Johnson, Sickle Cell)
• Healthy young person with fever, malaise,
  myalgias viral hepatitis (try to locate source)

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Clinical Features

• Gradually develops symptoms hepatic/bile duct
  obstruction (consider ETOH liver dz/cirrhosis)
• Develops acutely with abd pain acute
  cholangitis 2 to choledocholithiasis

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Clinical Features

• Painless jaundice in older person with epigastric
  mass weight loss biliary obstruction from
  malignancy
• Hepatomegaly with pedal edema, JVD, and gallop
  CHF

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Laboratory Tests

• Serum bilirubin level (total and direct)
• Liver aminotransferase levels
• Alk. Phos
• U/A for bilirubin and urobilogen

• CBC
• PT
• Other labs pertinent to history
• Coombs test
• Hgb electrophoresis
• Viral hepatitis panel
• U/S Gallbladder

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Disposition

• Hemodynamically stable, new-onset jaundice, no
  evidence of liver failure or acute biliary
  obstruction ? discharge with follow up
• If one of above violated ? admission with surgery
  consult

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Cholecystitis and Biliary Colic

• Tintanalli Chapter 85
• Pages 561-566

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Biliary Tract Emergencies Related to Gallstones

• 1) Biliary Colic
• 2) Cholecystitis
• 3) Gallstone pancreatitis
• 4) Ascending cholangitis

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Gallstones

• Most gallstones are asymptomatic
• Usually seen in obese females 20-40 yoa and
  pregnancy (Remember fat, fertile, flatulent,
  female, forty)
• Associated with upper abdominal pain

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Gallstones

• Uncommon in children (seen with hemolytic d/o,
  idiopathic, cystic fibrosis, obesity, ileal
  resection, long term use of TPN)
• Elderly
• 14-27 symptomatic gallstone dz.
• More likely biliary sepsis/gangrenous GB
• ? perioperative morbidity
• Mortality rate 19

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Gallstone Risk Factors

• Familial
• Asian descent
• Chronic biliary tract infections
• Parasitic infections (ascaris lumbricoides)
• Chronic liver dz (ETOH)
• Chronic intravasular dz (Sickle Cell, Hereditary
  Scherocytosis)
• Hepatitis A, B, C, E
• HIV
• Herpesvirus

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Pathophysiology

• Bile
• Manufactured secreted from hepatocytes ?GB
  storage in canaliculi, ductiles, bile ducts
  ?bile ducts enlarge ?form R and L hepatic ducts
  ?form common hepatic duct ?joins cystic duct from
  GB to form CBD ?Ampulla of Vater ?duodenum

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Pathophysiology

• Release of bile stimulated by cholecystokinin
  secreted from small int. mucosal cells when fats
  AA enter duodenum

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Pathophysiology

• Symptomatic cholelithiasis stone migration from
  GB into biliary tract with eventual obstruction
  ?obstruction of hollow viscus ?pain, nausea
  vomiting ?acute cholecystitis

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Pathogens Involved in AcuteCholecystitis

• E. coli/Klebsiella-70
• Enterococci-15
• Bacteroides-10
• Clostridium-10
• Group D Strep
• Staphylococcal species

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Clinical Features

• Overlap of s/s of PUD, gastritis, GERD,
  nonspecific dyspepsia
• RUQ pain
• Upper abd/epigastric pain
• Radiation to L upper back
• Pain persisant lasting 2-6h

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THANKING U