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Clinical Management of Patient with
Jaundice
JAUNDICE
Yellow pigmentation of skin, sclera and mucosa
due to elevated bilirubin level
Visible at 3mg/dL
Imbalance between production and clearance of
bilirubin.
Sclera- high affinity because of elastin content-
3mg/dl
Bilirubin Metabolism:
Classified by:
Type of Circulating Bilirubin:
1.Conjugated
2.Unconjugated
Site of the Problem:
1.Prehepatic
2.Hepatocellular
3.Cholestatic/ Obstructive
Pre-hepatic Jaundice:
- Excess Bilirubin production
1.hemolysis
2.inadequately liver uptake
3.deficient hepatic conjugation
- Unconjugated Bilirubin enters the blood
- Unconjugated Bilirubin is water insoluble  not excreted in the
urine
- Resulting in Unconjugated (Indirect) Hyperbilirubinemia
Hepatocellular Jaundice:
- With hepatocellular damage +/- cholestasis
- Causes:
- Viruses: Hep, CMV, EBV
- Drugs
- Alcoholic Hep, cirrhosis, liver mets/abscess, hemochromatosis
- AIH
- sepsis, leptospirosis
- a1 antitrypsin deficiency
- Budd Chiari Syndrome, Wilsons Disease
- Failure to Excrete Bilirubin (Dubin – Johnson & Rotor Syndrome)
- Right Heart Failure
- Toxins( Carbon Tetrachloride)
- Fungi (Amanita phaloides)
Cholestatic/Obstructive Jaundice:
- Blockage of the Common Bile Duct  Conjugated Hyperbilirubinemia
- Conjugated Bilirubin is water soluble  easily excreted in the urine
- Pt usually c/o dark, tea-colored urine
- Clay-colored stool  due to lack of conjugated bilirubin reaching the
GUT
- Causes:
1.Choledocholithiasis
2.Pancreatic cancer
3.Porta-hepatis LN
4.Drugs
5.Cholangiocarcinoma
6.Sclerosing Cholangitis
7.PBC
8.Choledochal cyst
9.Biliary atresia
Clinical Manifestations:
Ask about:
1.Previous blood transfusion
2.IVDU
3.Body Piercing
4.Tattoos
5.Sexual Activities
6.Travel Hx
7.In Contact with person with Jaundice
8.Family Hx
9.Alcohol Consumption
10.Medications
Physical Exam:
1.Look for signs of chronic liver disease
2.Hepatic Encephalopathy
3.LAD
4.Hepatomegaly
5.Splenomegaly
6.Palpable GB
7.Ascites
8.Pale stools and dark urine
Lab test:
Bilirubin (-) in pre-hepatic causes
Urobilinogen (-) in Obstructive Jaundice
Signs of Hemolysis:
Anemia
• Elevated LDH
• Low Haptoglobin
• High Reticulocytes
• (+) Coombs test
LFT
Virology: EBV, CMV, HAV, HBV, HCV
Hemochromatosis: elev ferritin & iron:TIBC ratio  high serum iron sat(>50-60)
A1-antitrypsin Deficiency – genetic analysis
Wilson’s Disease – low serum & high Urine Copper Level, low serum Ceruloplasmin
PBC – high anti-mitochondrial ab, AMA
AIH – high anti-nuclear & anti-smooth muscle ab
US – to check for CBD obstruction
MRCP/ERCP – if CBD are dilated
Liver Biopsy – if Bile ducts are normal
MRI/CT
Approach to a patient with JAUNDICE
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Approach to a patient with JAUNDICE

  • 1. Clinical Management of Patient with Jaundice
  • 2. JAUNDICE Yellow pigmentation of skin, sclera and mucosa due to elevated bilirubin level Visible at 3mg/dL Imbalance between production and clearance of bilirubin. Sclera- high affinity because of elastin content- 3mg/dl
  • 4. Classified by: Type of Circulating Bilirubin: 1.Conjugated 2.Unconjugated Site of the Problem: 1.Prehepatic 2.Hepatocellular 3.Cholestatic/ Obstructive
  • 5. Pre-hepatic Jaundice: - Excess Bilirubin production 1.hemolysis 2.inadequately liver uptake 3.deficient hepatic conjugation - Unconjugated Bilirubin enters the blood - Unconjugated Bilirubin is water insoluble  not excreted in the urine - Resulting in Unconjugated (Indirect) Hyperbilirubinemia
  • 6. Hepatocellular Jaundice: - With hepatocellular damage +/- cholestasis - Causes: - Viruses: Hep, CMV, EBV - Drugs - Alcoholic Hep, cirrhosis, liver mets/abscess, hemochromatosis - AIH - sepsis, leptospirosis - a1 antitrypsin deficiency - Budd Chiari Syndrome, Wilsons Disease - Failure to Excrete Bilirubin (Dubin – Johnson & Rotor Syndrome) - Right Heart Failure - Toxins( Carbon Tetrachloride) - Fungi (Amanita phaloides)
  • 7. Cholestatic/Obstructive Jaundice: - Blockage of the Common Bile Duct  Conjugated Hyperbilirubinemia - Conjugated Bilirubin is water soluble  easily excreted in the urine - Pt usually c/o dark, tea-colored urine - Clay-colored stool  due to lack of conjugated bilirubin reaching the GUT - Causes: 1.Choledocholithiasis 2.Pancreatic cancer 3.Porta-hepatis LN 4.Drugs 5.Cholangiocarcinoma 6.Sclerosing Cholangitis 7.PBC 8.Choledochal cyst 9.Biliary atresia
  • 8. Clinical Manifestations: Ask about: 1.Previous blood transfusion 2.IVDU 3.Body Piercing 4.Tattoos 5.Sexual Activities 6.Travel Hx 7.In Contact with person with Jaundice 8.Family Hx 9.Alcohol Consumption 10.Medications
  • 9. Physical Exam: 1.Look for signs of chronic liver disease 2.Hepatic Encephalopathy 3.LAD 4.Hepatomegaly 5.Splenomegaly 6.Palpable GB 7.Ascites 8.Pale stools and dark urine
  • 10. Lab test: Bilirubin (-) in pre-hepatic causes Urobilinogen (-) in Obstructive Jaundice Signs of Hemolysis: Anemia • Elevated LDH • Low Haptoglobin • High Reticulocytes • (+) Coombs test LFT Virology: EBV, CMV, HAV, HBV, HCV Hemochromatosis: elev ferritin & iron:TIBC ratio  high serum iron sat(>50-60) A1-antitrypsin Deficiency – genetic analysis Wilson’s Disease – low serum & high Urine Copper Level, low serum Ceruloplasmin PBC – high anti-mitochondrial ab, AMA AIH – high anti-nuclear & anti-smooth muscle ab US – to check for CBD obstruction MRCP/ERCP – if CBD are dilated Liver Biopsy – if Bile ducts are normal MRI/CT