child with jaundice

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CHILD WITH JAUNDICE

2. Learning Objectives
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 Definition of Jaundice
 Mechanism of Bilirubin metabolism
 Types of jaundice and its clinical characteristics
 Obstructive jaundice
 Approach to jaundice.

3. What Is Jaundice??
Condition which is characterized by yellowish
discoloration of the skin, sclera and mucous
membrane due to increase concentration of
bilirubin above normal level.
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4. • Normal Value:- 0.2 to 0.8 mg/dl
• Latent Jaundice :1 mg to 1.9 mg/dl
• Clinical Jaundice : more than 2 mg / dl
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5. GLOBIN
Heme
oxygenese
Biliverdin
Reductase
ALBUMIN
Bilirubin Urobilinogen
Stercobilinogen
Stercobilin
Unconjugated
UDP
Glucoronyl
transferase
BILIRUBIN METABOLISM

6. Pathway For Bile Flow
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7. Types Of Jaundice
PREHEPATIC
HEPATIC
POSTHEPATIC
HAEMOLYSIS
OBSTRUCTIVE
OR SURGICAL
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8. Classification
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Neonatal Jaundice
ConjugatedUnconjugated
Physiological Pathological
Hemolytic Non-Hemolytic
• Heriditary
Spherocytosis
• Sickle Cell
Disease
• Thalassemia
• Breast Milk Jaundice
• Sepsis
• Hypothyroidism
Hepatic Post Hepatic
• Torch Infection
• Galactosemia
• Biliary Atresia
• Cholodocal
Cyst

9. Physiological Jaundice
In neonates, jaundice tends to develop because of
• More RBC mass
• Life span of RBC is less (90 days)
• Breakdown of fetal hemoglobin as it is replaced
with adult hemoglobin
• Increased intrahepatic circulation
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10. • Relatively immature hepatic metabolic pathways of
liver, which are unable to conjugate and excrete
bilirubin as quickly as an adult
• Resulting in accumulation of bilirubin in the blood
(hyperbilirubinemia), leading to the symptoms of
jaundice
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11. Pathological Jaundice
 Jaundice that is visible during the first 24 hours and
after 2 weeks of life is likely to be non physiological
 Neonates who present with jaundice after 3-4 days
of life may also require closer monitoring
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12. Breast Milk Jaundice
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 Indirect hyperbilirubinemia in a breast feed new
born that develop after 4-7 days of life.
 Progesterone Present in breast milk inhibit UDP-
glucuronyl transferase
 Decrease UDP-glucuronyl activity in new born
 Increase concentration of nonesterified free fatty
acids that inhibit hepatic glucuronyl transferase.

13. Where To Look For…....
 Sclera
 Ventral surface of Tongue
 Palmar Crease
 Sole of foot
 Whole body
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14. Clinical Assessment
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15. Causes Of Jaundice
In neonatal period
Surgical cause
 Biliary atresia
 Choledochal cyst
Medical Cause
 Breast feeding jaundice
 Hemolytic disease
 Hypothyroidism

16. In infantile period
Surgical causes
• Biliary atresia
• Choledocal cyst
• Choledocholithiasis
• Sclerosing cholangitis
• Pyogenic cholangitis
• Traumatic stricture
• Benign or malignant tumor of CBD
• Extramural compression.
• Worm In CBD

17.  Medical
 Liver disease – hepatitis
 Metabolic liver diseases
 Hemolytic jaundice
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18. When To Concern…...
 Jaundice is progressive
 Medical management fail
 It lasts for more than two weeks
 It is associated with Hepatosplenomegaly
 History suggestive of obstructive cause – Dark urine,
pale stool

19. Clinical Features
 Yellowish discoloration of skin, sclera & mucous membrane
 Pale or clay colored stools
 Dark colored urine
 May have high grade fever with or without chills and rigor
 Itching all over body
 Loss of appetite
 Nausea and vomiting
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20. How To Proceed ?
History taking
 Age
 Jaundice
 Onset
 Fluctuation
 Progression
 Association with other symptoms like pain , fever &
itching

21. Cont.
 Colour of Urine
 Colour of Stool
 Weight loss
 Drug History
 Ante-natal History ( TORCH of Mother )
 Family history of jaundice
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22. Examination
ON GENERAL EXAMINATION
 Jaundice
 Anemia
 Nutritional Status
 Body build
 Temperature
 Hydration Status

23. ON SYSTEMIC EXAMINATION
Gastrointestinal System:
Inspection:
Yellowish coloration of skin, Abdomen Distended,
Engorged vein , Position of Umbilicus ,Scar marks
Palpation:
Hepatosplenomegaly
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24. Percussion:
 Upper Border Of liver Dullness
 Ascites
05-Apr-16
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25. Investigation
 Blood : CBC,ESR, Hb % ,Peripheral Blood Film
: LFT ( Serum Bilirubin, ALT, AST, Alk Phos,PT, )
: Viral Marker
 Imaging: Usg of hepatobiliary system
: CT of hepatobiliary system
: MRCP
: HIDA
Urine : Urine RE, Urobilinogen

26. Table Of Diagnostic Tests
Function test Pre-hepatic jaundice Hepatic jaundice Post-hepatic jaundice
Total bilirubin Normal / increased Increased
Conjugated bilirubin Normal Increased Increased
Unconjugated bilirubin Normal / increased Increased Normal
Urobilinogen Normal / increased Decreased Decreased / negative
Urine color Normal
Dark (urobilinogen +
conjugated bilirubin)
Dark (conjugated
bilirubin)
Stool color Normal Normal/pale Pale
Alkaline phosphatase
levels
Normal
Increased
Alanine transferase and
aspartate transferase
levels
Increased
Conjugated bilirubin in
urine
Not present Present
Splenomegaly Present Present Absent
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27. MANAGEMENT
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28. GENERAL MANAGEMENT
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PRINCIPLES OF GENERAL MANAGEMENT
• Correction of dehydration and electrolyte
• Correction of coagulation profile
• To prevent hepatic failure
• Control/prevention of infection
• To prevent translocation of gut organism

29. Correction Of Dehydration &
Electrolyte
 Adequate hydration by intravenous fluid infusion
 Correction of electrolyte imbalance
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30. Correction of coagulation
profile
 Inj. Vitamin-K IM/IV once daily for 3 days.
 Then check the prothrombin time; if not corrected then
repeat this treatment and again check for prothrombin
time.
 If not corrected then arrange Fresh Frozen Plasma
(FFP) before operation and perform operation.
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31. To prevent hepatic failure
 Avoid hepatotoxic drugs.
 Encourage glucose containing diet.
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32. Control/prevention of
infection
 3rd generation cephalosporin+ Metronidazole
 2nd generation cephalosporin (Cefuroxime).
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33. To prevent translocation
of gut organism
 Lactulose to decrease gut organism.
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34. Surgical Management
 According to Cause
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