JAUNDICE

By
Dr. M. Anthony David, MD
Professor of Physiology

NOMAD: BP: Jaundice I 1

 WHAT IS JAUNDICE?
 Also called as ICTERUS,
HYPERBILIRUBINEMIA.
 Defined as yellowish
discoloration of:
 Skin
 Mucosa
 Other tissues, eg. Cerebral Cortex,
Kernictus (Erythroblastosis fetalis)
 Why? Increase in the levels of
Bilirubin:
 Plasma NOMAD: BP: Jaundice I 2
 Tissue Fluids
 BILIRUBIN BLOOD LEVELS
 NORMAL BLOOD LEVELS OF
BILIRUBIN: 0.3 to 1.0 mg./dLt of
blood.
 LEVELS HIGHER THAN 2.0 mg./dLt of
blood cause JAUNDICE.
 JAUNDICE IS BOTH A:
 SYMPTOM: Patient or relative recognizes
the discoloration
 SIGN: the doctor examines and finds it
out.
 INVESTIGATION: Urine & Blood levels
of Bilirubin. NOMAD: BP: Jaundice I 3
 TYPES OF JAUNDICE : A
CLASSIFICATION
 HEMOLYTIC JAUNDICE or PRE
HEPATIC JAUNDICE

 HEPATO CELLULAR OR HEPATIC

JAUNDICE

 OBSTRUCTIVE JAUNDICE or POST

HEPATIC JAUNDICE
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 HEMOLYTIC JAUNDICE
 Excessive breakdown of
Erythrocytes
 Breakdown of Hemoglobin into
Heme and Globin.
 Heme is converted into Bilirubin.
 Breakdown of Erythrocytes is
called Hemolysis. So this is
Hemolytic Jaundice.
 Since this happens before the
Liver, it is called Pre Hepatic
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Jaundice.
 HEPATIC/HEPATOCELLULAR
JAUNDICE
 Damage caused to the liver or
liver cells (Hepatocytes).
Damage may be due to:
 Infections: Hepatitis A, or B, or
instance.
 Toxins: Alcohol, etc.
 Due to damage, the liver cannot
process Bilirubin and so its
blood level increases.
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 OBSTRUCTIVE JAUNDICE
 Also called Post Hepatic Jaundice.
 The root cause is obstruction to the
bile ducts.
 This causes a block in the flow of
bile.
 Since there is an obstruction, it is
called Obstructive Jaundice.
 Since the cause of the Jaundice is
beyond the liver, it is called Post
Hepatic Jaundice.
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 HEPATIC JAUNDICE
 Hepatocytes produce bile.
 The bile salts in it help in the
emulsification and absorption of Fats.
 In Liver damage, bile is not produced
and so fats are not emulsified or
absorbed.
 So the feces in such patients will be:
 Bulky: all the fats are unabsorbed
 Greasy: due to fat content
 Foul smelling: due to bacterial action
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 OBSTRUCTIVE JAUNDICE
 Feces is greasy & foul smelling.
 If the obstruction is complete,
the stools will be colorless.
 This is because the stools do not
have stercobilin, which gives the
characteristic color to normal
stools.

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 Pre hepatic jaundice
 No abnormalities of fat
emulsification and absorption.
 Stools are normal.
 The blood picture shows anemia.
 There is reticulocytosis or the
presence of extra reticulocytes
in the blood.
 Abnormal erythrocytes are also
found: Anisocytosis &
Poikilocytosis .
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 JAUNDICE:
ETIOLOGIC CLASSIFICATION
 HEMOLYTIC JAUNDICE or PRE
HEPATIC JAUNDICE

 HEPATIC OR HEPATOCELLULAR
JAUNDICE

 OBSTRUCTIVE JAUNDICE or POST

HEPATIC JAUNDICE
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 HOW DO JAUNDICED
PATIENTS LOOK LIKE?

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 HOW DO JAUNDICED
PATIENTS LOOK LIKE?

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 BILIRUBINURIA? :
HEMOLYTIC JAUNDICE
 Bilirubin is lipophilic and
hydrophobic.
 It exists as a protein conjugate
in the plasma.
 It is not excreted in the urine
normally.
 So in hemolytic jaundice, the
urine is of normal color, so called
Acholuric jaundice.
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 BILIRUBINURIA:
HEPATIC/POST HEPATIC
JAUNDICE
 But the glucunorides of Bilirubin are
water soluble.
 They are regurgitated back to the
blood and get attached to plasma
proteins.
 This is how they cause
hyperbilirubinemia
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BILIRUBINURIA: HEPATIC/POST
HEPATIC JAUNDICE
 As these
glucoronides are
hydrophilic, they
dissociate from
proteins and escape
through the
glomerular filters in
the kidney.
 Thus bilirubinuria is

seen whenever the

plasma bilirubin
level is above
2mg./dLit.
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 THE VAN DEN BERGH TEST
 A mixture of Sulfanilic acid,
Hydrochloric acid, and the Diazo
reagent(Sodium Nitrate) is added
to the serum containing Bilirubin
glucunoride…
 A reddish- violet color results
within 30 seconds.
 This is called the Direct Vanden
bergh reaction.
 This is positive only in Post hepatic
jaundice.
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 THE VAN DEN BERGH TEST
 In both pre and hepatic jaundice
jaundice cases, only bilirubin is high
in the serum.
 When alcohol is added to this serum
along with the Diazo reagent, the
characteristic reddish violet color
results.
 This is called the Indirect Van den
bergh reaction.
 The alcohol provides the solvent or
the lipophilic bilirubin.
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 OTHER SYNDROMES WITH
JAUNDICE:
 ICTERUS GRAVIS
NEONATORUM,
ERYTHROBLASTOSI
S FETALIS:
KERNICTERUS
 HERIDITARY
SPHEROCYTOSIS:
CONGENITAL
HEMOLYTIC
ICTERUS
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 TESTS OF JAUNDICE
TEST PRE HEPATIC POST
Urine Bile Absent Present Present
Salts
Urine Absent Present Present
Bilirubin
Fecal Fat Absent Increased Increased
Liver Normal Impaired Normal or
Function impaired
Tests
Van den Indirect Mainly Mainly
Bergh Test Reactio Direct
NOMAD: BP: Jaundice I Direct
20
 REVIEW
 Jaundice is the yellowish
discoloration of the skin and
mucous membranes due to high
levels of Bilirubin. It is also
called Icterus.
 It can have Hemolytic, Hepatic,
or Obstructive etiology.
 Tests such as the Van den
berghs test help us determine
the cause of Jaundice.
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ICTERUS & ANEMIA IN THE
SAME PATIENT

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NOMAD: BP: Jaundice I 23