Jaundice

Jaundice
Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

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Overview
Normal Physiology Pathophysiology Broad Differential Diagnosis DDx of Obstructive Jaundice Work-up for Medical Jaundice Work-up if Obstructive Jaundice Treatment of Obstructive Jaundice

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Normal Physiology
Bilirubin is from breakdown of hemoglobin Unconjugated bilirubin transported to liver
Bound to albumin because insoluble in water

Transported into hepatocyte & conjugated

With glucuronic acid now water soluble

Secreted into bile In ileum & colon, converted to urobilinogen

10-20% reabsorbed into portal circulation and re-excreted into bile or into urine by kidneys

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Pathophysiology
Jaundice = bilirubin staining of tissue @ lvl greater than ~2 Mechanisms:
production of bilirubin hepatocyte transport or conjugation Impaired excretion of bilirubin Impaired delivery of bilirubin into intestine surgically relevant jaundice or obstructive jaundice Cholestasis refers to the latter two, impaired excretion and obstructive jaundice

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Broad Differential Diagnosis

production transport or Impaired conjugation excretion Unconjugate Unconjugate Conjugated Hemolysis Transfusions Txfusion rxn Sepsis Burns Hgb-opathies Gilberts Crigler-Najarr Neonatal Cirrhosis Hepatitis Rotors Biliary obstruction Conjugated CH/CBD stone

DubinJohnson Stricture Cancer Cirrhosis Hepatitis Cancer Chronic pancreatitis PSC

Drug inhibition Amyloidosis Pregnancy

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DDx: Unconjugated bilirubinemia

production
Extravascular hemolysis Extravasation of blood into tissues Intravascular hemolysis Errors in production of red blood cells

Impaired hepatic bilirubin uptake(trnsport)

CHF Portosystemic shunts Drug inhibition: rifampin, probenecid

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DDx: Unconjugated bilirubinemia

Impaired bilirubin conjugation
Gilberts disease Crigler-Najarr syndrome Neonatal jaundice (this is physiologic) Hyperthyroidism Estrogens Liver diseases
chronic hepatitis, cirrhosis, Wilsons disease

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DDx: Conjugated Bilirubinemia

Intrahepatic cholestasis/impaired excretion
Hepatitis (viral, alcoholic, and non-alcoholic)
Any cause of hepatocellular injury

Primary biliary cirrhosis or end-stage liver dz Sepsis and hypoperfusion states TPN Pregnancy Infiltrative dz: TB, amyloid, sarcoid, lymphoma Drugs/toxins i.e. chlorpromazine, arsenic Post-op patient or post-organ transplantation Hepatic crisis in sickle cell disease

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DDx: Obstructive Jaundice

This is the slide to remember for surgeons Obstructive Jaundice extrahepatic cholestasis
Choledocholithiasis (CBD or CHD stone) Cancer (peri-ampullary or cholangioCA) Strictures after invasive procedures Acute and chronic pancreatitis Primary sclerosing cholangitis (PSC) Parasitic infections
Ascaris lumbricoides, liver flukes

Just remember top 5 (not parasites)

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Initial Evaluation: History

Jaundice, acholic stools, tea-colored urine Fever/chills, RUQ pain (cholangitis)
Could lead to life-threatening septic shock

Reasons to have hepatitis or cirrhosis?

Alcohol, Viral, risk factors for viral hepatitis

Exposure to toxins or offending drugs Inherited disorders or hemolytic conditions Recent blood transfusions or blood loss? Is patient septic or on TPN? Recent gallbladder surgery? (CBD injury)

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Initial Evaluation: Physical Exam

Signs of end stage liver disease (cirrhosis)
Ascites, splenomegaly, spider angiomata, and gynecomastia

Jaundice evident first underneath the tongue, also evident in sclerae or skin Courvoisiers sign = painless, but palpable or distended gallbladder on exam
Could indicate malignant obstruction

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Screening Labs
NL LFT r/o hepatic injury or biliary tract dz
Consider inherited disorders or hemolysis

Alk Phos moreso than AST/ALT implies cholestasis (intrahepatic vs obstruction)

Alk Phos also seen in sarcoid, TB, bone In this case, GGT is specific for biliary origin

Predominant AST/ALT implies intrinsic hepatocellular disease

AST/ALT ratio > 2 in alcoholic hepatitis

albumin or INR c/w advanced liver dz

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Subsequent Labs
If no concern for obstructive jaundice:
Viral (Hep B&C) serologies for viral hepatitis anti-mitochondrial Ab (PBC) anti-smooth muscle Ab (Auto-immune) iron studies (hemochromatosis) ceruloplasmin (Wilsons) Alpha-1 anti-trypsin activity (for deficiency)

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Imaging for Obstructive Jaundice

RUQ Ultrasound
See stones, CBD diameter

CT scan
Identify both type & level of obstruction

ERCP
Direct visualization of biliary tree/panc ducts Procedure of choice for choledocholithiasis Diagnostic AND- therapeutic (unlike MRCP)

PTC useul of obstruction is prox to CHD Endoscopic Ultrasound or EUS

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Treatment
If Medical, then treat the etiology If Obstructive Jaundice:
Should r/o ascending cholangitis, ABC/resusc
For cholangitis: IVF, IV Antibiotics, Decompression

Stones (remove stones vs stent vs drainage)

Done via ERCP or PTC or open (surgery)

Benign stricture (stent vs drainage catheter) Cancer (Stent vs drainage +/- resect the CA)

The key principle is decompression, either externally(drainage) or internally(stenting) the duct open to allow better drainage

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Take Home Points

Above is a comprehensive approach For surgery clerkship, all you need to know is:
1. Broad categories (no specific diagnoses) 2. The four DDx of obstructive jaundice 3. H&P (ask about fevers/chills, jaundice, acholic stools, dark urine, weight loss for CA), r/o ascending cholangitis = emergency 4. Labs (LFT: ?cholestatic, CBC w diff, BMP) 5. Imaging (U/S, CT, MRCP, EUS) 6. Therapy (ERCP vs PTC vs surgery)