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Pre-hepatic /
Hemolytic
jaundice
Hepatic jaundice
Post-hepatic /
Obstructive/
Surgical jaundice
Hemolytic Jaundice/Pre hepatic Jaundice
Excess production of
bilirubin due to excess
breakdown of hemoglobin
Indirect bilirubin
(insoluble in water since
unconjugated).
Causes of pre hepatic jaundice
HEMOLYTIC DISORDERS
1. Inherited
a. Spherocytosis, elliptocytosis- Hereditary condition, with defect or
absence of RBC membrane protiens.
b. glucose 6 phosphate dehydrogenase- Most common cause of enzyme
deficiency hemolysis.
- autosomal recessive condition
triggered by certain certain food,
drugs, etc. Avoiding such triggers
is advised.
c. pyruvate kinase deficiency- second most common cause of enzyme
deficiency hemolysis.
b. sickle cell anemia- Abnormal haemoglobin synthesis leading to
sickeling under low oxygen condition. Incresed hemolysis.
2. Acquired
a. Microangiopathic haemolytic anemias
b. Paroxysmal nocturnal hematuria.
c. Spur cell anemia.
d. Immune haemolysis.
e. Parasitic infections-
- Malaria- patient presents with fever chills rigor, hepatosplenomegaly
- Babesiosis
INEFFECTIVE ERYTHROPOIESIS
1. Cobalamin, Folate deficiency- Megaloblastic anemia
2. severe iron deficiencies- Microcytic hypochromic anemia
3. Thalassemia
• DRUGS
1. Rifampicin, ribavirin, Probenecid.
Hepatic Jaundice
VIRAL HEPATITIS
features HAV HBV HCV HDV HEV
INTRAHEPATIC CAUSES
1. Viral hepatitis-
a. Fibrosing cholestatic hepatitis- hep.B and C
b. hep A, Epstein barr, cytomegalovirus infection.
2. Alcoholic hepatitis
3. Drug Toxicity-
a. Pure cholestasis- anabolic and contraceptive steroids
b. Choleststic hepatitis- chlorpromazine, erythromycin estolate
c. Chronic cholestasis- prochlorperazine and chlorpromazine
4. Primary biliary cirrhosis
5. Primary sclerosing cholangitis
6. Vanishing bile duct syndrome
- chronic rejection of liver transplants
- sarcoidosis
- drugs
7. Congestive hepatopathy and ischemic hepatitis
8. Inherited conditions-
- progressive familial intrahepatic cholestasis
- Benign recurrent cholestsis
9. Cholestasis of pregnancy
10. Total parenteral nutrition
11. Non hepato biliary sepsis
12. Benign post operative cholestasis
13. Paraneoplastic syndrome
14. veno-occlusive disease
15. Graft versus host disease
16. Infiltrative disease-
- tuberculosis, amyloidosis, and lymphomas
17. infections-
-malaria, leptospirosis
EXTRAHEPATIC CAUSES
1. Malignant conditions
- Cholangiocarcinoma
- Gallbladder cancer
- Pancreatic cancer
- Ampullary carcinoma
- malignant involvement of porta hepatis lymph nodes
2. Benign conditions
- Choledocolithiasis
- post operative biliary strictures
- Primary sclerosing cholangitis
- Chronic pancreatitis
- AIDS Cholangiopathy
- ascariasis
Sign & Symptoms
Early features
- Yellowish discolouration(skin, sclera, etc)
- Pale/Clay coloured stool
- Dark Urine
- Pruritis
Late Features
- Xanthelasma and Xanthomas
- Malabsorption- weight loss, steatorrhea,
Osteomalacia,Incresed bleeding
Tendency
Fever, Rigor, pain (features of cholangitis)
INVESTIGATION
OF
J AUNDI C E
Investigation
The typical investigation will include blood levels of enzymes found primarily from the
liver, such as the aminotransferases (ALT, AST), and alkaline phosphatase (ALP);
bilirubin (which causes the jaundice); and protein levels, specifically, total protein and
albumin. Other primary lab tests for liver function include gamma glutamyl
transpeptidase (GGT) and prothrombin time (PT)
Pre-hepatic Jaundice
Enzymatic test:-
1. AST,ALT – highly raised (due to lysis of liver parenchymatic cells)
2. ALP, GGT – is slightly raised
AST and ALT rise is significantly higher than the ALP and GGT rise
Plasma albumin level is low but plasma globulins are raised due to an increased
formation of antibodies
Disorders Bilirubin Aminotransferases Alkaline phospha. Albumin Prothrombin time
Post Hepatic/Obstructive Jaundice
Detoxification test
1. Serum bilirubin – Direct(conjugated)– increased
2. Urine – Bilirubin- Present
- Urobilinogen – absent
3. fecal stercobilinogen- trace to absent
Enzymatic Test
1. AST,ALT – Slightly increase
2. ALP, GGT- Highly Incresed
If the ALP (10–45 IU/L) and GGT (18–85) levels rise
proportionately about as high as the AST (12–38 IU/L) and
ALT (10–45 IU/L) levels, this indicates a cholestatic
problem
Disorder Bilirubin Aminotransferases Alkaline phosphatase Albumin Prothrombin Time
Radiological Investigation
Biopsy
• Usually done at last in series of investigation to establish the cause of
Jaundice.
• In patients with apparent intrahepatic cholestasis, the diagnosis is often
made by serologic testing in combination with percutaneous liver biopsy.
• to assess the condition of the liver tissue if it may have been damaged by a
condition such as cirrhosis or liver cancer.
Treatment of Jaundice
General Treatment
Treatment of pre hepatic causes
• Spherocytosis
o These infants should be treated with phototherapy
and/or exchange transfusion as clinically indicated.
o Folic acid is required to sustain erythropoiesis.
o Patients with HS are instructed to take supplementary
folic acid for life in order to prevent a megaloblastic
crisis.
o Splenectomy is the definitive treatment for HS
• Sickle cell anaemia
o Treatments may include medications to reduce pain and
prevent complications, blood transfusions and supplemental
oxygen, as well as a bone marrow transplant.
o Antibiotics -Children with sickle cell anemia may begin taking
the antibiotic penicillin when they're about 2 months of age and
continue taking it until they're at least 5 years old.
• Immune related hemolysis – corticosteroids, folic acid is
main line of treatment
• Parasitic Infections like malaria are treated with
antimalarial drugs like chloroquine, artesunate,
lumefantrine,amodiaquine
• Ineffective erythropoiesis- iron and folic acid
supplementation, vit B12 tablets given and repeated blood
transfusions
Treatment of hepatic causes
• Viral hepatitis
Hepatitis A is mostly self limiting no treatment is
required, but in some cases 0.02 ml/kg administration
of anti-HAV Ig can be given.
Hepatitis B treated with combination of HBIG and Hep
b vaccines.
Recombivax and Engerix-B are 2 vaccines for
hepatitis B
Hepatitis C is treated with interferons.
• Other Viral infections like EBV, CMV, HSV are treated
with Antiviral medications like acyclovir , ganciclovir
and foscarnet.
• Alcoholic hepatitis
Discriminant function - determines the prognosis of the person suffering from
alcoholic liver disease. Given by Maddrey.
It is calculated by a simple formula:
(4.6 x (PT test - control))+ S.Bilirubin in mg/dl
A value more than 32 implies poor outcome.