Causes & Approach

Dr Shubham Upadhyay

© Medi - Lectures Dr Shubham Upadhyay 1

CONTENTS
• Introduction
• Bilirubin Production & Metabolism
• Measurement of Serum & Urine Bilirubin
• Approach
Isolated Elevation of Serum Bilirubin
 Unconjugated Hyperbilirubinemia
 Conjugated Hyperbilirubinemia
Elevation of serum bilirubin with other liver test abnormalities
 Hepatocellular Conditions
 Cholestatic Conditions
• Summary
© Medi - Lectures Dr Shubham Upadhyay 2
INTRODUCTION
• Jaundice is the yellowish discoloration of body tissues resulting from
deposition of bilirubin
• Normal levels- 1 to 1.5 mg/dl
• D/D of yellowish discoloration of skin
Carotenoderma
Quinacrine
Phenol Exposure
• Most sensitive site for detection - Sclera
• Serum Bilirubin ↑ if imbalance occurs between Bilirubin production
& clearance

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BILIRUBIN PRODUCTION & METABOLISM

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MEASUREMENT OF SERUM BILIRUBIN
Van den Bergh Reaction
Delta Bilirubin/ Biliprotein
• Albumin linked fraction of conjugated
bilirubin
• Cholestatic Jaundice
• Half life same as albumin i.e 12-14
days
• Implications
 Absence of bilrubinuria
 Late decline in s. bilirubin n recovering
patients

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MEASUREMENT OF URINE BILIRUBIN
• Which bilirubin can be detected in urine?
• Any bilirubin which is detected in urine is conjugated bilirubin
• Urine dipstick test (Ictotest)
• False negative test?

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APPROACH
• Isolated elevation of serum bilirubin?
• Conjugated or Unconjugated fraction?
• Other Liver test abnormalities?
• Hepatocellular or Cholestatic?
• Intrahepatic or Extrahepatic cholestasis?
• Hyperbilrubinemia
1. Overproduction of bilirubin
2. Impaired uptake, Conjugation or excretion of bilirubin
3. Regurgitation of unconjugated or conjugated bilirubin

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TYPES OF HYPERBILIRUBINEMIA

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 ISOLATED HYPERBILIRUBINEMIA
INDIRECT HYPERBILIRUBINEMIA DIRECT HYPERBILIRUBINEMIA
(UNCONJUGATED) (CONJUGATED)
A. HEMOLYTIC DISORDERS A. Dubin Johnson Syndrome
B. INEFFECTIVE ERYTHROPOESIS B. Rotor Syndrome
C. INCREASED BILIRUBIN PRODUCTION
• Massive blood transfusion
• Resorption of hematoma
D. DRUGS
• Rifampicin
• Probenecid
• Ribavirin
• Protease inhibitors
E. INHERITED CONDITIONS
• Gilbert’s Syndrome
• Criggler Najjar Types 1 & 2 © Medi - Lectures Dr Shubham Upadhyay 11
 FEATURE CRIGGLER NAJJAR 1 CRIGGLER NAJJAR 2 GILBERT’S SYNDROME

UDPGT
levels
Mode of
Inheritence
Total
Bilrubin
Kernicterus

Mortality
(without Rx)
Liver Biopsy

Treatment

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FEATURE DUBIN JOHNSON SYNDROME ROTOR SYNDROME

CAUSE

MODE OF
INHERITENCE

SERUM BILIRUBIN

KERNICTERUS

MORTALITY

INVESTIGATION

TREATMENT
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 ↑s.BILRUBIN WITH OTHER TESTS ABNORMAL
HISTORY PHYSICAL EXAMINTAION LABORATORY TESTS
• Exposure to drugs or GENERAL • s. Bilirubin
chemicals • Nutritional status & • SGOT/AST
• Parenteral Exposures Wasting • SGPT/ALT
• Sexual Activity • Stigmata of CLD? • ALP
• Travel , contaminated • Enlarged LN? • s. Albumin
food, occupational • ↑JVP? • PT
exposure ABDOMINAL
• Alcohol intake • Liver Size & Consistency
• Duration of Jaundice • Splenomegaly?
• Accompanying symptoms • Ascites?
• Changes in urine & stool • Pain & Tenderness
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HEPATOCELLULAR CONDITIONS
CONDITION FEATURES
VIRAL HEPATITIS
• Hepatitis A, B, C, D & E
• Epstein Barr Virus
• CMV
• HSV
ALCOHOLIC HEPATITIS
CHRONIC LIVER DISEASE & CIRRHOSIS
DRUG TOXICITY
• Predictable
• Idiosyncratic
ENVIRONMENTAL TOXINS
WILSON’S DISEASE
AUTOIMMUNE HEPATITIS © Medi - Lectures Dr Shubham Upadhyay 18
CHOLESTASIS- INTRAHEPATIC
CONDITION FEATURE
• Viral hepatitis
• Alcoholic hepatitis
• Drug toxicity
• Primary biliary cholangitis
• Primary sclerosing cholangitis
• Vanishing bile duct syndrome
• Congestive hepatopathy and ischemic hepatitis
• Inherited conditions
• Cholestasis of pregnancy
• Total parenteral nutrition
• Nonhepatobiliary sepsis
• Benign postoperative cholestasis
• Paraneoplastic syndrome
• Veno-occlusive disease
• Graft-versus-host disease
• Infiltrative disease
• Infections © Medi - Lectures Dr Shubham Upadhyay 20
CHOLESTASIS- INTRAHEPATIC
CONDITION FEATURE
• Viral hepatitis
• Alcoholic hepatitis
• Drug toxicity
• Primary biliary cholangitis
• Primary sclerosing cholangitis
• Vanishing bile duct syndrome
• Congestive hepatopathy and ischemic hepatitis
• Inherited conditions
• Cholestasis of pregnancy
• Total parenteral nutrition
• Nonhepatobiliary sepsis
• Benign postoperative cholestasis
• Paraneoplastic syndrome
• Veno-occlusive disease
• Graft-versus-host disease
• Infiltrative disease
• Infections © Medi - Lectures Dr Shubham Upadhyay 23
CHOLESTASIS- EXTRAHEPATIC
CONDITION FEATURE
• Malignant
1. Cholangiocarcinoma
2. Pancreatic cancer
3. Gallbladder cancer
4. Ampullary cancer
5. Malignant involvement of lymph nodes
• Benign
1. Choledocholithiasis
2. Postoperative biliary strictures
3. Primary sclerosing cholangitis
4. Chronic pancreatitis
5. AIDS cholangiopathy
6. Mirizzi’s syndrome
7. Parasitic disease (ascariasis) © Medi - Lectures Dr Shubham Upadhyay 26
SUMMARY

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