BIOCHEMICAL PROFILE OF JAUNDICE

DR MUHAMMAD MUSTANSAR

Introduction
• Bilirubin is the orange-yellow pigment derived from senescent red blood cells. • It is a toxic waste product in the body.

• It is extracted and biotransformed mainly in the liver, and excreted in bile and urine.
• It is a bile pigment • Elevations in serum and urine bilirubin levels are normally associated with Jaundice.

Erythrocytes become “old” as they lose their flexibility and become pikilocytes (spherical), increasingly rigid and fragile. Once the cell become fragile, they easily destruct during passage through tight circulation spots, especially in spleen, where the intra-capillary space is about 3 micron as compared to 8 micron of cell size
RBCs useful life span is 100 to 120 days,After which they become trapped and fragment in smaller circulatory channels, particularly in those of the spleen. For this reason, the spleen is sometimes called the “red blood cell graveyard.” Dying erythrocytes are engulfed and destroyed by macrophages.

Formation of Bilirubin • Primary site of synthesis:SPLEEN: The Graveyard of Red Blood Cells • Secondary site of synthesis:LIVER & BONE MARROW .

 An average person produces about 4 mg/kg of bilirubin per day. TOTAL BILIRUBIN 85% HEMOGLOBIN FROM SENESCENT RBC’S DESTROYED IN RETICULOENDOTHELIAL CELLS OF LIVER.  The daily bilirubin production from all sources in man averages from 250 to 300 mg. SPLEEN & BONE MARROW 15% RBC PRECURSORS DESTROYED IN THE BONE MARROW CATABOLISM OF HEME-CONTAINING PROTEINS (MYOGLOBIN. CYTOCHROMES & PEROXIDASES) .

Bone marrow. & Spleen) Phagocytosis & Lysis Hemoglobin Globin Heme Fe2+ Bilirubin Amino acids Amino acid pool Recycled Excreted .Extravascular Pathway for RBC Destruction (Liver.

Pathophysiology RBCs Breakdown Hemoglobin Produces & Breakdown Heme Heme Oxygenase Biliverdin Biliverdin Reductase Bilirubin .

• The globin is recycled or converted into amino acids, which in turn are recycled or catabolized as required. • Heme is oxidized, with the heme porphyrin ring being opened by the endoplasmic reticulum enzyme, heme oxygenase. • The oxidation occurs on a specific carbon producing equimolar amounts of the biliverdin, iron , and carbon monoxide (CO). This is the only reaction in the body that is known to produce CO. • Most of the CO is excreted through the lungs, with the result that the CO content of expired air is a direct measure of the activity of heme oxygenase in an individual.

In the first reaction, a b r i d g i n g m e t h yl e n e group is cleaved by heme oxygenase to form Linear Biliverdin from Cyclic Heme m o l e c u l e .
Fe 2+ is released from the ring in this process. I

Oxidation

Heme Oxygenase

III

IV

II

Heme Oxygenase

I IV
Fe2+

C
II

NADP H

III

O2

O2

IV III II I Biliverdin .

H NADP H Bilirubin .

a second bridging methylene (between rings III and IV) is reduced by biliverdin reductase.• I In the next reaction. III IV II Reduction Biliverdin Reductase I III IV II . producing bilirubin.

• Peripherally arising bilirubin is transported to the liver in association with albumin. • The latter catabolic changes in the structure of tetrapyrroles are responsible for the progressive changes in color of a hematoma.• biliverdin causing a change in the color of the molecule from blue-green (biliverdin) to yellow-red (bilirubin). in which the damaged tissue changes its color from an initial dark blue to a red-yellow and finally to a yellow color before all the pigment is transported out of the affected tissue. or bruise. where the remaining catabolic reactions take place. .

Bilirubin is not very water-soluble. so most of it is carried to the liver bound to albumin. .

. bilirubin undergoes modification to increase its water solubility so that it can be excreted more easily.In cells of the liver. creating bilirubin diglucuronide. b.Bilirubin is conjugated to two molecules of glucuronic acid. Bilirubin diglucuronide is transported out of the hepatocytes into the bile canaliculi and is thus excreted in bile. a.

5 mg bilirubin – Fatty acids & drugs can displace bilirubin – Indirect positive reaction in van den Bergh test . albumin. Unconjugated bilirubin – Lipid soluble – : limits excretion – 1 gm albumin binds 8. liver & bone marrow is unconjugated bilirubin. • It is hydrophobic in nature so it is transported to the liver as a complex with the plasma protein.In Blood • The bilirubin synthesized in spleen.

Albumin Dissolved in Blood .Role of Blood Proteins in the Metabolism of Bilirubin 1.

Blood Liver Ligandin Ligandin (-) charge (-) charge Ligandin Prevents bilirubin from going back to plasma .

. unconjugated bilirubin is converted to water soluble mono.In Endoplasmic Reticulum In the microsomes of the endoplasmic reticulum.or di.conjugates by sequential covalent coupling with glucuronic acid.

glucuronide .& di.Bilirubin is conjugated in a two step process to form bilirubin mono.

Conjugation with Glucoronates BILIRUBIN DIGLUCORONIDE .

Heme Heme oxygenase Biliverdin Biliverdin reductase Bilirubin BILIRUBIN PHYSIOLOGY .

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Excretion of Bilirubin .

and c) oxidation of unconjugated bilirubin to brown colored mesobilifuscins.In the Intestine • In the small intestine. but are partly hydrolyzed back to unconjugated bilirubin by catalytic action of bacterial ß-glucuronidases. conjugated bilirubins are poorly reabsorbed. anaerobic flora mediate further catabolism of bile pigments: a) hydrolysis of conjugated bilirubin to unconjugated bilirubin by bacterial β-glucuronidases. In the distal ileum and colon. b) multistep hydrogenation (reduction) of unconjugated bilirubin to form colorless urobilinogens. • .

– Stercobilinogen (6H) – Mesobilinogen (8H)&.• Urobilinogens is a collective term for a group of 3 tetrapyrroles. – Urobilinogen (12H) • Upto 20 % of urobilinogen produced daily is reabsorbed from the intestine & enters the entero-hepatic circulation. Urobilinogen Structure .

the 3 urobilinogens spontaneously oxidize to produce the corresponding bile pigments. . • A small fraction (2 % . – Stercobilin – Mesobilin & – Urobilin.• Most of the reabsorbed urobilinogen is taken up by the liver & is re-excreted in the bile. • In the lower intestinal tract.5 %) enters the general circulation & appears in the urine. which are orange-brown in color and are the major pigments of stool.

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JAUNDICE .

SYMPTOMS o Yellowing of the skin. scleras (white of the eye). and mucous membranes (jaundice) o Detectable when total plasma bilirubin levels exceed 2mg/100mL AHHH!!! I have symptoms of hyperbilirubinemia!!! .

sclerae and mucous membrane.Clinical Significance Hyperbilirubinemia & Types of Jaundice • Hyperbilirubinemia : Increased plasma concentrations of bilirubin (> 3 mg/dl) occurs when there is an imbalance between its production and excretion. a yellow discoloration of the skin. • Recognized clinically as jaundice. • Also known as icterus. .

sclerae and mucous membranes – Itching (pruritus) due to deposits of bile salts on the skin – Stool becomes light in color – Urine becomes deep orange and foamy . • Several types of Jaundice: – Hemolytic – Hepatocellular – Obstructive • Symptoms: – Yellow discoloration of the skin.5mg/dL.• Jaundice becomes clinically evident when the serum bilirubin level exceeds 2.

Different Causes of Jaundice • • • • Excessive Production of Bilirubin Reduced Hepatocyte Uptake Impaired Bilirubin conjugation Impaired Bile Flow .

Classification Jaundice Pre-hepatic Hepatic Post-Hepatic .

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Prehepatic (hemolytic) jaundice • Results from excess production of bilirubin (beyond the livers ability to conjugate it) following hemolysis • Excess RBC lysis is commonly the result of autoimmune disease. or breakdown of extravasated blood • High plasma concentrations of unconjugated bilirubin (normal concentration ~0.or ABOincompatibility).5 mg/dL) . hemolytic disease of the newborn (Rh. structurally abnormal RBCs (Sickle cell disease).

or secretion of bilirubin • Reflects a generalized liver (hepatocyte) dysfunction • In this case. conjugation.Hepatic jaundice • Impaired uptake. hyperbilirubinemia is usually accompanied by other abnormalities in biochemical markers of liver function .

• – This overloads the capacity of the RE system to metabolize heme. • – Failure to conjugate bilirubin to glucuronic acid causes accumulation of bilirubin in the unconjugated form in the blood. .• Hemolytic jaundice arises as a consequence of excessive destruction of RBCs.

• – Consequently. . urobilinogen is elevated in the urine.• Hepatocellular jaundice arises from liver disease. unconjugated bilirubin spills over into the blood. • –In addition. • – Liver dysfunction impairs conjugation of bilirubin. either inherited or acquired.

hence. This produces a nodular. firm liver. The nodules seen here are larger than 3 mm and.Ongoing liver damage with liver cell necrosis followed by fibrosis and hepatocyte regeneration results in cirrhosis. this is an example of "macronodular" .

due to an obstructive cause. .Obstructive jaundice Definition : Is a condition characterized by Yellow discoloration of the skin . sclera & mucous membrane as a result of an elevated Sr. Bilirubin conc.

. • In a complete obstruction. • Plasma bilirubin is conjugated.Posthepatic(Obstructive) jaundice • Caused by an obstruction of the biliary tree. such as bile acids accumulate in the plasma. urobilin is absent from the urine. • Characterized by pale colored stools (absence of fecal bilirubin or urobilin). and dark urine (increased conjugated bilirubin). and other biliary metabolites.

• – This prevents passage of bile into the intestine and consequently conjugated bilirubin builds up in the blood. • – Patients with this condition suffer severe abdominal pain associated with the obstruction (if due togallstone) and their feces are gray in color due to lack of stercobilin. as the name implies.• • Obstructive jaundice. is caused by blockage of the bile duct by a gallstone or a • tumor (usually of the head of the pancreas). .

Pre-hepatic cause Hepatic Post hepatic Excessive break down Of RBC’s Malaria.HS Gilbert Syndrome unconjugated Absent Achloric jaundice Because of increased stercobilinogen Infective Liver Damage Bile Duct Obstruction Serum Bilirubin Urine bilirubin Both conj+unconj. Bilirubinemia + Deep yellow urine Decreases Because of decreased stercobilinogen Reduced Pale coloured stool Increased 40-50% Bulky.pale greasy foul smelling faeces Impaired SGOT/SGPT conjugated As in hepatic jaundice ++ Absent(-) Urine urobilinogen Increases Fecal stercobilinogen 20-250mg/day Fecal fat 5-6% Markedly increased Dark brown stool normal Absent clay colored stool As hepatic jaundice Liver functions normal Normal Alkaline phosphatase++ Vonden burg test Indirect+ biphasic Direct+ .

Diagnoses of Jaundice .

• Transient (resolves in the first 10 days). non-toxic form. . • Due to immaturity of the enzymes involved in bilirubin conjugation. particularly in premature infants. • High levels of unconjugated bilirubin are toxic to the newborn – due to its hydrophobicity it can cross the blood-brain barrier and cause a type of mental retardation known as kernicterus • If bilirubin levels are judged to be too high. then phototherapy with UV light is used to convert it to a water soluble.Neonatal Jaundice • Common.

exchange blood transfusion is used to remove excess bilirubin • Phenobarbital is oftentimes administered to Mom prior to an induced labor of a premature infant – crosses the placenta and induces the synthesis of UDP glucuronyl transferase • Jaundice within the first 24 hrs of life or which takes longer then 10 days to resolve is usually pathological and needs to be further investigated .• If necessary.

CLINICAL FEATURES • Severe unconjugated hyperbilirubinemia at birth Prior to phototherapy: • Kernicterus • Death in infancy .

Phototherapy •Phototherapy is usually not needed unless the bilirubin levels rise very quickly or go above 16-20 mg/dl in healthy. During phototherapy. full term babies. the treatment of choice for jaundice. • . babies are placed under blue lights that convert the bilirubin into compounds that can be eliminated from the body.

Phototherpy for infants .

• This condition develops in newborns with prolonged jaundice due to: – Polycythemia – Rh incompatibility between mother & fetus . the basal ganglia. • It is a form of permanent brain damage caused by excessive jaundice..e.Bilirubin Toxicity .Kernicterus • Kernicterus or brain encephalopathy refers to the yellow staining of the deep nuclei (i. • The concentration of bilirubin in serum is so high that it can move out of the blood into brain tissue by crossing the fetal blood-brain barrier. the kernel) of the brain namely.

Inherited Disorders of Bilirubin Metabolism • • • • • • Gilbert’s Syndrome Crigler-Najjar (Type I) Crigler-Najjar (Type II) Lucey-Driscoll Dubin-Johnson Rotor’s Syndrome .

5 to 20 mg/dl • Lucey-Driscoll .<3 mg/dl • Crigler-Najjar (Type I) . subsequent fractionation of the bilirubin Conjugated Unconjugated Possibility of following syndromes based on the bilirubin concentration: • Gilbert’s .>25 mg/dl • Crigler-Najjar (Type II) .Transiently ~ 5 mg/dl Possibility of the following syndromes: • Dublin-Johnson • Rotor .Algorithm for differentiating the familial causes of Hyperbilirubinemia Isolated increased serum bilirubin Ruling out of hemolysis.

• It is inherited as an autosomal recessive trait.Crigler-Najjar Syndrome (Type I) • Crigler-Najjar Syndrome (Type I) is a rare genetic disorder caused by complete absence of UDP-glucuronyltransferase and manifested by very high levels of unconjugated bilirubin. . • Most patients die of severe brain damage caused by kernicterus within the first year of life. • Early liver transplantation is the only effective therapy.

Crigler-Najjar Syndrome (Type II) • This is a rare autosomal dominant disorder. . • Unconjugated bilirubin is usually 5 – 20 mg/dl. Type II responds dramatically to Phenobarbital & a normal life can be expected. • Unlike Crigler-Najjar Type I. • It is characterized by partial deficiency of UDPglucuronyltransferase.

. • It affects 3% – 5% of the population.5 & 3 mg/dl. • The concentration of Bilirubin in serum fluctuates between 1. • In this condition the activity of hepatic glucuronyltransferase is low as a result of mutation in the bilirubin-UDPglucuronyltransferase gene(UGT1A1).Gilbert’s Syndrome • Gilbert’s syndrome is also called as familial non-hemolytic non-obstructive jaundice. • mild unconjugated Hyperbilirubinemia. It is often misdiagnosed as chronic Hepatitis.

• Excretion of various conjugated anions and bilirubin into bile is impaired. • The Liver has a characteristic greenish black appearance and liver biopsy reveals a dark brown melaninlike pigment in hepatocytes and kupffer cells. . reflecting the underlying defect in canalicular excretion.Dubin-Johnson Syndrome • It is a benign. autosomal recessive condition characterized by jaundice with predominantly elevated conjugated bilirubin and a minor elevation of unconjugated bilirubin.

Rotor’s Syndrome • It is another form of conjugated hyperbilirubinemia. • It is similar to dubin-johnson syndrome but without pigmentation in liver. .

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