JAUNDICE

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

NOMAD: BP: Jaundice I

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WHAT IS JAUNDICE?
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Also called as ICTERUS, HYPERBILIRUBINEMIA. Defined as yellowish discoloration of:
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Skin Mucosa Other tissues, eg. Cerebral Cortex, Kernictus (Erythroblastosis fetalis)

Why? Increase in the levels of Bilirubin:
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Plasma NOMAD: BP: Jaundice I Tissue Fluids

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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:
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SYMPTOM: Patient or relative recognizes the discoloration SIGN: the doctor examines and finds it out.
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INVESTIGATION: Urine & Blood levels of Bilirubin. NOMAD: BP: Jaundice I

TYPES OF JAUNDICE : A CLASSIFICATION

HEMOLYTIC JAUNDICE or PRE HEPATIC JAUNDICE

HEPATO CELLULAR OR HEPATIC JAUNDICE OBSTRUCTIVE JAUNDICE or POST HEPATIC JAUNDICE
NOMAD: BP: Jaundice I 4

HEMOLYTIC JAUNDICE

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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 Jaundice I Hepatic Pre NOMAD: BP: 5 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.
NOMAD: BP: Jaundice I 6

OBSTRUCTIVE JAUNDICE
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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. Jaundice I NOMAD: BP:

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HEPATIC JAUNDICE
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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:
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Bulky: all the fats are unabsorbed Greasy: due to fat content Foul smelling: due to bacterial action
NOMAD: BP: Jaundice I 8

OBSTRUCTIVE JAUNDICE
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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.

NOMAD: BP: Jaundice I

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Pre hepatic jaundice

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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. BP: Jaundice I NOMAD: 10

JAUNDICE: ETIOLOGIC CLASSIFICATION

HEMOLYTIC JAUNDICE or PRE HEPATIC JAUNDICE HEPATIC OR HEPATOCELLULAR JAUNDICE OBSTRUCTIVE JAUNDICE or POST HEPATIC JAUNDICE
NOMAD: BP: Jaundice I 11

HOW DO JAUNDICED PATIENTS LOOK LIKE?

NOMAD: BP: Jaundice I

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HOW DO JAUNDICED PATIENTS LOOK LIKE?

NOMAD: BP: Jaundice I

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BILIRUBINURIA? : HEMOLYTIC JAUNDICE
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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.
NOMAD: BP: Jaundice I 14

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
NOMAD: BP: Jaundice I 15

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. NOMAD: BP: Jaundice I 16

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.
NOMAD: BP: Jaundice I 17

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 NOMAD: BP: Jaundice the lipophilic bilirubin.I

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OTHER SYNDROMES WITH JAUNDICE:

ICTERUS GRAVIS NEONATORUM, ERYTHROBLASTOSI S FETALIS: KERNICTERUS HERIDITARY SPHEROCYTOSIS: CONGENITAL HEMOLYTIC ICTERUS
NOMAD: BP: Jaundice I 19

TESTS OF JAUNDICE
TEST Urine Bile Salts Urine Bilirubin Fecal Fat Liver Function Tests Van den Bergh Test PRE Absent Absent Absent Normal HEPATIC Present Present POST Present Present

Increased Increased Impaired Normal or impaired Mainly 20 Direct

Indirect Mainly NOMAD: Reactio BP: Jaundice I Direct

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

NOMAD: BP: Jaundice I

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NOMAD: BP: Jaundice I

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