JAUNDICE

Definition-
 Jaundice (icterus) is defined as yellowish
pigmentation of skin, mucus membranes and
sclera due to increased levels of bilirubin in the
blood.
 The scleral involvement is because of its rich
elastic tissue that has special affinity for
bilirubin.
 Normal serum bilirubin level is – 0.3 to 1.2
mg/dl.
 Jaundice is clinically detected when the serum
bilirubin level is above 2.0 to 2.5 .mg/dl .
Classification of Jaundice

Based on the underlying cause

Predominantly unconjugated
hyperbilirubinemia

Predominantly conjugated
hyperbilirubinemia
Predominantly unconjugated
hyperbilirubinemia
1) Increased 2) Reduced Hepatic 3) Impaired bilirubin
production of bilirubin Uptake conjugation

•Hemolytic anemias • Drug that interference •Physiologic jaundice of

• Resorption internal
hemorrhage (e.g. GI
bleeding, hematomas)
• Ineffective erythropoisis
with membrane carrier the newborn
system
• Crigler-Najjar syndrome
• Diffuse liver disease types I and II
(hepatitis, cirrhosis)
•Gilbert syndrome
• Some cases of Gilbert
syndrome •Diffuse liver disease
(hepatitis cirrhosis)
Predominantly conjugated
hyperbilirubinemia
1) Decreased hepatocellular 2) Impaired intra/extrahepatic bile
excretion flow

• Liver damage or toxicity (e.g. hepatitis) • Inflammatory destruction of bile ducts

(e.g. primary biliary cirrhosis)
• Deficiency of membrane transporters
Dubin-Johnson syndrome, Rotor syndrome • Gall Stones

• Carcinoma: Head of pancreas,

periampullary carcinoma,
cholangiocarcinoma
Hemolytic (pre-hepatic) jaundice

 Increased destruction of red blood cells

or their precursors causes increased
production of bilirubin.

 Unconjugated bilirubin accumulates in

the plasma and results in jaundice.

 Jaundice is usually mild because normal

liver cas easily handle the increased Conjunctiva showing mild jaundice in
bilirubin production. hemolytic anemia
Causes:-

Intracorpuscu Extracorposc
lar defects ular defects
• Autoimmune, alloimmune
• Hereditary: Spherocytosis,
hemolytic anemias
Sickle cell disease,
• Fragmentation syndromes:
Thalassemia, G6PD
deficiency Prosthetic valves
• Drugs e.g. Sulfasalazine,
• Acquired: Vitamin B12 and
dapsone
folate deficiency • Infections of RBCs, Malaria
Clinical features

2) Mild jaundice
1) Pallor due without any signs
to anemia of liver disease

3) Dark Stools 4) Urine turns

due to increased dark yellow Pallor due to anemia

sterecobilinogen on standing

5)
Investigations

1 • Peripheral smear – shows features of hemolysis

2 • Urinary urobilinogen is increased (more than 4mg/24 hours)

Hemolysis

3 • No bilirubin in urine because unconjugated bilirubin is water insoluble

4 • Predominantly unconjugated hyperbilirubinemia. Serum bilirubin is raised (<6mg%)

Hepatocellular Jaundice
 It occurs as a consequence of parenchymal liver
disease.
 This leads to inability of the liver to transport
bilirubin across the hepatocyte into the bile.
 Defect in transport may occur at any point
between:-
- Uptake of unconjugated bilirubin into the
hepatocyte
- Transport of conjugated bilirubin into the Deep jaundice in viral hepatitis
biliary canaliculi
 Both unconjugated and conjugated bilirubin level
rise in the blood.
Clinical Features:-

Yellowing of
Conjunctiva of
Clinical Dark urine
eyes Features or pale stool

Darkening
skin
Hepatocellular Jaundice Causes:-

• Viral, alcoholic hepatitis

• Chronic hepatitis

• Cirrhosis

• Infilterations

• Ischemic liver

• Drug – induced hepatitis: Chlorpromazine,

imipramine, INH, rifampicin, erythromycin
Investigations:-

1
• Raised transaminases (AST and ALT)
•Acute Jaundice with AST>1000 U/L is highly
suggestive of an infectious cause (e.g. hepatitis
A,B), drugs (e.g. paracetamol) or hepatic ischemia

2 • Imaging

3 • Liver Biopsy
Obstructive Jaundice (Surgical Jaundice)

 Jaundice that occur due to

obstruction to the outflow of
bile is called obstructive
jaundice.

 Since these cases are to be

managed by surgical
interventions, it is also called
surgical jaundice.
Continued…
 Cholestasis can be
intrahepatic of
extrahepatic.
 Consequences of
cholestasis:
- Retention of bile
acids and bilirubin in the
liver and blood
- Deficiency of bile
acids in the intestine
Aetiology

3) Causes from
1) Causes in 2) Causes in outside (due to
the lumen the wall pressure)
• Stones in the common • Carcinoma head
bile duct • Periampullary
• Ova, cysts, ascaris of pancreas
carcinoma • Chronic
worms
• Hydatid cyst of the
• Choledochal cyst
• Bile duct stricture pancreatitis
biliary tree • Lymph nodes at
• Stones in the • Klatskin’s tumour
pancreatic duct the porta hepatitis
Continued…
Courvoisier’s law

 In a jaundiced patient, if the gall bladder is

palpably enlarged, it is not due to stones. In
case of stones, previous inflammation would
have made gall bladder fibrotic and hence,
will not be palpable.

 90% of cases of obstructive jaundice are due

to stones, periampullary carcinoma or
carcinoma of the head of pancreas.
Exceptions to Courvoisier

 Double impaction: One Stone in the CBD and one stone in

the cystic duct.

 Periampullary carcinoma in a patient who has undergone

cholecystectomy.

 Primary oriental cholangiohepatitis causing stones in the

CBD (gall bladder is normal in these cases.)
Reynold’s Pentad of acute obstructive
cholangitis
1) Persistent Pain

2) Fever

3) Persistent jaundice

4) Shock

5) Altered mental status

Clinical Features
Symptoms
• Jaundice
• Pruritus
• Pale, clay colored stool
• Dark urine (increased conjugated
bilirubin)
Depending on the cause
• Fever with chills and rigors
(cholangitis)
• Weight loss (malabsorption)
• Bleeding tendency (Vit K deficiency)
• Abdominal pain (gall stones)
Signs
• Deep jaundice with a greenish hue
• Scratch marks
• Xanthelasmas on eyelids and
xanthomas over tendons
Depending on the cause
• Palpable gallbladder observd in
carcinoma head of pancreas
• Large hard irregular liver (malignancy)
• Late features: Secondary biliary
cirrhosis and signs of liver cell failure
Investigations

1) Hb% is low in malignancy.

2) TC, DC are increased in cases of infections.

3) BT, CT, PT are altered in cases of obstructive jaundice.

4) Urine for urobilnogen is negative in obstructive jaundice.

5) Serum alkaline phosphatase: Normal Value is 60-300 units/L. More

than 500 units is suggestive of obstructive jaundice.
Continued…

6) Abdominal ultrasound: It is most useful,

noninvasive, reliable and quick investigation
for obstructive jaundice.
- Dilated biliary radicals, both
intrahepatic and extrahepatic can be
demonstrated.
- Stones can be diagnosed with their
posterior acoustic shadow.
Continued…

7) CT scan: A head mass of even 2-3

cm in size and portal vein
infilteration can be demonstrated CT Scan
by CT scan.

8) Endoscopy: useful to diagnose

periampullary carcinoma.

Endoscopy showing growth

in the periampullary region.
Continued…

9) ERCP (Endoscopic Retrograde

Cholangio-pancreato-graphy)
- Stones appear as filling
defects in the CBD or in the
common hepatic duct (CHD)
- Chronic pancreatitis may
show the dilated duct and
stones in the pancreatic duct- ERCP showing stones in the CBD
'chain of lakes' appearance.
Continued…

10) MRI scan (MRCP)

- It is noninvasive and
delineates the bile ducts very
well so that a biliary bypass
can also be planned.

MRC (magnetic resonance

cholangiogram) showing high
stricture
Treatment of Obstructive Jaundice

Preoperational prepration:-
1) Correction of fluid and electrolyte status and adequate hydration
before surgery for 2-3 days
2) Injection dopamine 2 μg/kg/min can be given to improve the urinary
output.
3) Injection vitamin K, 10 mg, subcutaneously or intravenously for 3 days
is given to correct the prothrombin time.
4) Broad spectrum antibiotics are given before, during and after surgery
5) Adequate blood transfusion to correct anaemia.
Investigation and
treatment of
Obstructive Jaundice
Treatment of CBD stones

 Cholecystectomy is done first. This is followed by

introduction of a cannula into the cystic duct and a radio-
opaque dye is injected

 This is called OTC (On Table Cholangiography)

Clinical features useful in differentiating
different types of jaundice
Feature Hemolytic Hepatocellular Obstructive

Jaundice Color Depth Lemon yellow - Orange yellow - Greenish yellow

mild variable - deep
Pruritus - Variable +
Bleeding tendancy - + + (late)

Anemia + - -
Splenomegaly + Variable Absent
Palpable gallbladder - - May be present
 Continued…

Feature Hemolytic Hepatocellular Obstructive

Features of - + (early) + (late)
hepatocellular failure
Conjugated bilirubin Absent Raised Raised

AST or ALT Normal Increased Normal

ALP Normal Normal Raised
Urine bilirubin Absent Present Present
Urine urobilinogen Present Present Absent
Thank You