PATHOPHYSIOLOGY OF JAUNDICE

JAUNDICE
• Jaundice is the yellowish discoloration of
sclera, skin and mucus membrane due to the
deposition of bilirubin.
•Normal bilirubin level 0.2 to 0.8 mg/dL
•Jaundice: when bilirubin level exceeds 2 mg/dl
• Latent or subclinical jaundice: 0.8 – 2 mg%
• First appears in sclera because bilirubin has
high affinity for scleral protein elastin
BILIRUBIN METABOLISM
Bilirubin metabolism
• Jaundice is due to hyperbilirubinemia
1. Unconjugated hyperbilirubinemia: in
Hemolytic jaundice
2. Conjugated hyperbilirubinemia: in
obstructive jaundice
 HEMOLYTIC JAUNDICE OR PREHEPATIC
JAUNDICE
• Occurs from increased destruction of RBCs
• This leads to increased bilirubin production
• Usually mild (except in the newborns)
• Bilirubin in plasma forms complex with
albumin  Unconjugated bilirubin
• Since Unconjugated bilirubin increases, more
amount of unconjugated bilirubin enters the
liver and more conjugated bilirubin is formed.
• More quantity of conjugated bilirubin is
delivered to intestine
• Increased amount of stercobilinogen is formed
• Increased excretion of: fecal stercobilinogen
urinary urobilinogen
• Unconjugated bilirubin level increases in
serum. This cannot be excreted in urine since
albumin molecule is large enough not to get
filtered in renal glomeruli
• Therefore, Urinary bilirubin is absent
• Note: urinary urobilinogen increases, urinary
bilirubin is absent
 HEPATIC JAUNDICE
• Cause: viral hepatitis, glucuronyl transferase dysfunctioning
• Uptake, conjugation and excretion of bilirubin is affected
• Conjugation of bilirubin is impaired. Due to this liver may not
be able to conjugate all the load of bilirubin. Thus blood
contains Unconjugated bilirubin
• Also some amount of conjugated bilirubin is not excreted in
bile due to:
• Intrahepatic obstruction: narrowing of biliary canaliculus
• due to this the conjugated bilirubin accumulates in liver cells
diffusions across the cell membrane into the bloodstream
• Consequently conjugated bilirubin is excreted in the urine this
makes urine yellow due to the presence of urinary bilirubin
• It is not excreted in the bile hence fecal stercobilinogen and
urinary urobilinogen are reduced
 OBSTRUCTIVE JAUNDICE/ POST HEPATIC
JAUNDICE
• Causes: Gallstones
• Occurs due to obstruction to bile secretion
into intestine
• No bile reaches intestine
• Therefore, no fecal stercobilinogen is formed
and stool becomes clay coloured
• Also urinary urobilinogen is absent
• The conjugated bilirubin is regurgitated by the
liver cells into the bloodstream
• Therefore level of conjugated bilirubin in the
blood is high which is excreted in urine and
causes deep yellow urine
• As bile salt is reduced in intestine, there is
increased fecal excretion of fat (steatorrhea)
CLINICAL ASPECT:
• Physiological jaundice:
• Seen in some newborns and therefore it is
also known as neonatal jaundice
• the jaundice usually appears on the second or
third day of life
• It occurs due to subnormal activity of
glucuronyl transferase that impairs
conjugation of bilirubin in hepatocyte.