CLASSIFICATION AND CAUSES OF JAUNDICE

Jaundice
Jaundice is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood). This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid. Concentration of bilirubin in blood plasma is normally below 1.2 mg/dL (<25mol/L). A concentration higher than 2.5 mg/dL (>50mol/L) leads to jaundice

Pre-Hepatic or Hemolytic Jaundice E.g Hereditary spherocytosis, G6PD deficiency, Acquired autoimmune haemolytic, Anaemia, Haemoglobinopathies Hepatic or Hepatocellular Jaundice Hereditary/congenital: Impaired hepatic bilirubin transport E.g Gilberts syndrome, Crigler-Najjar, Dubin-Johnson, Rotor Acquired: hepatocellular dysfunction E.g Hepatitis (viral, bacterial, alcohol, drugs, poisons), cirrhosis, metabolic diseases (Wilsons) Post-Hepatic or Obstructive Jaundice

Pre-Hepatic or Hemolytic Jaundice

Pre-hepatic jaundice is caused by anything which causes an increased rate of hemolysis (breakdown of red blood cells) In jaundice secondary to hemolysis, the increased production of bilirubin, leads to the increased production of urine-urobilinogen. Bilirubin is not usually found in the urine because unconjugated bilirubin is not water-soluble, so, the combination of increased urine-urobilinogen with no bilirubin (since, unconjugated) in urine is suggestive of hemolytic jaundice.

 Occurs prior to the liver. Diagnosis : LFT (normal). Urine colour (Normal). Spleenomegaly (May present). Urobilinogen (Increase). Common conditions: Hereditary spherocytosis, G6PD deficiency, Acquired autoimmune haemolytic, Anaemia, Haemoglobinopathies C/F: Anaemia, Fatigue.

Hepatic or Hepatocellular Jaundice

Hepatocellular (hepatic) jaundice can be caused by acute or chronic hepatitis, hepatotoxicity, cirrhosis, drug induced hepatitis and alcoholic liver disease. Cell necrosis reduces the liver's ability to metabolize and excrete bilirubin leading to a build up of unconjugated bilirubin in the blood.

 Occurs within the liver. Concentration of both unconjugated and conjugated bilirubin rises in the blood. Common conditions: Hepatitis, Liver CA, Alcoholic Liver Disease, Liver Cirrhosis. C/F : Pain in RHC, ascites, varicose vein.

Post-Hepatic or Obstructive Jaundice

Post-hepatic jaundice, also called obstructive jaundice, is caused by an interruption to the drainage of bile in the biliary system. In complete obstruction of the bile duct, no urobilinogen is found in the urine, since bilirubin has no access to the intestine and it is in the intestine that bilirubin gets converted to urobilinogen to be later released into the general circulation. In this case, presence of bilirubin (conjugated) in the urine without urine-urobilinogen suggests obstructive jaundice, either intra-hepatic or post-hepatic.

 Occurs after the conjugation of bilirubin in the liver. Due to the obstruction to the drainage of conjugated bilirubin in the biliary system. Common condition: Gallstone, liver fluke infestation, cholangitis, pancreatic cancer, Courvoisier's law applied. C/F: Colicky pain in RHC.

Function test

Pre-hepatic Jaundice

Hepatic Jaundice

Post-hepatic Jaundice

Total bilirubin

Normal / Increased

Increased
Increased Increased Decreased Dark (urobilinogen + conjugated bilirubin) Normal/Pale Increased Normal Decreased / Negative Dark (conjugated bilirubin) Pale

Conjugated bilirubin Normal Unconjugated bilirubin Urobilinogen Normal / Increased Normal / Increased

Urine Color Stool Color Alkaline phosphatase levels

Normal Normal

Increased

Alanine transferase Normal and Aspartate transferase levels Conjugated Bilirubin Not Present in Urine Splenomegaly Present

Increased

Present Present Absent