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Jaundice
Tad Kim, M.D.
UF Surgery
tad.kim@surgery.ufl.edu
(c) 682-3793; (p) 413-3222
Jaundice
Overview
• Normal Physiology
• Pathophysiology
• Broad Differential Diagnosis
• DDx of Obstructive Jaundice
• Work-up for “Medical” Jaundice
• Work-up if Obstructive Jaundice
• Treatment of Obstructive Jaundice
Jaundice
Normal Physiology
• Bilirubin is from breakdown of hemoglobin
• Unconjugated bilirubin transported to liver
– Bound to albumin because insoluble in water
• Transported into hepatocyte & conjugated
– With glucuronic acid → now water soluble
• Secreted into bile
• In ileum & colon, converted to urobilinogen
– 10-20% reabsorbed into portal circulation and
re-excreted into bile or into urine by kidneys
Jaundice
Pathophysiology
• Jaundice = bilirubin staining of tissue @ lvl
greater than ~2
• Mechanisms:
– ↑ production of bilirubin
– ↓ hepatocyte transport or conjugation
– Impaired excretion of bilirubin
– Impaired delivery of bilirubin into intestine
• “surgically relevant jaundice” or obstructive
jaundice
– “Cholestasis” refers to the latter two, impaired
excretion and obstructive jaundice
Jaundice
Pregnancy
Jaundice
Screening Labs
• NL LFT r/o hepatic injury or biliary tract dz
– Consider inherited disorders or hemolysis
• ↑Alk Phos moreso than AST/ALT implies
“cholestasis” (intrahepatic vs obstruction)
– ↑Alk Phos also seen in sarcoid, TB, bone
– In this case, GGT is specific for biliary origin
• Predominant ↑AST/ALT implies intrinsic
hepatocellular disease
– AST/ALT ratio > 2 in alcoholic hepatitis
• ↓albumin or ↑INR c/w advanced liver dz
Jaundice
Subsequent Labs
• If no concern for obstructive jaundice:
– Viral (Hep B&C) serologies for viral hepatitis
– anti-mitochondrial Ab (PBC)
– anti-smooth muscle Ab (Auto-immune)
– iron studies (hemochromatosis)
– ceruloplasmin (Wilson’s)
– Alpha-1 anti-trypsin activity (for deficiency)
Jaundice
Treatment
• If Medical, then treat the etiology
• If Obstructive Jaundice:
– Should r/o ascending cholangitis, ABC/resusc
• For cholangitis: IVF, IV Antibiotics, Decompression
– Stones (remove stones vs stent vs drainage)
• Done via ERCP or PTC or open (surgery)
– Benign stricture (stent vs drainage catheter)
– Cancer (Stent vs drainage +/- resect the CA)
• The key principle is decompression, either
externally(drainage) or internally(stenting)
the duct open to allow better drainage
Jaundice