Jaundice & its clinical approach

Gatot Sugiharto, MD, Internist

Internal Medicine Department
Faculty of Medicine, Wijaya Kusuma University
Surabaya
 Bilirubin

The breakdown product of Hb from injured RBCs

and other heme containing proteins.
Produced by reticuloendothelial system
Released to plasma bound to albumin
Hepatocytes conjugate it and extrete through bile
channels into small intest.
 Definition

Jaundice : Yellow discoloration of sclera, skin,

mucous membranes due to deposition of bile
pigment
Normal Serum Bilirubin (SB) is 0.3 to 1.0 mg/dl
Jaundice is increased levels of SB > 1.0 mg/dl
Clinically detected with serum bilirubin 2-2.5 mg/dL
or (2 times normal)
 Hemoglobin metabolism
Liver, Spleen &
Bone marrow

Phagocytosis & Lysis

Hemoglobin

Globin Heme Bilirubin

Amino acids Fe2+ Through Liver

Amino acid pool Excreted

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 Bilirubin metabolism

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Urobilinogen in Unconjugated Conjugated
urine Bilirubin Bilirubin
Normally traces Not filtered or Bound (20 days)
in Cholestaiss secreted Bilirubin in urine is
Nil in urine conjugated
Bilirubin metabolism in Kidney
The Hepatobiliary & Portal System

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 Pathophysiology

Over production of Bilirubin (Hemolytic)

From hemolysis of RBC
Lysis of RBC precursors Ineffective
erythropoesis
Impaired hepatic function (Hepatitic)
Hepatocellular dysfunction in handling bilirubin
Uptake, Metabolism and Excretion of bilirubin
Obstruction to bile flow (Obstructive)
Intrahepatic cholestasis
Extrahepatic Obstruction (Surgical Jaundice)
 Clinical Appearance of Jaundice
Jaundice is masked with edema and dark skin
Easily observed :
Sclera
Darkening of the urine
Skin discoloration Yellowish
Mucosa hard palate (in dark skinned)
Greenish hue of skin and sclera due Biliverdin
long standing jaundice
Generalized pruritus Obstructive Jaundice

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 Unconjugated vs. Conjugated

Unconjugated
production exceeds ability
of liver to conjugate
Ex. Hemolytic anemias,
hemoglobinopathies, in-born
errors of metab., transfusion
reaction.
Conjugated
Can produce but not excrete
Metabolic defect
Intra- or extrahepatic
obstruction
 Clues from history taking(1)
Family history (Gilbert, Rotor, Crigler-Najjar, Dubin-Johnson,
Sickle Cell)
Duration of jaundice Acute / Chronic
Abdominal pain v/s painless jaundice
Gradually develops symptoms hepatic/bile duct
obstruction
Develops acutely with abd pain acute cholangitis 2nd to
choledocholithiasis
Painless jaundice in older person with epigastric mass &
weight loss biliary obstruction from malignancy
(pancreas)
 Clues from history taking(2)
With fever, malaise, myalgias viral hepatitis,
bacteria, sepsis
Arthralgia, rash, glands; pruritus obstructive
Appetite Hepatocellular / Malignancy
Weight loss Malignancy CAH
Colour of stools chalky white obstructive
History of transfusion, promiscuity, IDU
Alcohol abuse, Medications INH, Largactil
Hepatomegaly with edema, JVD, and gallop CHF

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 Tea like urine Differ. Dx

Bilirubin in urine due to Jaundice (CB)

Concentrated urine in dehydration
Fluid deprivation syndromes
Sulfasalazine use for Ulcerative colitis
Rifampicin, Pyridium, Clofazamine and Thiamine
use
Red urine Porphyria,
Hemoglobin & Myoglobinuria, Hematuria
Dark black urine in Ochronosis
Melanin excretion from Melanoma
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 An Approach to Jaundice

History and Interpretation Radiological

physical of laboratory tests and
examination tests and procedures

unconjugated
hepatocellular liver test or conjugated
or cholestatic abnormalities fraction

intra- or
extrahepatic

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 Laboratory Tests

Serum bilirubin level (total CBC

and direct) PT
Liver aminotransferase Other labs pertinent to
levels history
Alk. Phos Coombs test
U/A for bilirubin and Hb electrophoresis
urobilogen Viral hepatitis panel
 Radio-imaging study

Ultrasound : Preferred initial imaging technique for

demonstrating dilated bile ducts (indicating biliary
obstruction) non invasive
Endoscopic retrograde cholangio- pancreatography
(ERCP) Invasive procedure of choice
Computed tomography Highly accurate
Magnetic resonance cholangiopancreatography (MRCP) :
Preferred diagnostic approach if ERCP is likely to be
unsuccessful

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 Lab Diagnosis of Jaundice D.D

Prehepatic Intrahepatic Posthepatic

Features
(Heamolytic) (Hepatocellular) (Obstructive)

Unconjugated Normal Normal

Conjugated Normal
AST or ALT Normal Normal

Alkaline phos.
and GGT
Normal Normal
Urine bilirubin Absent Present Increased

Urobilinogen Increased Present Absent

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Causes of Jaundice - Frequency
 When to refer to Specialist
Unexplained jaundice
Suspected biliary obstruction
Acute hepatitis - severe or fulminant
Unexplained abnormal LFTs persisting (for 6 months or greater)
Unexplained cholestatic liver disease
Cirrhosis (in non-alcoholic) for consideration of liver transplant
Suspected hereditary hemochromatosis
Suspected Wilson's disease
Suspected autoimmune hepatitis
Chronic hepatitis C for consideration of antiviral therapy