Jaundice are three Hemolytic, Hepatic and Obstructive Jaundice.

1. M.Prasad Naidu
MSc Medical Biochemistry,
Ph.D.Research Scholar

2.  Clinical marker of defect in metabolism &/or
excretion of bilirubin.
 ER task to initiate lab eval or imaging studies to
identify cause and determine admission or
outpt therapy.

3.  Yellow discoloration of sclera, skin, mucous
membranes due to deposition of bile pigment
 Clinically detected with serum bilirubin 2-
2.5mcg/dL or ↑ (2 times nl)

4.  The breakdown product of Hgb 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.

5.  Overproduction by reticuloendothelial system
 Failure of hepatocyte uptake
 Failure to conjugate or excrete
 Obstruction of biliary excretion into intestine

6.  Unconjugated
 ↑ production exceeds
ability of liver to
conjugate
 Ex. Hemolytic anemias,
hemoglobinopathies, in-
born errors of metab.,
transfusion rxn.
 Conjugated
 Can produce but not
excrete
 Metabolic defect
 Intra- or extrahepatic
obstruction

7.  Careful history and PE
 Family history (Gilbert, Rotor, Crigler-Najjar,
Dubin-Johnson, Sickle Cell)
 Healthy young person with fever, malaise,
myalgias = viral hepatitis (try to locate source)

8.  Gradually develops symptoms = hepatic/bile
duct obstruction (consider ETOH liver
dz/cirrhosis)
 Develops acutely with abd pain = acute
cholangitis 2° to choledocholithiasis

9.  Painless jaundice in older person with
epigastric mass & weight loss = biliary
obstruction from malignancy
 Hepatomegaly with pedal edema, JVD, and
gallop = CHF

10.  Serum bilirubin level
(total and direct)
 Liver aminotransferase
levels
 Alk. Phos
 U/A for bilirubin and
urobilogen
 CBC
 PT
 Other labs pertinent to
history
 Coombs test
 Hgb electrophoresis
 Viral hepatitis panel
 U/S Gallbladder

11.  Hemodynamically stable, new-onset jaundice,
no evidence of liver failure or acute biliary
obstruction → discharge with follow up
 If one of above violated → admission with
surgery consult

12. Tintanalli Chapter 85
Pages 561-566

13.  1) Biliary Colic
 2) Cholecystitis
 3) Gallstone pancreatitis
 4) Ascending cholangitis

14.  Most gallstones are asymptomatic
 Usually seen in obese females 20-40 yoa and
pregnancy (Remember fat, fertile, flatulent,
female, forty)
 Associated with upper abdominal pain

15.  Uncommon in children (seen with hemolytic d/o,
idiopathic, cystic fibrosis, obesity, ileal resection, long
term use of TPN)
 Elderly
 14-27% symptomatic gallstone dz.
 More likely biliary sepsis/gangrenous GB
 ↑ perioperative morbidity
 Mortality rate 19%

16. Familial
Asian descent
Chronic biliary tract infections
Parasitic infections (ascaris lumbricoides)
Chronic liver dz (ETOH)
Chronic intravasular dz (Sickle Cell, Hereditary
Scherocytosis)
Hepatitis A, B, C, E
HIV
Herpesvirus

17.  Bile
 Manufactured & secreted from hepatocytes →GB
storage in canaliculi, ductiles, & bile ducts →bile
ducts enlarge →form R and L hepatic ducts →form
common hepatic duct →joins cystic duct from GB to
form CBD →Ampulla of Vater →duodenum

18.  Release of bile stimulated by cholecystokinin
secreted from small int. mucosal cells when
fats & AA enter duodenum

19.  Symptomatic cholelithiasis = stone migration
from GB into biliary tract with eventual
obstruction →obstruction of hollow viscus
→pain, nausea & vomiting →acute
cholecystitis

20.  E. coli/Klebsiella-70%
 Enterococci-15%
 Bacteroides-10%
 Clostridium-10%
 Group D Strep
 Staphylococcal species

21.  Overlap of s/s of PUD, gastritis, GERD,
nonspecific dyspepsia
 RUQ pain
 Upper abd/epigastric pain
 Radiation to L upper back
 Pain persisant lasting 2-6h

22. THANKING U