Approach to the Patients with Jaundice Dr Suresh Kubavat MD (Internal Medicine) Consultant Physician Shrad Shr adha ha Arog rogyam yamand andir ir - Jun Junaga agadh dh 9427257977
Gross Hepatic Anatomy
Gross Hepatic Anatomy
Gross Hepatic Anatomy
Liver Histological Structure
Liver Histological Structure
Functions of the Liver 1.Metabolism
Fats ,Proteins,Carbohydrates,Hormones
2.Storage (as Glycogen) 3.Interconversion= Glucose-Fat-Amino acids 4.Production:Fatty acids,Triglycerides,Phos -pholipids,ketones,Cholesterol,Albumin, Fibrinogen 5.Exocrine:Bile-Bilirubin-Helps digestion 6.Detoxification of ciculating toxins. 7. Drug metabolism and excretion. 8. Removal of particulate matters-Kupffer cells
Normal Bile Physiology
300mg bile/day 2 roles: 1. excretion 2. emulsification of fat
Water (98%)
Bile Salts
Bile pigments (Bilirubin)
Fatty Acids
Lecithin (Fat emulsifier,Cell protector)
Cholesterol
Na,K,Ca,Cl,Hco3
Normal Bilirubin Metabolism
Bile:300mg/Day-80% from aged dying RBCs -20% from premature destruction in BM
Hemoglobin Heme + Globin HemeBiliverdin+CO+Iron Biliverdin(Water insoluble)Binds with Albumin(becomes water soluble)Liver:unconj bil taken up by hepatocytes conjugates
to glucuronic acidBileexcr to intestine goes to terminal ilium+colonbecomes unconjugated
converted
to urobilinogen80-90% excreted in faeces
as urobilins+10-20% absorbed thru intestine portal v. Liver Reexcreted
A small fraction escapes hepatic uptake excr in urine
Pathophysiology
Jaundice = Bilirubin staining of tissue @ level greater than 3
Mechanisms: ±
production of bilirubin (Hemolysis)
±
hepatocyte transport
±
conjugation
±
Impaired excretion of bilirubin(Hepatitis,drugs,sepsis, Dubin-Johnson )
±
Impaired delivery of bilirubin into intestine
±
³surgically relevant jaundice´ or obstructive jaundice
³Cholestasis´ refers to the latter two, impaired excretion and obstructive jaundice
Definition of Jaundice
Jaundice is yellow discoloration of the sclera, skin and mucous membranes resulting from accumulation of bilirubin.
Normal bilirubin levels are 0.4+0.2 mg per dl, with
> 95% unconjugated.
Hyperbilirubinemia is separated into two classes : unconjugated (> 80% of total bilirubin) and conjugated (>30 % of total bilirubin)
Algorithm for PT with jaundice. History+Physical exam+Lab tests Bilirubin & other liver tests elevated
Isolated elevation of the Bilirubin Direct hyperbilirubinemia
Indirect hyperbilirubinemia
Inherited disorders 1. Dubin ± Johnson Syndrome 2. Rotor¶s Syndrome
Drugs Rifampicin
Inherited Disorders 1. Gilbert¶s Syndrome 2. Crigler ±Najjar Syndromes
Hemolytic Disorders-Sphero,Ellipto,G6PD,Sickle,immune Ineffective erythropoiesis-Iron,Folate,B12 def,Thallesemia.
ALGORITHM CONTINUED Bilirubin & other liver tests elevated
Hepatocellular Pattern
Cholestatic Pattern
SGPT/OT elevated out of proportion to Alkaline phosphatase
Alkaline phosphatase elevated out of proportion to SGPT/OT
Hepatocellular Pattern 1. Viral Serologies Hepatitis A IgM Hepatitis B Surface Antigen & core antibody (IgM) Hepatitis C RN A 2. Toxicology screen Acetaminophen level 3. Ceruloplasmin (If Pt < 40) 4. AN A, SMA, LKM(Liver Kidney Microsomal Antibody), SPEP( Serum protein electrophoresis)
If negative
If negative
Liver Biopsy
Additional Virologic Testing CMV DN A, EBV capsid antigen Hepatitis D antibody(If indicated) Hepatitis E IgM(If indicated)
Cholestatic Pattern Dilated Ducts Extra hepatic cholestasis
Ultrasound
Ducts not Dilated Intra hepatic cholestasis
CT/ERCP Negative
MRCP/Liver Biopsy
Liver Biopsy
AMA +ve
Serologic testing AMA Hepatitis Serologies Hepatitis A CMV, EBV Review Drugs
Prehepatic Unconguated
Bil
LFT¶s N
Haptoglobins (a protein in blood that combines with hb to form a complex that is removed from @ by the liver)
Reticulocytes
Coombs test +ve
Urine
urobilinogen +
Hepatic
ALT(SGPT)
ALP N or
Bil
Albumin
INR
Hepatitis serology
Autoantibodies
Anti-mitochondrial PBC
Anti-nuclear & antimicrosomal, Autoimmune hepatitis
Caeruloplasmin
-Globulins
Cirrhosis esp autoimmune
Transferrin
Wilson¶s
Haemochromatosis
-foetoprotein, FP
HCC(Hepato cellula Carcinoma) in cirrhosis
Hepatic Causes
Viral Hepatitis : A,B,C,D,E / EBV / CMV /Herpes Simplex.
Alcohol
Drug toxicity : Predictable: Paracetamol Unpredictable:INH
Environmental toxins : Vinyl chloride (PVC) Ca Jamaica Bush Tea Kava Kava Wild mushrooms
Wilson¶s disease
Autoimmune hepatitis.
