Jaundice

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Information about Jaundice

Published on April 8, 2008

Author: hanash

Source: slideshare.net

Jaundice Dr E M Said

objectives About jaundice History taking Discussion

About jaundice

History taking

Discussion

 

definition Jaundice (or icterus) is a term used to describe the yellow pigmentation of a patient's skin and sclerae caused by excess bilirubin in the blood. Jaundice become visible at >35umole/L Jaundice is not itself a diagnosis and the cause should always be sought. Many diseases cause jaundice through a variety of different mechanisms.

Jaundice (or icterus) is a term used to describe the yellow pigmentation of a patient's skin and sclerae caused by excess bilirubin in the blood.

Jaundice become visible at >35umole/L

Jaundice is not itself a diagnosis and the cause should always be sought.

Many diseases cause jaundice through a variety of different mechanisms.

Classification & causes

Pre-hepatic hepatic post-hepatic haemoglobin bile duct breakdown Hepatocyte Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

haemoglobin bile duct

breakdown

Hepatocyte

Unconjugated

bilirubin conjugation

Liver uptake conjugated

bilirubin

Prehepatic jaundice: excess production or failure of uptake into liver Haemolysis, eg G6PD deficiency Autoimmune Congentital hyperbilirubinaemia eg Gilberts, Crigler Najar

excess production or failure of uptake into liver

Haemolysis, eg G6PD deficiency

Autoimmune

Congentital hyperbilirubinaemia eg Gilberts,

Crigler Najar

Pre-hepatic hepatic post-hepatic haemolysis bile duct haem breakdown Hepatocyte Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

haemolysis bile duct

haem breakdown Hepatocyte

Unconjugated

bilirubin conjugation

Liver uptake conjugated

bilirubin

Hepatocellular jaundice Hepatocyte failure / damage (ALT>ALP) Alcohol Viral Hepatitis A, B and C , EBV Cirrhosis Drugs Auto immune Hepatoma Metastases Wilsons Hepatic congestion from cardiac failure

Hepatocyte failure / damage (ALT>ALP)

Alcohol

Viral Hepatitis A, B and C , EBV

Cirrhosis

Drugs

Auto immune

Hepatoma

Metastases

Wilsons

Hepatic congestion from cardiac failure

Pre-hepatic hepatic post-hepatic blood bile duct haem Hepatocyte damage Unconjugated bilirubin conjugation Liver uptake conjugated bilirubin

blood bile duct

haem Hepatocyte damage

Unconjugated

bilirubin conjugation

Liver uptake conjugated

bilirubin

Chronic liver disease Alcohol & viral hepatitis are the most common causes of chronic liver disease and cirrhosis. Develop when the functional capacity of the liver can no longer maintain normal physiological conditions Jaundice is a feature of chronic liver disease

Alcohol & viral hepatitis are the most common causes of chronic liver disease and cirrhosis.

Develop when the functional capacity of the liver can no longer maintain normal physiological conditions

Jaundice is a feature of chronic liver disease

 

 

Cholestatic jaundice impaired excretion of bile (ALP>ALT) Gallstones Head of pancreas cancer Porta hepatis lymph nodes PBC Sclerosisng Cholangitis

impaired excretion of bile (ALP>ALT)

Gallstones

Head of pancreas cancer

Porta hepatis lymph nodes

PBC

Sclerosisng Cholangitis

Pre-hepatic hepatic post-hepatic blood bile duct haem Hepatocyte Unconjugated Bilirubin conjugation Liver uptake obstruction conjugated bilirubin

blood bile duct

haem Hepatocyte

Unconjugated

Bilirubin conjugation

Liver uptake

obstruction

conjugated bilirubin

 

 

History When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature?

When the patient first noticed it?

Was it gradually deepening?

Any prev episodes of jaundice?

Any family Hx of jaundice?

Pruritis?

Dark urine /pale stool?

Any abd pain and its nature?

History When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature? Painful jaundice Alcoholic,infective,biliary colic,pancreatitis,cholecystitis,metastasis.

When the patient first noticed it?

Was it gradually deepening?

Any prev episodes of jaundice?

Any family Hx of jaundice?

Pruritis?

Dark urine /pale stool?

Any abd pain and its nature?

When the patient first noticed it? Was it gradually deepening? Any prev episodes of jaundice? Any family Hx of jaundice? Pruritis? Dark urine /pale stool? Any abd pain and its nature? History Painless jaundice Haemolysis,PBS pancreatic/ biliary malignancy,cirrhosis Heamochromatosis,

When the patient first noticed it?

Was it gradually deepening?

Any prev episodes of jaundice?

Any family Hx of jaundice?

Pruritis?

Dark urine /pale stool?

Any abd pain and its nature?

Associated symptoms? Continue history…

Associated symptoms?

Continue history… Associated symptoms? N/V Haematamesis Fatigue Malaise Fever Loss of apetite/Wt Rash/arthritis Abd swelling Confusion Sleep pattern

Associated symptoms?

N/V

Haematamesis

Fatigue

Malaise

Fever

Loss of apetite/Wt

Rash/arthritis

Abd swelling

Confusion

Sleep pattern

Continue history… Associated symptoms? Any cardiac/respiratory symptoms?

Associated symptoms?

Any cardiac/respiratory symptoms?

Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx. Continue history…

Associated symptoms?

Any cardiac/respiratory symptoms?

Full alcohol Hx.

Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx Continue history… CAGE questionnaire Drinking at work Driving offences Psychological/social problems

Associated symptoms?

Any cardiac/respiratory symptoms?

Full alcohol Hx

CAGE questionnaire

Drinking at work

Driving offences

Psychological/social problems

Associated symptoms? Any cardiac/respiratory symptoms? Full alcohol Hx Relevant PMHx Continue history…

Associated symptoms?

Any cardiac/respiratory symptoms?

Full alcohol Hx

Relevant PMHx

Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Continue history… Liver & gall stone disorder Malignancy,recent anaesthesia,blood transfusion,autoimmune disorders

Associated symptoms

Any cardiac/respiratory symptoms

Full alcohol Hx

Relevant PMHx

Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Continue history…

Associated symptoms

Any cardiac/respiratory symptoms

Full alcohol Hx

Relevant PMHx

Full drug Hx

Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Continue history… Antibiotics,antirhuematic,etc

Associated symptoms

Any cardiac/respiratory symptoms

Full alcohol Hx

Relevant PMHx

Full drug Hx

Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Risk factors for viral hepatitis Continue history…

Associated symptoms

Any cardiac/respiratory symptoms

Full alcohol Hx

Relevant PMHx

Full drug Hx

Risk factors for viral hepatitis

Associated symptoms Any cardiac/respiratory symptoms Full alcohol Hx Relevant PMHx Full drug Hx Risk factors for viral hepatitis Continue history…

Associated symptoms

Any cardiac/respiratory symptoms

Full alcohol Hx

Relevant PMHx

Full drug Hx

Risk factors for viral hepatitis

examination Temp, pulse, BP Anaemia, lymph nodes Features of cirrhosis Encephalopathy Nutritional status Hepato / splenomegaly Tattoos

Temp, pulse, BP

Anaemia, lymph nodes

Features of cirrhosis

Encephalopathy

Nutritional status

Hepato / splenomegaly

Tattoos

Investigations

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC

Routine Bloods - LFT, GGT, UE, FBC

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen blood film, reticulocytes, low haptoglobin, high LDH, DCT

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Non Invasive Liver Screen

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Immunoglobulins, Auto antibodies (smoth muscle, ANA, AMA, LKM) Viral hepatitis serology ferritin, caeruloplasmin alpha 1 anti-trypsin

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Non Invasive Liver Screen

Immunoglobulins,

Auto antibodies (smoth muscle, ANA, AMA, LKM)

Viral hepatitis serology

ferritin,

caeruloplasmin

alpha 1 anti-trypsin

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Radiology USS MRCP

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Non Invasive Liver Screen

Radiology USS

MRCP

Continue Investigations… Routine Bloods - LFT, GGT, UE, FBC Haemolysis Screen Non Invasive Liver Screen Radiology USS MRCP Invasive Tests ERCP Liver biopsy

Routine Bloods - LFT, GGT, UE, FBC

Haemolysis Screen

Non Invasive Liver Screen

Radiology USS

MRCP

Invasive Tests

ERCP

Liver biopsy

Treatment Remove toxin Antibiotics Fluids Relieve obstruction – ERCP, Percutaneous drainage (PTC) Ursodeoxycholic acid Steroids / immunosupressants Liver transplant

Remove toxin

Antibiotics

Fluids

Relieve obstruction – ERCP, Percutaneous drainage (PTC)

Ursodeoxycholic acid

Steroids / immunosupressants

Liver transplant

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