Approach to a patient with JAUNDICE

1. Clinical Management of Patient with
Jaundice

2. JAUNDICE
Yellow pigmentation of skin, sclera and mucosa
due to elevated bilirubin level
Visible at 3mg/dL
Imbalance between production and clearance of
bilirubin.
Sclera- high affinity because of elastin content-
3mg/dl

3. Bilirubin Metabolism:

4. Classified by:
Type of Circulating Bilirubin:
1.Conjugated
2.Unconjugated
Site of the Problem:
1.Prehepatic
2.Hepatocellular
3.Cholestatic/ Obstructive

5. Pre-hepatic Jaundice:
- Excess Bilirubin production
1.hemolysis
2.inadequately liver uptake
3.deficient hepatic conjugation
- Unconjugated Bilirubin enters the blood
- Unconjugated Bilirubin is water insoluble  not excreted in the
urine
- Resulting in Unconjugated (Indirect) Hyperbilirubinemia

6. Hepatocellular Jaundice:
- With hepatocellular damage +/- cholestasis
- Causes:
- Viruses: Hep, CMV, EBV
- Drugs
- Alcoholic Hep, cirrhosis, liver mets/abscess, hemochromatosis
- AIH
- sepsis, leptospirosis
- a1 antitrypsin deficiency
- Budd Chiari Syndrome, Wilsons Disease
- Failure to Excrete Bilirubin (Dubin – Johnson & Rotor Syndrome)
- Right Heart Failure
- Toxins( Carbon Tetrachloride)
- Fungi (Amanita phaloides)

7. Cholestatic/Obstructive Jaundice:
- Blockage of the Common Bile Duct  Conjugated Hyperbilirubinemia
- Conjugated Bilirubin is water soluble  easily excreted in the urine
- Pt usually c/o dark, tea-colored urine
- Clay-colored stool  due to lack of conjugated bilirubin reaching the
GUT
- Causes:
1.Choledocholithiasis
2.Pancreatic cancer
3.Porta-hepatis LN
4.Drugs
5.Cholangiocarcinoma
6.Sclerosing Cholangitis
7.PBC
8.Choledochal cyst
9.Biliary atresia

8. Clinical Manifestations:
Ask about:
1.Previous blood transfusion
2.IVDU
3.Body Piercing
4.Tattoos
5.Sexual Activities
6.Travel Hx
7.In Contact with person with Jaundice
8.Family Hx
9.Alcohol Consumption
10.Medications

9. Physical Exam:
1.Look for signs of chronic liver disease
2.Hepatic Encephalopathy
3.LAD
4.Hepatomegaly
5.Splenomegaly
6.Palpable GB
7.Ascites
8.Pale stools and dark urine

10. Lab test:
Bilirubin (-) in pre-hepatic causes
Urobilinogen (-) in Obstructive Jaundice
Signs of Hemolysis:
Anemia
• Elevated LDH
• Low Haptoglobin
• High Reticulocytes
• (+) Coombs test
LFT
Virology: EBV, CMV, HAV, HBV, HCV
Hemochromatosis: elev ferritin & iron:TIBC ratio  high serum iron sat(>50-60)
A1-antitrypsin Deficiency – genetic analysis
Wilson’s Disease – low serum & high Urine Copper Level, low serum Ceruloplasmin
PBC – high anti-mitochondrial ab, AMA
AIH – high anti-nuclear & anti-smooth muscle ab
US – to check for CBD obstruction
MRCP/ERCP – if CBD are dilated
Liver Biopsy – if Bile ducts are normal
MRI/CT

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