this ppt was made by me for my colleagues by the request of Dr. Ahilan (Consultant Physician )

1. HOW TO DIAGNOSE THE
CAUSE OF JAUNDICE?
MIM.ILHAM
4th Batch
FHCS,EUSL

2. Contents
•
•
•
•
•
Bilirubin metabolism.
Causes of Jaundice
History
Examination
Special test.

3. Bilirubin metabolism.

5. Causes of Jaundice

6. Causes of Jaundice
• Increased bilirubin load (Haemolytic Jaundice)
1.
2.
3.
4.
5.
6.
7.
8.
Hereditary spherocytosis
Hereditary non spherocytic anaemia
Sickle cell disease
Thalassemia
Acquired haemolytic anaemia
Incompatible blood transfusion
Severe sepsis
Drugs

7. Causes of Jaundice
• Disturbed bilirubin uptake and conjugation of
bilirubin
1.
2.
3.
4.
5.
6.
Viral hepatitis
Hepatotoxins
Cirrhosis
Gilbert’s familial hyperbilirubinaemai (AD)
Familial neonatal hyperbilirubinaemia
Crigler-Najjar’s familial jaundice (Type1- AR, Type2AD)

8. Causes of Jaundice
• Disturbed bilirubin excretion
Excess of conjugated serum bilirubin known as cholestasis
Intra hepatic (without mechanical obstruction)
1.
2.
3.
4.
5.
6.
Cirrhosis
Viral (chronic active) hepatitis.
Drugs- chorpromazine, methyl testosterone
Dubin-Johnson’s familial hyperbilirubinaemia(AR)
Primary biliary cirrhosis
Parenteral or enteral feeding with synthetic
nutrition

9. Causes of Jaundice
Extra hepatic cholestasis
• Inside the duct
1. Gallstones
2. Foreign body eg- Broken T-tube, parasites
(Hydatid,liver fluke, round worms)
• In duct wall
1. Congenital atresia
2. Traumatic stricture
3. Sclerosing cholangitis
4. Tumor of the bile duct

10. Causes of Jaundice
• Outside duct
1. Carcinoma of head of the pancreas
2. Carcinoma of the ampulla
3. Pancreatitis
4. Lymph node metastases

11. History
Age:
• Young age- Hepatitis is common
• Old age- Malignancy (CA) is common

12. History
PC:
• Jaundice (Yellowish discoloration of
sclera+mucus membrane+Skin)
• Exclude other causes for yellow discolouration
*Carotenaemia (Only skin, mainly palm and sole
are orange color) in eating carrot,mango,papaya
and hypothyroidism
*Antimalarial drugs
*Vit-B12 deficiency

13. History
HPC & Systemic Rvw
• Jaundice
1. Sudden onset- Gall stones OR Viral hepatitis
2. Gradual onset- Cirrhosis, Pancreatic CA OR
Porta hepatis metastases
3. Progressive- Malignant obstruction
4. Fluctuaing- Stones in the CBD, CA of the
duodenal papilla OR repeated hemolytic
episodes.

14. History
• Pain:
1. Painless- Viral hepatitis (Dragging subcostal ache
due to hepatic enlargement)
2. Pailess+Fluctuating- intermittent obstruction by
gallstone OR necrosing ampullary CA
3. Painless+Progressive- Malignant obstruction of
CBD
4. Painful- Gallstones OR Pancreatic CA
Biliary colic- right subcosatl pain radiating beneath
the costal margin to shoulder blade
Moderate boring pain passing through to backChronic pancreatitis OR pancreatic tumor

15. History
• Fever:
1. Fever with chills- Extra hepatic cholestasis with
cholangitis due to bile duct stone,Liver abscess
and leptospirosis
2. Fever without chills- Viral hepatitis, Drug
induced hepatitis
• Pruritus:
Results from the irritation of cutaneous nerves by
retained bile salt
Cholestatic jaundice

16. History
• Weight lossProgressive weight loss- Malignancy
Also in chronic hepatocellular damage.
• Anorexia and fatigue
Early signs of hepatitis
(This is due to production of cachexin and TNF)

17. History
• Colour of the urine and stool
Pre hepatic
Hepatic
Post hepatic
Urine colour
Normal
Dark
Dark
Stool colour
Normal
Normal
Pale

18. History
Contact history:
1. Contact with jaundice patients from work
mates, family- hygienic habits such as toilets,
drinking water, taking meals from out side
(HepA & HepB)
2. Contact Hx of muddy water in leptospirosis

19. History
 Obstetric Hx:
• Ask about LRMP and calculate POA
• Benign intra hepatic cholestasis is common in
pregnancy period

20. History
PMHx
• Viral hepatitis
• History of transfusion of blood OR blood
products (HepB & HepC)
• Recent parenteral injection (HepB & HepC)
• Amoebic dysentery
• Jaundice following febrile illness- some
congenital haemolytic anaemia may be
triggered by febrile illness eg- G6PD deficiency

21. History
• Recurrent left hypochondrial pain due to
splenomegaly eg- Hereditary spherocytosis
• Recurrent foot ulcer eg- some form of chronic
haemolytic anaemia such as sickle cell disease
• Hx of breast cancer and bowelcancer
• SLE and other connective tissue disorders (Hx
suggestive of joint pain, skin rash)

22. History
PSHx
• Previous difficult biliary surgery suggest –
traumatic stricture OR a residual stones in the
CBD
• Post operative jaundice
1. Resorption of haematomas,haemoperitonium,
haemolysis of transfused erythrocyte
2. Impaired hepatocellular function- halogenated
anaesthetics, sepsis

23. History
DRUG Hx:
• Smilar to pre-hepatic jaundice- rifampicin,
methyldopa
• Intra-hepati jaundice- ethanol (cirrhosis ),
paracetamol, halothane, methyldopa,
barbiturates
• Post-hepatic jaundice- isoniazid, chlorpromazine
• Antileprosy drugs and Antipsychotic drugs
• OCP,Saliclate,Sulfonamide , MAOi

24. History
Family Hx:
• FHx of jaundice+anaemia+splenectomyHereditary spherocytosis
• FHx of jaundice+anaemia- congenital
hyperbilirubinaemias
• Consanguinity of parents- Inherited congenital
haemolytic anaemia eg- G6PD deficiency
• Neuropsychiatry llness+jaundice- Wilson’s
disease

25. History
 Social Hx:
• Hx of Alcohol consumption in Units for yearsChronic alcohol liver disease Hepatocellular CA
jaundice
Cirrhosis and pancreatic CA
• Toddy consumption- Amoebic liver abscess
• Sexual promiscuity and unprotected sexual behaviorHepB transmission
• Occupational HxSheep farmers OR allied workers- Hydatid infestation
Working at chemical enviorment eg-CCl4

26. Examination
 General:
• Depth of jaundice:
Lemmon yellow- haemolytic jaundice
Orange- hepatocellular cause
Deep mahogany hue- Prolonged obstructive
jaundice

27. Examination
• Anaemia:
Suggestive of Haemolytic,malignant OR cirrhotic
causes

28. Examination
• Liver failure

29. Examination
• Supraclavicular node enlargementMetastatic CA
• SkinScratches and xanthomas in chronic cholestasis

30. Examination
• PyrexiaCholangitis, Viraemia and hepatic involvement
eg-Infectious mononucleosis, septicaemia and
haemolysis and hepatic abscess

31. Examination
Abdominal Ex:
• Scars: previous surgery of biliary tree

32. Examination
• Caput medusae
Dilated periumblical vein indicatye portal HT and
cirrhosis

33. Examination
• Site of tenderness:
Tenderness over the gall bladder indicate biliary
inflammation

34. Examination
• Gall bladder
A palpable gall bladder in the presence of the
jaundice means that janundice is unlikely to be
due to a stone (Courvoisier’s sign). CA of head of
the pancreas must be suspected

35. Examination
• Liver:
1. Palpable large nodule of large proportionmetastatic malignancy
2. Small nodules- cirrhosis
3. Slightly enlarged smooth live chronic
cholestasis
4. Tender liver- viral hepatitis and liver abscess

36. Examination
• Spleen:
Splenomegaly may be evident of congenital
haemolytic anaemia

37. Examination
• Abdominal mass
Hard and irregular abdominal mass suggestive
of malignancy.
• Ascites
Due to abdominal malignancy or liver failure

38. Examination
• Rectal Ex
Colour of the stool
Presence of a primary malignancy or metastatic
deposit in the pouch of douglas