1. JAUNDICE

3. Definition
• Is a yellowish
pigmentation of the
skin, the
conjunctival
membranes over
the sclerae (whites
of the eyes), and
other mucous
membranes caused
by
hyperbilirubinemia
(increased levels of
bilirubin in the

4. Pathophysiology

5. Pre-hepatic
Hepatic
Entero-
hepatic
Circulation
Post-hepatic

6. Etiology
1.Unconjugated hyperbilirubinaemia
• Pre-hepatic
- increases the load of bilirubin to be metabolized by the
liver
2 . Conjugated hyperbilirubinaemia
• Hepatocellular
-damages or reduces the activity of the transferase
enzyme or hepatocyte
• Post-hepatic
-also called obstructive jaundice, is caused by an
interruption to the drainage of bile in the biliary
system

7. Etiology
• Pre-hepatic
Hemolytic anemias;Polycythemia; Shortened red cell life as a result
of immaturity or transfused cells ;Drug induced (antimalarias);G-
6PD;etc.
• Hepatocellular
Viruses:Hepatitis(A,B,C,D,E);CMV,EBV;Drugs;Autoimmune
Hepatitis;Wilson's Disease;Right Heart Failure;Drug
induced(Paracetamol, Isoniazid,rifampicin,pyrazinamide); etc.
• Post-hepatic
Extrinsic obstruction of the bile duct ;Biliary atresia;Common bile
duct gallstones;Drugs induced (steroids,flucloxacilin);etc.

8. Common Causes In Older Children
• Infection-eg. Viral (Hepatitis
A,B,C,D,E),EB,Malaria,Leptospira
• Autoimmune eg. SLE,Kawasaki
• Infiltrative eg.Malignancy
• Metabolic eg. Wilson,CF
• Narrow or obstructed bile ducts
• Toxin & drugs eg.Acetaminophan
I MET 3

10. History Taking
• ID/CC: Age, sex, symptom
• HoPI:
-Elaborate the symptoms
1. Onset (sudden or progressively)?
• sudden (Infection .)
• proggressive ( Obstrustion above hepatobiliary duct, chornic
hemolysis eg.Thalassaemia ,chronic hepatitis etc.)
2. Asso: symptoms- Fever, LOA, Pallor, Stool & urine
colour,vomiting,abdo;pain, rash, arthralgia
3. if there is any aggravating factor (bloods transfusion, intake of
food / drugs).
4. Exposures to epidemic areas?

11. History Taking cont:
Sleep—quantity, quality, disturbances (restlessness),

12. History Taking
• PMH:
• Pregnancy—gravida/para status, maternal age, duration, exposures
(medications,
alcohol, tobacco, drugs, infections, radiation); complications (bleeding, gestational
diabetes, hypertension, etc.), problems with past pregnancies
• Labor and delivery—length of labor, rupture of membranes, fetal movement,
medications, presentation/delivery,mode of delivery, assistance (forceps,
vacuum), complications, Apgars
• Neonatal—birth height/weight, abnormalities/injuries, length of hospital stay,
complications (respiratory distress,cyanosis, anemia, jaundice, seizures,
anomalies, infections), behavior
• Infancy—temperament, feeding, family reactions to infant
• Illnesses/hospitalizations/surgeries/accidents/injuries —dates,
medications/interventions, impact on child/family
• Past medical illness
• Medicatioion/Drug H/O—past (antibiotics, especially), present, reactions
• Allergies—include reaction
• Immunizations—up to date, reactions
• Family history—relatives, ages, health problems, deaths (age/cause),
miscarriages/stillbirths/deaths of infants
or children
• Social history—parents’ education and occupation, living arrangements, pets,
water (city or well), lead exposure(old house, paint), smoke exposure, , risk-taking
behaviors,school/daycare

13. Physical Examination

14. Physical Examination
• General— Lethargic, Tired, Hydration
status,Malnutrition,Jaundice,Concious level,Weight,Height
• Hand-
Pallor,Cyanosis,Leuconychia(hypoalbuminaemia?),Clubbing,Live
r palms,Aneamia,Hepatic Flap
• Skin—Bruising,Scratch marks, Spider Naevi
• Eyes—Jaundice,Pallor
• Nose— Flaring nostrils
• Mouth—Cyanosis,Ulcer
• Throat—Oropharynx (red, moist, injection, exudate)
• Lymph—Lympoedema(Cervical, axillary, inguinal)
• Legs-Edema(Pretibial/Medial malleolus)

15. Physical Examination
• Abdomen
1. Inspection-Distention,Scar,Prominent veins
2. Palpation-
Hepatomegaly(Hepatitis,Cirrhosis?),Spleenomegaly(Hemolysi
s?),Tenderness,Gallbladder(Murphy?),Kidneys.
3. Percussion-Liver,Spleen,Shifting dullness(Ascites?)
4. Ausculation- Bowel sounds.
For extra Eamination
• Respiratory （ Pulmonary Edema?)—Rate, Grunting,Basal
Crackles? Sputum?
• Cardiovascular(Heart Failure?)—Heart rate,Gallop Rhythnm?

16. Investigation
• Full blood count (RBC,Retic )
• Liver function tests(ALT, AST,GGT, AKP,T&DP,TB,UCB,CB)
1. TB+UCB = pre-hepatic
2. TB+UCB+CB =hepatic
3. TB+CB = post-hepatcic
• Coagulation profile –PT,INR
• Ultrasound (In adavanced MRCP,ERCP)
• Urine FEME,
• Urine for leptospiral Ag
• Renal function test
• Stool test
• Genetic Test (G-6PD ,Thalasseamia)
• Serology Test for viruses(Hepatitis A,B,C,D,E)
• Serology Test for Autoimmune
• Coomb's test
• Liver biopsy

18. Table of Diagnosis Test
Function test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic Jaundice
Total bilirubin Normal / Increased Increased Increased
Conjugated bilirubin Normal Increased Increased
Unconjugated Normal / Increased Increased Normal
bilirubin
Urobilinogen Normal / Increased Increased Decreased / Negative
Urine Color Normal Dark (urobilinogen + Dark (conjugated
conjugated bilirubin) bilirubin)
Stool Color Normal Normal/Pale Pale
Alkaline phosphatase Normal Increased Increased
levels
Alanine transferase Normal Increased Increased
and Aspartate
transferase levels
Conjugated Bilirubin Not Present Present Present
in Urine

19. References
• Goljan, Edward F., Rapid Review
Pathology 2nd edition. Pg. 368–369.
2007.
• First Aid For The Pediatric Clerkship
Pg.9-10
• Oxford Handbook Of Clinical Medicine
Pg.250-251
• Nelson's Pediatrics 18th edition
• Essential Nelson
• Current Paed: