2. AIMS:
• define jaundice
• recognise the associated
symptoms of jaundice
• look at the diseases which might
cause jaundice
• look at the management of
obstructive jaundice

3. JAUNDICE: yellow pigmentation of the
skin, sclera & mucosa due to increased
plasma bilirubin
Bilirubin levels:
Normal levels are
between:
3- 17 μmol/L Jaundice becomes
apparent at:
>35 μmol/L

4. Some Anatomy…

5. right
lobe
left
lobe
caudate
lobe
quadrate
lobe
POSTERIOR
VIEW
Fundus
Body
Cystic
duct
Hepatic
duct
Common
bile duct
GALLBLADDER

6. Bile
The components of bile:
 Water
 Cholesterol
 Lecithin (a phospholipid)
 Bile pigments (bilirubin & biliverdin)
 Bile salts (sodium glycocholate & sodium
taurocholate)
 Bicarbonate ions

7. Hb
Unconjugated
bilirubin
Conjugated
bilirubin
Bile
Hepatic
jaundice
Unconjugated
bilirubin
Stercobilin Urobilin
Pre-hepatic
jaundice
Post-hepatic
jaundice

8. - Type of bilirubin
- uncongugated (insoluble)
- conjugated (soluble)
- Site of problem
- pre-hepatic
- hepatic
- post-hepatic
Classification of jaundice:

9. Pre-hepatic jaundice
• Pre hepatic jaundice occurs when unconjugated (insoluble) bilirubin is
produced in excess or not taken up by the liver.
• It results in unconjugated hyperbilirubinaemia.
 V ascular
 I nfective/inflammatory
 N eoplasia
 T rauma
 A utoimmune
 M etabolic
 E ndocrine
 D rugs
 I atrogenic
 C ongenital
Causes:
Haemolytic anaemia
Malaria
Hereditary spherocytosis
Autoimmune red cell destruction

10. Hepatic jaundice
• Hepatic jaundice is caused by disorders of up-take or conjugation of bilirubin.
• Results in conjugated and unconjugated hyperbilirubinaemia.
 V ascular
 I nfective/inflammatory
 N eoplasia
 T rauma
 A utoimmune
 M etabolic
 E ndocrine
 D rugs
 I atrogenic
 C ongenital
Causes:
Viral hepatitis
Criger-Najjar, Gilbert’s syndrome, Dubin-Johnson
syndrome, Rotor syndrome, Wilson’s disease, α1-
Antitrypsin deficiency, Haemochromatosis
Autoimmune hepatitis
Liver mets, Hepatic carcinoma
Budd-Chiari, Right heart failure
Paracetamol, Anti-TB, Statins, MAO-I. Toxins: CCl4, fungi.

11. Post-hepatic jaundice
(or ‘Obstructive’ or ‘Cholestatic’ jaundice)
• Post-hepatic or obstructive jaundice occurs when bilirubin fails to reach
the gut.
• This results in conjugated bilirubinaemia.
 V ascular
 I nfective/inflammatory
 N eoplasia
 T rauma
 A utoimmune
 M etabolic
 E ndocrine
 D rugs
 I atrogenic
 C ongenital
Causes:
Aortic aneurysm
Pancreatic cancer; Cholangiocarcinoma
Choledocholithiasis (gallstones)
Primary biliary cirrhosis, Primary sclerosing cholangitis
Congenital biliary atresia
Post-op strictures in bile duct
Abx, Anabolic steroids, OCP, Chlorpromazine, Sulphonylureas

12. Taking a jaundice history
Ask about:
 Duration of jaundice
 Associated pain
 Previous episodes of jaundice
 Chills, fever, systemic symptoms
 Itching (‘pruritis’)
 Exposure to prescribed, OTC and illegal drugs
 Biliary surgery
 Weight loss, anorexia
 Colour of stools and urine
 History of injections or blood transfusions
 Contact with jaundiced patients
 Occupation

13. On examination…
 Palmar erythema, clubbing, leukonychia,
gynaecomastia, Dupuytren’s contracture (chronic
liver disease)
 Scratch marks (itching)
 Scars of previous surgery (strictures)
 Irregular hepatomegaly (hepatic carcinoma)
 Palpable gallbladder (carcinoma below cystic
duct)
 Abdominal masses (carcinomas; cysts in
pancreas or gallbladder)

14. Investigations
Blood tests
 FBC
 U&E
 LFT
 ALT
 ALP
 γGT
 bilirubin
 albumin
 INR
 Ca++
 Antibodies
Urine
■ Dipstick
Radiology
■ Ultrasound (first-line in
jaundice)
■ CT
Other investigaions
 ERCP
 MRCP
 PTC
 Liver biopsy
(last resort: 0.01% mortality)

15. Findings in obstructive jaundice
The 2 most common causes of cholestatic jaundice are:
• gallstones
• pancreatic carcinoma
 Increased ALP & γGT together are strongly indicative of
cholestasis.
 Bilirubin >19umol/L in blood & bilirubin in urine (must be
conjugated)
 High INR: absence of bile in intestine poor absorption of
vitamin K
 Ultrasound can identify both gallstones and pancreatic carcinoma
(stones themselves or dilated bile ducts)
 CT scan can identify tumours.

16. Management of obstructive jaunfice
It is important to diagnose & manage
obstructive jaundice quickly as secondary
conditions such as biliary cirrhosis can
develop.
Depending on the diagnosis:
• Conservative
• Medical
• Surgery: REMOVE BLOCKAGE

17. Case study: History & Exam
 Mr Jones, 76, retired farmer
PC/ ‘I have gone yellow’
HPC/ Yellow skin associated with itching. Has lost 1stone
over last year and decreased appetite; has noticed
pale stools.
ROS/ CVS/RS, CNS: Migraines, MS: Rheum-arthritis
PMH/ NIDDM, Duodenal ulcers for 5yrs, Inguinal hernia
repair ’05.
DH/ Omeprazole, rheum pills?
FH/ Father died of cancer at 60, can’t remember what
type.
SH/ Lives with wife, independent in ADL, moderate
drinker, non-smoker

18. O/E
End-of-bed-o-gram: looks thin, muscle wasting
Hands: nothing of note
Face: yellow sclera and buccal membrane
Neck: nothing of note
Chest: nothing of note
Abdomen:
• Soft non-tender
•RIF scar, 4cm, well healed
• Palpable lump under costal
margin
•Scratch marks

19. Differential diagnosis
 Cancer (weight loss, obstruction)
 liver, gallbladder, pancreas
 Gallstones (palpable gallbladder)
 Aortic aneurysm (epigastric pain)
 Gastric/ duodenal ulcers (epigastric pain)

20. Investigations
Bloods
 LFTs: raised conjugated bilirubin, γ-glutamyl
transpeptidase and ALP levels indicate obstruction
 INR of 3
 Ca++
: check for bony mets
Urine:
 Dark coloured, raised bilirubin
Radiology
 Ultrasound or abdominal CT used to identify tumour.
 ERCP to find site of obstruction

21. Diagnosis:
Carcinoma of head of pancreas
 Carcinoma of head of pancreas can obstruct the bile
duct and often presents as painless obstructive
jaundice.
 Courvoisier's law defines the presence of jaundice
and a painlessly distended gallbladder as strongly
indicative of pancreatic cancer, and may be used to
distinguish pancreatic cancer from gallstones.
 Risk factors: smoking, alcohol, diabetes, male, >60y
 Causes ~6500 deaths/year in UK

22. Management
Conservative
Talk to patient: pancreatic cancer has a poor prognosis
partly because the cancer usually causes no
symptoms early on, leading to metastatic disease at
time of diagnosis.
Medical
Fluorouracil, gemcitabine, and erlotinib are the
chemotherapeutic drug agents of choice.
Surgery
The Whipple procedure is the most common surgical
treatment for cancers involving the head of the
pancreas.

23. The Whipple Procedure

24. SummarySummary
 Jaundice is a clinical sign in which there is yellow
pigmentation of skin, sclera & membranes.
 It is caused by hyperbilirubinaemia (>35umol/L).
 Hyperbilirubinaemia can be caused by:
 too much bilirubin production
 defective bilirubin processing
 impaired bilirubin passage from liver  gut
 Obstructive jaundice requires rapid management
and treatment.