Jaundice

(French jaunice, “yellowness”)

 Jaundice

• Yellowish discoloration of the body tissues due to:

• Bilirubin deposition
• Serum hyperbilirubinemia
• Normal serum bilirubin:
• 1-1.5 mg/dl

Icterus → > 3 m g/dl

serum bilirubin
 Measurement of Serum Bilirubin

Conjugated bilirubin
- direct bilirubin
- polar, water soluble
- reacts with diazotized sulfanilic acid
Unconjugated bilirubin
- indirect bilirubin
- nonpolar, lipid soluble
- difference between total and direct bilirubin
 Jaundice

• Prehepatic
• Excessive production of bilirubin
• Intrahepatic
• Pathology within hepatocytes
• Post hepatic
• Problem with biliary flow
 Bilirubin
Production
and
Metabolism
 How to Approach a Patient with
Jaundice
History
• Presenting complaint
• Acute or chronic
• Associated features
• RUQ pain, Nausea, vomiting, fever,
• dark urine, Diarrhea, Weight loss,
• loss of appetite
 How to Approach a Patient with
Jaundice
History
• Presenting complaint suggestive of gallstone
disease
Severe, steady ache or fullness in
the epigastrium or RUQ of the abdomen with
frequent radiation to the interscapular area,
right scapula, or shoulder
 How to Approach a Patient with
Jaundice
History
• Past Medical History
• Gallstones, Liver disease
• Recent transfusion
• Medications
• Herbal meds
• Paracetamol overdose
• Rifampicin, isoniazid
 How to Approach a Patient with
Jaundice
History
• Social History
• Alcohol Consumption
• IV drug use
• Sexual history
• Travel history
• Family history
• Jaundice, Liver disease, Cancer
• Hemolytic ds.
 How to Approach a Patient with
Jaundice
Physical Examination
• General assessment: patient’s nutritional status
• Signs of
• Chronic liver disease
• Hepatic Congestion
• JV distention
• Malignancy
 How to Approach a Patient with
Jaundice
Physical Examination
• Abdominal examination
• Size and consistency of the liver
• Palpable spleen
• Ascites
• Abdominal mass
• Abdominal tenderness
• RUQ tenderness with respiratory arrest on
inspiration (Murphy’s sign)
How to Approach a Patient with
Jaundice

History
Physical examination
Lab tests: Bilirubin with fractionation,
ALT, AST, ALP, PT, albumin

Isolated Hyperbilirubinemia
Hyperbilirubinemia +
↑ LFT

Harrison’s Principles of Internal Medicine 21st ed.

How to Approach a Patient with Jaundice

Isolated
Hyperbilirubinemia

Indirect Direct
Hyperbilirubinemia Hyperbilirubinemia
(Direct <15%) (Direct >15%)

Harrison’s Principles of Internal Medicine 21st ed.

Harrison’s Principles of Internal Medicine 21st ed.
 How to Approach a Patient with
Jaundice
History (focus on medication/drug exposure)
Physical examination
Lab tests: Bilirubin with fractionation,
ALT, AST, ALP, PT, albumin

Isolated Hyperbilirubinemia
Hyperbilirubinemia +
↑ LFT

Harrison’s Principles of Internal Medicine 21st ed.

How to Approach a Patient with Jaundice
Hyperbilirubinemia
+
↑ LFT

Harrison’s Principles of Internal Medicine 21st ed.

Harrison’s Principles of Internal Medicine 21st ed.
Harrison’s Principles of Internal Medicine 21st ed.
Harrison’s Principles of Internal Medicine 21st ed.
Obstructive Jaundice
Choledocholitihiasis
 Choledocholithiasis

• Stones in the CBD

and biliary tree
• Occurs in 10–15%
of patients with
cholelithiasis
 Choledocholithiasis

• Primary—Rare 5%—brown pigment stones.

• formed in CBD and biliary tree itself, and are multiple,
often sludge like
• Causes: Biliary stasis, biliary dyskinesia, caroli’s disease,
choledochal cyst, clonorchiasis, ascariasis
• Secondary—Common 95%—black pigment
stones/cholesterol stones, 75% are
cholesterol stones, 25% are pigment
stones.
 Choledocholithiasis

Clinical Features
• 50% asymptomatic
• Biliary colic: pain in RUQ & epigastrium
• Intermittent chills, fever, or jaundice accompanies biliary
colic: Charcot’s triad: Ascending cholangitis
• Reynold’s pentad: Persistent pain, fever, jaundice, shock &
AMS
• Painful jaundice with dark color urine, clay colored
stool and pururitus.
• Features of Ac Pancreatitis in distal CBD stone
impaction
 Choledocholithiasis
• Patient may be icteric and toxic, with high fever
and chills, or may appear to be perfectly healthy.
• A palpable gallbladder is unusual in patients with
obstructive jaundice from cbd stones
• Courvoisier’s Law: “ In a jaundiced patient if GB
is palpably enlarged it is not due to Gall stone”.
• Tenderness in the right upper quadrant is not often
as marked as in acute cholecystitis, DU perforation
or Ac Pancreatitis
• Tender enlarged liver
 Investigation: Labs
• In cholangitis, leukocytosis of 15,000/mL is usual,
and values above 20,000/mL are common
• T bilirubin level <10 mg/dL, range 2-4 mg/dL. The
direct fraction exceeds the indirect, but the latter
becomes elevated in most cases.
• Bilirubin levels do not ordinarily reach the high
values seen in malignant tumors.
• Serum alkaline phosphatase & GGT levels usually
rises
• Mild increases in AST and ALT are often seen
 Imaging:
Hepatobiliary Ultrasound
• Rapid Simultaneous scanning of GB, liver, bile
ducts, pancreas
• Accurate identification of dilated bile ducts
• Not limited by jaundice, pregnancy
• Guidance for fine-needle biopsy
 Computed Tomography

• Simultaneous scanning of GB, liver, bile ducts,

pancreas
• Accurate identification of dilated bile ducts,
masses
• Not limited by jaundice, gas, obesity, ascites
• High-resolution image
• Guidance for fine-needle biopsy
 Magnetic Resonance
Cholangiopancreatography
• Useful modality for visualizing pancreatic and
biliary ducts
• Has excellent sensitivity for bile duct dilatation,
biliary stricture, and intraductal abnormalities
• Can identify pancreatic duct dilatation or stricture,
pancreatic duct stenosis, and pancreas divisum
 Endoscopic Retrograde
Cholangiopancreatography

• Simultaneous pancreatography
• Best visualization of distal biliary tract
• Bile or pancreatic cytology
• Endoscopic sphincterotomy and stone removal
• Biliary manometry
 Percutaneous Transhepatic
Cholangiogram

• Extremely successful when bile ducts

dilated
• Best visualization of proximal biliary tract
• Bile cytology/culture
• Percutaneous transhepatic drainage
Imaging Studies
 Treatment

• When CBD stones are suspected prior to

laparoscopic cholecystectomy, preoperative ERCP
with endoscopic papillotomy and stone extraction
is the preferred approach.
 Treatment

• In absence of cholangitis: ERCP, Sphincterotomy, CBD

stone removal followed by Lap cholecystectomy.
• In presence of cholangitis: ERCP with sphincterotomy
and stone extraction or stent placement- decompression
• PTBD- Percutaneous transhepatic biliary drainage in
ERCP failed cases
• Surgical treatment: Only when above two procedures
not possible. Open cholecystectomy, intra op
cholangiogram, choledocholithotomy with T tube
placement.
Thank You!