Presentation on theme: "Jaundice Yellow discoloration of sclera, skin, mucous membranes due to deposition of bile pigment Clinically detected with serum bilirubin 2-2.5mg/dL or."— Presentation transcript:
1 JaundiceYellow discoloration of sclera, skin, mucous membranes due to deposition of bile pigmentClinically detected with serum bilirubin 2-2.5mg/dL or (2 times normal)
2 What is bilirubin?The breakdown product of Hemoglobin from injured RBCs and other heme containing proteins.Produced by reticuloendothelial systemReleased to plasma, bound to albuminHepatocytes conjugate it and extrete through bile channels into small intestine.
7 Drugs that may cause liver damage AnalgesicsParacetamolAspirinNon-steroidal anti-inflammatory drugsCardiac drugsMethyldopaAmiodaronePsychotropic drugsMonoamine oxidase inhibitorsPhenothiazines (such as chlorpromazine)OthersSodium valproateOestrogens (oral contraceptives and hormone replacement therapy)
8 SymptomsYellow discoloration of the skin, sclerae and mucous membranesItching (pruritus) due to deposits of bile salts on the skinStool becomes light in colorUrine becomes deep orange and foamy
9 Clinical Features Careful history and examination Family history (Gilbert, Rotor, Crigler-Najjar, Dubin-Johnson, Sickle Cell)Healthy young person with fever, malaise, myalgias = viral hepatitis (try to locate source)Gradually develops symptoms = hepatic/bile duct obstruction (consider liver disease/cirrhosis)Develops acutely with abdominal pain = acute cholangitis sec to choledocholithiasis
10 Clinical FeaturesPainless jaundice in older person with epigastric mass & weight loss = biliary obstruction from malignancyHepatomegaly with pedal edema, JVP, and gallop = CHF
11 History that should be taken from patients presenting with Jaundice Duration of jaundicePrevious attacks of jaundicePainChills, fever, systemic symptomsItchingExposure to drugs (prescribed and illegal)Biliary surgeryAnorexia, weight lossColour of urine and stoolContact with other jaundiced patientsHistory of injections or blood transfusionsOccupation
12 Examination of patients with Jaundice LiverSizeShapeSurfaceEnlargement of gall bladderSplenomegalyAbdominal massColour of urine and stoolsDepth of jaundiceScratch marksSigns of chronic liver diseasePalmar erythemaClubbingWhite nailsDupuytren’s contractureGynaecomastia
13 Laboratory Tests Pigment studies Alkaline Phosphatase Serum bilirubin, directSerum bilirubin, totalUrine R/E for bilirubin and urobilinogenAlkaline PhosphataseLiver aminotransferrase levelsASTALTElevated levels usually indicate cellular damage to the liver> 70% of liver cells may be damaged before LFT’s become elevated
14 Blood Studies Serum Ammonia Liver converts ammonia to urea. Ammonia rises in liver failureProtein StudiesSerum albuminLow levels seen with liver diseaseSerum GlobulinElevated levels with advanced cirrhosis and chronic active hepatitis
15 CBCPTOther labs pertinent to historyCoombs testHb electrophoresisViral hepatitis screenULTRASOUND
16 Tumor MarkerAlpha-fetoprotein (AFP)Increased levels are seen with hepatic carcinomaProthrombin Time (PT)Time required for a firm fibrin dot to formIn liver dysfunction, increase clotting time with increased risk of bleeding
17 Liver Biopsy Used to obtain a specimen of liver tissue Done under local anesthesia
18 Autoantibody and immunoglobulin characteristics in liver disease Auto antibodiesImmunoglobulinPrimary billiary cirrhosisHigh titre of antimitochondrial antibody in 95% of patientsRaised IgMAutoimmune chronic active hepatitisSmooth muscle antibody in 70%, antinuclear factor in 60%, Low antimitochondrial antibody titre in 20%Raised IgG in all patientsPrimary sclerosing cholangitisAntinuclear cytoplasmic antibody in 30%
19 SummaryAn isolated raised serum bilirubin concentration is usually due to Gilbert’s syndrome, which is confirmed by normal liver enzyme activities and full blood countJaundice with dark urine, pale stools, and raised alkaline phosphatase and gamma-glutamyl transferase activity suggests an obstructive cause, which is confirmed by presence of dilated bile ducts on ultrasonographyJaundice in patients with low serum albumin concentration suggests chronic liver diseasePatients with high concentrations of bilirubin (>100 micro mol/l) or signs of sepsis require emergency specialist referralImaging of the bile ducts for obstructive jaundice is increasingly performed by magnetic resonance cholangiopancreatography, with endoscopy becoming reserved for the therapeutic interventions
21 Haemolysis Gilberts Excess bilirubin production Failure to conjugate Unconjugated Bil ++Normal ALP/ALTLow Hb/retics++SplenomegalyPigmented gallstonesGilbertsFailure to conjugate2-5%Autosomal recessiveAsymptomaticBilirubin UnconjugatedNormal ALT/ALPWorse if infection, miss a meal
29 Intrinsic to the ductal system GallstonesSurgical stricturesInfection (cytomegalovirus, Cryptosporidiuminfection in patients with acquiredimmunodeficiency syndrome)Intrahepatic malignancyCholangiocarcinomaExtrinsic to the ductal systemExtrahepatic malignancy (pancreas, lymphoma)Pancreatitis
30 CASE SCENARIOA 54 years old female is presented in emergency department with complaints of low grade fever, nausea and loss of appetite for last 10 days. now she is worried because of yellow discoloration of sclera and dark colored urine for one day.What physical signs you can suspect in this case?
31 , CASE SCENARIOOn examination, she has fever of 100-F.she is jaundiced and having tender hepatomegaly.How will you investigate this case ?
32 CASE SCENARIO Bilirubin 10mg/dl ALT 1593IU Alkaline phosphatase 840IU Hb 12.3TLC 8900PlateletsPT 3 seconds prolongSerum albumin 3.6mg/dlWhat is your likely diagnosis ?
33 CASE SCENARIOHepatitis AHepatitis BHepatitis CHepatitis D
34 CASE SCENARIOHow will you differentiate hepatitis A and hepatitis E infection ?How will you manage this case ?
35 CASE SCENARIOBed restIncrease oral juices intake in anorexic patientsAnti emeticsParenteral feeding if severe anorexia and vomitingVitamin and liver supportive agents