1. JAUNDICES

2. What is Jaundice?
Jaundice is yellowish discoloration of the skin, sclera and mucous membranes due to hyperbilirubinemia and deposition of bile pigments .
Equilibrium between bilirubin production and clearance is disturbed .
Serum bilirubin level greater than 2mg/dL
Jaundice is NOT a disease, but rather a sign that can occur in many different diseases.

4. What is bilirubin?
Bilirubin is a yellowish pigment found in bile, a fluid made by the liver.
The breakdown product of Hgb from injured RBCs and other heme containing proteins.
Produced by reticuloendothelial system
Released to plasma bound to albumin
Hepatocytes conjugate it and extrete through bile channels into small intest.

5. Bilirubin di-glucoronid

6. Unconjugated bilirubin
Heme
Biliverdin
Unconjugated bilirubin
Conjugated bilirubin
Urobilinogen
Stercobilin
Globin
Heme oxygenase
Biliverdin reductase
UDPGT
Intestinal bacteria
LIVER
INTESTINE
KIDNEY
Urinary Urobilinogen
BILIRUBIN METABOLISM

7. NORMAL METABOLISM OF BILE PIGMENTS
CELLS OF RES
Indirect bilirubin
NADP+
NADPH2
Biliverdin reductase
Biliverdin
Iron
Globin
Verdoglobin
Hemoxi-genase
Hemoglobin
ERYTHROCYTES
KIDNEYS
Stercobilinogen
URINE
Stercobilin
Indirect bilirubin 1,7-20,5 mkmol/l
albumin
UDP-glucoronil-transferase
Direct bilirubin mkmol/l
BLOOD
LIVER
Bilirubin mono-glucoronid, 20 %
Bilirubin di-glucoronid, 80 %
Dipyrols
-glucoro-nidase
Glucoronic acid
Direct bilirubin
BILE
INTESTINE
Mesobilirubin
Mesobilirubin (urobilinogen)
STOOL

8. Normal Range of Bilirubin
What causes  bilirubin?
Overproduction by reticuloendothelial system
Failure of hepatocyte uptake
Failure to conjugate or excrete
Obstruction of biliary excretion into intestine
Normal Range of Bilirubin
It is normal to have some bilirubin in your blood. Normal levels are:
Direct (also called conjugated) bilirubin: 0 to 0.3 mg/dL
Total bilirubin: 0.3 to 1.9 mg/dL

9. TYPES OF JAUNDICE PRE HEPATIC HEPATIC POST HEPATIC
Excessive amount of bilirubin is presented to the liver due to excessive hemolysis
Impaired cellular uptake, defective conjugation or abnormal secretion of bilirubin by the liver cell
Impaired excretion due to mechanical obstruction to bile flow
Elevated unconjugated bilirubin in serum
Both conjugated and unconjugated bilirubin may be elevated in serum
Elevated conjugated bilirubin in serum

10. TYPES OF JAUNDICE PRE HEPATIC HEPATIC POST HEPATIC Hemolytic Anemia
Hepatitis, cirrhosis, Crigler-Najjar Syndrome, Dubin-Johnson Syndrome, Rotor’s Syndrome
Gallstone, malignancy, inflammation

11. TYPES OF JAUNDICE TYPE PRE HEPATIC HEPATIC POST HEPATIC Urine color
normal
dark
Stool color
acholic
Pruritus no No
yes

12. There are other types of Jaundice :
Pathologic Jaundice
Pathologic jaundice can occur in children and adults and is diagnosed when jaundice presents a health risk. Several forms of hepatitis, cirrhosis of the liver and other liver diseases, bile duct blockage, along with infections and medications, can also cause pathological jaundice.
Gilbert Syndrome Jaundice
Gilbert's syndrome is a harmless hereditary condition that results in mild jaundice. During times of illness or stress, people with Gilbert's syndrome will experience low levels of some bilirubin-processing enzymes in their livers, according to LabTestsOnline.com. Once diagnosed, Gilbert's syndrome does not require further medical treatment.

13. Neonatal Jaundice
Jaundice is clinically detectable in the newborn when the serum bilirubin levels are greater than 85 μmol/L. This occurs in approximately 60% of term infants and 80% of preterm infants.
Neonatal jaundice first becomes visible in the face and forehead. Blanching reveals the underlying colour. Jaundice then gradually becomes visible on the trunk and extremities.

14. Signs and Symptoms of Neonatal Jaundice
Newborns, as the bilirubin level rises, jaundice will typically progress from the head to the trunk, and then to the hands and feet. Additional signs and symptoms that may be seen in the newborn include:
poor feeding
lethargy
changes in muscle tone
high-pitched crying
seizures.

15. HEMOLYTIC (PREHEPATIC) JAUNDICE
Jaundice due to the excessive breakdown of red blood cells.
Causes:
sickle cell anemia,
malaria,
thalassemia,
autoimmune disorders,
massive hemorrhage

16. METABOLISM OF BILE PIGMENTS IN HEMOLYTIC JAUNDICE
CELLS OF RES
Indirect bilirubin
albumin
Biliverdin reductase
UDP-glucoronil-transferase
Direct bilirubin
NADP+
NADPH2
Biliverdin
Iron
Globin
Verdoglobin
Hemoglobin
Hemoxi- genase
BLOOD
LIVER
Bilirubin mono-glucoronid, 20 %
Bilirubin diglucoronid, 80 %
-glucoro- nidase
Glucoronic acid
BILE
ERYTHROCYTES
KIDNEYS
INTESTINE
STOOL
Stool hypercholic
URINE
Urine dark
Mesobilirubin
Mesobilinogen (urobilinogen)
Stercobilinogen
Stercobilin
Urobilin

17. PARENCHYMAL (HEPATIC) JAUNDICE
occurs due to the liver disease and inability of liver to metabolize and remove bilirubin from the biliary system
Causes:
cirrhosis,
cancer,
viral hepatitis,
Gilbert’s syndrome, toxins or drugs, etc.

18. METABOLISM OF BILE PIGMENTS IN HEPATIC JAUNDICE
CELLS OF RES
Indirect bilirubin
albumin
Biliverdin reductase
UDP-glucoronil-transferase
Direct bilirubin
NADP+
NADPH2
Biliverdin
Iron
Globin
Verdoglobin
Hemoglobin
Hemoxi- genase
BLOOD
LIVER
Bilirubin mono-glucoronid, 20 %
Bilirubin diglucoronid, 80 %
-glucoro- nidase
Glucoronic acid
BILE
ERYTHROCYTES
KIDNEYS
Urobilinogen
INTESTINE
STOOL
Stool hypocholic
URINE
Urine dark
Stercobi-linogen
Stercobilin
Bilirubin
Urobilin
Mesobilirubin
Mesobilinogen (urobilinogen)
Stercobilinogen

19. ОBSTRUCTIVE (POST-HEPATIC)
JAUNDICE
Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the liver
INTRAHEPATIC
EXTRAHEPATIC

20. ОBSTRUCTIVE (POST-HEPATIC)
JAUNDICE
is caused by obstruction of bile flow from the liver
Causes:
carcinoma in the bile duct or gall bladder,
presence of gallstones in the biliary system,
infection by parasites,
pancreatitis, etc.

21. METABOLISM OF BILE PIGMENTS IN OBSTRUCTIVE JAUNDICE
CELLS OF RES
Indirect bilirubin
albumin
Biliverdin reductase
UDP-glucoronil-transferase
Direct bilirubin
NADP+
NADPH2
Biliverdin
Iron
Globin
Verdoglobin
Hemoglobin
Hemoxi- genase
BLOOD
LIVER
Bilirubin mono-glucoronid, 20 %
Bilirubin diglucoronid, 80 %
Bile acids
-glucoro- nidase
Glucoronic acid
BILE
ERYTHROCYTES
KIDNEYS
INTESTINE
STOOL
Stool acholic, steatorhea
URINE
Direct bilirubin
Bile acids
Urine dark, foaming

22. Causes of Obstructive Jaundice: intrahepatic
Primary biliary cirrhosis
Sclerosing cholangitis (Inflammation/scarring)
Primary biliary cirrhosis
Sclerosing cholangitis (Inflammation/scarring)

23. Causes of Obstructive Jaundice: Extrahepatic
Choledocholithiasis
Malignancy : Pancreatic (head of pancreas) carcinoma
Choledocholithiasis
Malignancy : Pancreatic (head of pancreas) carcinoma

24. Removal of Obstruction Jaundice
Non-surgical
Extracorporeal Shockwave Lithotripsy
Non-invasive
successive shock wave pressure pulses
fragment the stones into smaller pieces so they can easily pass through the duct
Endoscopic Retrograde Cholangionpancreatography
insertion of the endoscope up into the ducts in a direction opposite to or against the normal flow of bile down the ducts (retrograde)

25. Surgical Laparoscopic Cholecystectomy
aka minimally invasive surgery (MIS), bandaid surgery, keyhole surgery, or pinhole surgery
small incisions, usually cm
Laparoscope: a telescopic rod lens system, that is usually connected to a video camera.
fiber optic cable system connected to a light source and cannula or trocar for view of the operative field

26. Causes of Jaundice Jaundice occurs when there is:
too much bilirubin being produced for the liver to remove from the blood (for example, patients with hemolytic anemia have an abnormally rapid rate of destruction of their red blood cells that releases large amounts of bilirubin into the blood)
a defect in the liver that prevents bilirubin from being removed from the blood, converted to bilirubin/glucuronic acid (conjugated) or secreted in bile; or

27. 3- blockage of the bile ducts that decreases the flow of bile and bilirubin from the liver into the intestines. For example, the bile ducts can be blocked by cancer, gallstones, or inflammation of the bile ducts. The decreased conjugation, secretion, or flow of bile that can result in jaundice is referred to as cholestasis: however, cholestasis does not always result in jaundice.

28. Signs and Symptoms of Jaundice
Common signs and symptoms seen in individuals with jaundice include:
yellow discoloration of the skin
mucous membranes
the whites of the eyes
light-colored stools
dark-colored urine
itching of the skin.
nausea and vomiting
abdominal pain
fever
weakness
loss of appetite
headache
confusion
swelling of the legs and abdomen.

29. Diagnosis of Jaundice
The health care provider will perform a physical exam. This may reveal liver swelling.
A bilirubin blood test will be done.
Other tests vary, but may include:
Hepatitis virus panel to look for infection of the liver
Liver function tests to determine how well the liver is working
Complete blood count to check for low blood count or anemia
Abdominal ultrasound
Abdominal CT scan
Endoscopic retrograde cholangiopancreatography (ERCP)
Percutaneous transhepatic cholangiogram (PTCA)
Liver biopsy
Cholesterol level
Prothrombin time

30. Imaging tests
If intra-hepatic jaundice or post-hepatic jaundice is suspected, it's often possible to confirm the diagnosis using imaging tests to check for any abnormalities inside the liver or bile duct systems

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

32. What about jaundice in pregnancy?
Most of the diseases discussed previously can affect women during pregnancy, but there are some additional causes of jaundice that are unique to pregnancy.
1- Cholestasis of pregnancy.
Cholestasis of pregnancy is an uncommon condition that occurs in pregnant women during the third trimester. The cholestasis often is accompanied by itching but infrequently causes jaundice. The itching can be severe, but can be treated with drugs (ursodeoxycholic acid or ursodiol [Actigall, Urso]).
There also is an association between cholestasis of pregnancy and cholestasis caused by oral estrogens, and it has been hypothesized that it is the increased estrogens during pregnancy that are responsible for the cholestasis of pregnancy.

33. 3- Acute fatty liver of pregnancy.
2- Pre-eclampsia.
Pre-eclampsia, previously called toxemia of pregnancy, is a disease that occurs during the second half of pregnancy and involves several systems within the body, including the liver. It may result in high blood pressure, fluid retention, and damage to the kidneys as well as anemia and reduced numbers of platelets (thrombocytopenia) due to destruction of red blood cells and platelets. It often causes problems in the fetus. Although the bilirubin level in the blood is elevated in pre-eclampsia, it usually is mildly elevated, and jaundice is uncommon.
3- Acute fatty liver of pregnancy.
Acute fatty liver of pregnancy (AFLP) is a very serious complication of pregnancy. The cause of AFLP is unclear, but is often associated with pre-eclampsia. It occurs late in pregnancy and results in failure of the liver. It can almost always be reversed by immediate delivery of the fetus. There is an increased risk of infant death. Jaundice is common, but is not always present in AFLP.

34. Jaundice in Pregnancy

35. Can we prevent Jaundice?
Due to the wide range of potential causes, it's not possible to prevent all cases of jaundice. However, there are four main precautions that you can take to minimise your risk of developing jaundice. They are:
ensuring that you stick to the recommended daily amount (RDA) for alcohol consumption
maintaining a healthy weight for your height and build
if appropriate, ensuring that you're vaccinated against a hepatitis A or B infection, vaccination would usually only be recommended depending on where in the world you're travelling .
minimizing your risk of exposure to hepatitis C because there's currently no vaccine for the condition .

36. Jaundice Treatment
Treatment depends on the cause of the underlying condition leading to jaundice and any potential complications related to it. Once a diagnosis is made, treatment can then be directed to address that particular condition, and it may or may not require hospitalization.
Treatment may consist of expectant management (watchful waiting) at home with rest.
Medical treatment with intravenous fluids, medications, antibiotics, or blood transfusions may be required.
If a drug/toxin is the cause, these must be discontinued.
In certain cases of newborn jaundice, exposing the baby to special colored lights (phototherapy) or exchange blood transfusions may be required to decrease elevated bilirubin levels.
Surgical treatment may be required in case of obstruction jaundice.

37. Thank you!