Approach to a patient with jaundice Dr Ali Tumi

Jaundice Yellow discoloration of skin & sclera due to excess serum bilirubin. >40umol/l, (3mg/dl) Conjugated & Unconjugated types Obstructive & Non Obstructive (clinical) Pre-Hepatic, Hepatic & Post Hepatic types Jaundice - Not necessarily liver disease *

Bilirubin Metabolism Blood Conjugated & Unconjugated Urine – Urobilinogen Stool – Stercobilin

Common Causes of Jaundice Pre Hepatic (Acholuric) - Hemolytic Unconjugated/Indirect Bil, pale urine Hepatic – Viral, alcohol, toxins, drugs Liver damage - unconjugated Swelling, canalicular obstruction - Conjugated Post Hepatic (Obstructive) – Stone, tumor Conjugated/Direct Bil, High colored urine,

Critical Questions in the Evaluation of the Jaundiced Patient Acute vs. Chronic Liver Disease Hepatocellular vs. Cholestatic Biliary Obstruction vs. Intrahepatic Cholestasis Fever Could the patient have ascending cholangitis? Encephalopathy Could the patient have fulminant hepatic failure?

Evaluation of the Jaundiced Patient HISTORY Pain Fever Confusion Weight loss Sex, drugs, R&R Alcohol Medications pruritus malaise, myalgias dark urine abdominal girth edema other autoimmune dz HIV status prior biliary surgery family history liver dz

Evaluation of the Jaundiced Patient PHYSICAL EXAM BP/HR/Temp Mental status Asterixis Abd tenderness Liver size Splenomegaly Ascites Edema Spider angiomata Hyperpigmentation Kayser-Fleischer rings Xanthomas Gynecomastia Left supraclavicular adenopathy (Virchow’s node)

Cirrhosis Clinical Features

Yes Yes Treat

Evaluation of the Jaundiced Patient LAB EVALUATION AST-ALT-ALP Bilirubin – total/indirect Albumin INR Glucose Na-K-PO4, acid-base Acetaminophen level CBC/plt Ammonia Viral serologies ANA-ASMA-AMA Quantitative Ig Ceruloplasmin Iron profile Blood cultures

Evaluation of the Jaundiced Patient Ultrasound: More sensitive than CT for gallbladder stones Equally sensitive for dilated ducts Portable, cheap, no radiation, no IV contrast CT: Better imaging of the pancreas and abdomen MRCP: Imaging of biliary tree comparable to ERCP ERCP: Therapeutic intervention for stones Brushing and biopsy for malignancy

New Onset Jaundice Viral hepatitis Alcoholic liver disease Autoimmune hepatitis Medication-induced liver disease Common bile duct stones Pancreatic cancer Primary Biliary Cirrhosis (PBC) Primary Sclerosing Cholangitis (PSC)

Jaundiced Emergencies Acetaminophen Toxicity Fulminant Hepatic Failure Ascending Cholangitis

Jaundice Unrelated to Intrinsic Liver Disease Hemolysis (usually T. bili < 4) Massive Transfusion Resorption of Hematoma Ineffective Erythropoesis Disorders of Conjugation Gilbert’s syndrome Intrahepatic Cholestasis Sepsis, TPN, Post-operation

HBV Serology + - HBSAg HBcAb IgM IgG HBSAb Acute HBV Resolved HBV Chronic HBV HBV vaccinated

Jaundice

Jaundice

Yellow hands on top, red palms underneath - a sign of liver damage

Ascitis in Cirrhosis

Ascitis in Cirrhosis

Gynaecomastia in cirrhosis