This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student rotated under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

Jaundice By Saad AL-Robaiea Medical Student

Definition: Jaundice or icterus is yellowish discoloration of skin, mucous membranes and sclera result of rise in serum bilirubin Normal range of plasma bilirubin 3-17 mcmol/L (0.5 – 1 mg/dl) Clinically obvious     50 mcmol/L (3mg/dl)

NORMAL BILIRUBIN METABOLISM Bilirubin is derived mainly from breakdown of hemoglobin Unconjugated bilirubin is conjugated in the liver by glucuronyl transferase Conjugated bilirubin is water soluble and is secreted by the hepatocytes into the biliary canaliculi Converted to urobilinogen (colorless) by bacteria in the gut wich may reabsorbed and excreted by the kidneys or converted to stercobilin and excreted in faeces (colored)

Types hyperbilirubinemia Unconjugated hyperbilirubinaemia (Indirect) Conjugated hyperbilirubinaemia (Direct)

Causes of jaundice

Prehepatic (hemolytic) jaundice Results from overproduction of bilirubin (beyond the livers ability to conjugate it) following hemolysis Impaired hepatic uptake (Rifampine , Gilbert’s syndrom) Impaired conjugation (Chloramphenicol , Criglar-Najjar syndrom) Increased plasma unconjugated bilirubin Increased urobilinogen in urine ALP, ALT, AST - normal

Intrahepatic jaundice Impaired uptake, conjugation, or secretion of bilirubin Reflects a generalized liver (hepatocyte) dysfunction Excess bilirubin mixture unconjugated +conjugated Increased ALT/AST Slightly increased or Normal ALP

Posthepatic (Obstructive) jaundice Caused by an obstruction of the biliary tree Increased plasma conjugated bilirubin Characterized by pale colored stools (absence of fecal stercobilin), and dark urine (increased conjugated bilirubin) and urobilinogen is absent from the urine Increased ALP Slightly increased or Normal ALT,AST

History : Onset Fever abdominal pain Pruritus , dark urin , pale stools Travel Drugs Blood transfusion Family history Surgical history

Physical examination General examination Vital signs Murphy's sign Hepatomegaly , Splenomegaly Signs of chronic liver disease

Lab evaluation CBC , reticulocyte count , LFT , prothrmobine and INR Iron profile Viral serology Autoantibodies

U.S C.T ERCP MRCP Liver biopsy : - Cirrhosis - Chronic hepatitis - Undiagnosed hepatomegaly - Cholestasis of unknown cause

1- In obstructive jaundice: a. Urinary conjugated bilirubin is increased b. Serum unconjugated bilirubin is increased c. Urinary urobilinogen is increased d. Serum conjugated bilirubin is reduced e. Faecal stercobilin is increased

THANK YOU