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Approach to a patient with jaundice

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Presentation on theme: "Approach to a patient with jaundice"— Presentation transcript:

1 Approach to a patient with jaundice
Dr Ali Tumi

2 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 *

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


5 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,

6 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?

7 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

8 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)

9 Cirrhosis Clinical Features

10 Yes Yes Treat

11 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

12 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

13 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)

14 Jaundiced Emergencies
Acetaminophen Toxicity Fulminant Hepatic Failure Ascending Cholangitis

15 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

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

17 Jaundice

18 Jaundice

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

20 Ascitis in Cirrhosis

21 Ascitis in Cirrhosis

22 Gynaecomastia in cirrhosis















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