1. JAUNDICE
Index Case Term 2

2. Jaundice Definition Causes History Investigation-Imaging
Clinical Cases

3. Definition
Jaundice is a yellowing of the skin, conjunctiva and mucous membranes caused by hyperbilirubinaemia.

4. Anatomy

6. Causes excess bilirubin production (Haemolysis)
impaired uptake by the hepatocyte (hepatocellular jaundice)
failure of conjugation (hepatocellular jaundice)
impaired secretion of conjugated bile into the bile canaliculi (hepatocellular jaundice)
impairment of bile flow subsequent to secretion by the hepatocyte (obstructive or cholestatic jaundice)

7. Obstructive Jaundice Common Infrequent Rare Common bile duct stones
Carcinoma of the head of pancreas
Malignant lymph nodes at the porta hepatis
Infrequent
Ampullary carcinoma
Pancreatitis
Liver secondaries
Rare
Benign strictures - iatrogenic, trauma
Recurrent cholangitis
Mirrizi's syndrome
Sclerosing cholangitis
Cholangiocarcinoma
Bilary atresia
Choledochal cysts

8. History Abdominal pain, weight change, fever Drug history Injections
Alcohol
Transfusion blood, blood products
Contact with jaundiced individuals
Sexual activity
Ingestion raw shellfish, wild mushrooms

9. Jaundice N + Haemolytic +++ ++ Hepatocellular Cholestatic AlkP
Transami nases
Bilirubin
Liver Function Tests

10. Clinical Case 1 50 year old female Acute, severe pain in RUQ
Nausea and vomiting
Calls GP – pethidine pain relief
Next few days notices dark urine and pale stools
Her husband comments she has a pale yellow tinge

11. Emergency admission What investigations would you do ?
What results would you expect?

12. Abdominal Ultrasound showing multiple gallstones in gallbladder

13. US shows stone in Common Bile Duct

14. MRCP showing stone in Common Bile Duct

15. ERCP showing stone in Common Bile Duct

17. Case 1 Obstructive jaundice due to gallstone in common bile duct
Blood tests show high bilirubin and high alkaline phosphatase
Urine contains bilirubin
Treatment includes ERCP to remove stone and then plan Cholecystectomy

18. Clinical Case 2 65 year old female Loss of appetite and weight loss
Develops jaundice and itching
Scratch marks and bruising
Liver enlarged, palpable gallbladder

19. Emergency admission
What investigations and what results?

20. Abdominal Ultrasound Dilated common bile duct measuring 14mm
Obstruction at lower end of bile duct
Cause not clear on US

21. CT Abdomen Mass in head of pancreas Obstruction of common bile duct
Liver metastasis
Peritoneal disease and ascites

22. Endoscopic Ultrasound showing mass in head of pancreas obstructing the CBD

23. EUS Biopsy of pancreatic mass

24. Diagnosis Histology of pancreatic biopsy shows adenocarcinoma.
Not suitable for surgery as already spread to other organs eg peritoneum
Relieve jaundice and consider chemotherapy

25. Therapeutic ERCP Put guide wire across the obstruction of CBD
Insert bilary stent
Relieves jaundice and some of symptoms

26. In Summary Anatomy Disease processes that cause jaundice
2 Clinical cases of obstructive jaundice
Thought about investigation of jaundiced patient