Dr Umar Farooq Qureshi
Yellowish discoloration of skin sclera and
mucous membranes due to
Clinically detectable when plasma bilirubin
exceeds 3 mg/dl.
Bilirubin is produced from breakdown of Hb
in reticuloendothelial system
Daily production 250-300mg.
Biliverdin is formed from Haem and reduced
Bilirubin produced is unconjugated,insoluble
and is transported to liver attached to
In liver bilirubin is conjugated with
glucunonic acid and excreted in bile.
Conjugated bilirubin is water soluble.
In terminal ileum, bacterial enzymes release
free bilirubin that is reduced to urobilinogen.
Part of urobilinogen is excreted in stool as
stercobilin. Remainder absorbed from
terminal ileum through enterohepatic
This is bound to albumin and excreted in
Insoluble, transported bound to albumin
not filtered by gomeruli. In unconjugated
hyperbilirubinaemia, urine is normal in
Water soluble, filtered by glomeruli.
Urine becomes dark brown.
Increased production as in hemolysis, jaudice
is mild(normal liver can excrete 6times of
Decreased uptake of bilirubin by hepatocytes
as in Gilbert’s syndrome(autosomal
In hemolysis anemia with jaundice produces
pale lemon complextion
Stool and urine are normal in colour
Can cause conjugated as well unconjugated
Urine is dark and stool is normal in colour
Causes include viral hepatitis,alcohol
,drugs,autoimmune hepatitis and metbolic
diseases including wilson disease and
-failure of hepatocytes to initiate bile flow
-obstruction of bile flow at bile dutules and
-extrahepatic obstuctuion of bile flow
Obstruction can be;
Primary biliary cirrhosis
Primary sclerosing cholangitis
Pregnancy(benign recurrent intrahepatic
CA: pancreas, cholangicarcinoma
Fearture include pain right
hypochondrium,dark urine,clay coloured
stool and pruritis.
History must include
Age,sex,country of origin
Potential toxins (eg, drugs), environmental
chemicals (eg, solvents), or wild mushrooms
must be carefully excluded.
Risk factors for viral hepatitis should be elicited.
Possible risk factors include the following:
Intravenous (IV) drug use
Multiple sexual partners
Exposure to a person who is infected
Colicky abdominal pain or fever suggests
Weight loss or constitutional systems
suggests malignancy or chronic infection.
Recent anesthesia with the use of halothane
suggests halothane hepatitis.
A history of intense pruritus suggests
cholestatic disease resulting from biliary
obstruction or intrahepatic cholestasis.
A family history of jaundice suggests inborn
errors of bilirubin metabolism.
In patients younger than 20-25 years, a
history of a recent flulike syndrome treated
with aspirin raises the possibility of Reye
Pregnancy suggests benign recurrent
cholestasis or, in late pregnancy, acute fatty
liver of pregnancy.
The first manifestation in cases of conjugated
hyperbilirubinemia is commonly a brownish
discoloration of the urine, although scleral
icterus may also be present, this typically reflects
the unconjugated fraction of bilirubin that binds
tissues much more avidly.
If sufficient unconjugated bilirubin is present, the
skin, sclerae, and mucous membranes take on a
yellow cast, although this may be difficult to
detect if the tissues are pigmented naturally.
Look for stigmata of chronic liver disease;
Examine the abdomen for;
Distension and signs of free fluid(ascites)
Hepatomegaly and tenderness
Palpable gall bladder or gall bladder mass.
All patients should be tested for the
Complete blood cell (CBC) count
Serum aminotransferases (aspartate
aminotransferase [AST], alanine
Serologic screen for hepatitis, antiHCV,HBsAg
or antiHBc Ab.
Alkaline phosphatase (ALP)
Blood alcohol or acetaminophen levels
Antimitochondrial antibody when considering
primary biliary cirrhosis
Antinuclear antibodies (ANAs) and smooth-
muscle antibodies when considering
Iron and genetic studies when considering
Copper studies when considering Wilson
Alpha-1 antitrypsin fractionation
Abdominal ultrasonography (to exclude biliary
obstruction and to evaluate the liver parenchyma
for possible cirrhosis, tumor, steatosis, or
-Provides good visualization of the gallbladder,
bile ducts, and cystic lesions
-Can detect parenchymal liver disease, such as
cirrhosis or infiltration, and signs of portal
May not detect common bile duct stones
because of bowel gas
Abdominal computed tomography (CT) scan
Better resolution than ultrasonography
Provides good evaluation of the entire bile
Can define the anatomy better than
ultrasonography, especially if contrast agents
Better for evaluating suspected malignancies
Permits guided needle biopsies
More expensive and less portable than
Requires radiation exposure
Requires IV contrast medium for best results
Less sensitive than ultrasonography for
Abdominal magnetic resonance imaging (MRI)
Requires no exposure to ionizing radiation
(ie, safe in pregnancy)
Permits guided needle biopsies (open MRI
With special contrast agents, can evaluate bile
and pancreatic ducts
Not universally available
Cannot be used in most patients with metallic
Requires IV contrast medium for best results
Clinical experience is still somewhat limited
Allows treatment of obstruction using
sphincterotomy, stone extraction, stent
placement, or balloon-dilation of strictures
Permits biopsies under direct visualization
Provides excellent visualization of bile ducts
Requires conscious sedation and radiation
May cause pancreatitis and other
Not always successful, especially after
Treat the underlying cause.
Jaundice is a symptom not a disease.
Always try to find the cause of jaundice.
History and physical examination is very
important to narrow down list of differentials
Treatment of jaundice is treatment of the