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					Dr Umar Farooq Qureshi
   Yellowish discoloration of skin sclera and
    mucous membranes due to
    hyperbilirubinaemia .

   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
    to bilirubin.
   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
   Unconjugated;
        Insoluble, transported bound to albumin
    not filtered by gomeruli. In unconjugated
    hyperbilirubinaemia, urine is normal in
    colour(acholuric jaundice)

   Conjugated;
         Water soluble, filtered by glomeruli.
    Urine becomes dark brown.
   Classified into;



   Uncojugated hyperbilirubinaemia
   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
   Caused by;

-failure of hepatocytes to initiate bile flow

-obstruction of bile flow at bile dutules and
 portal tracts

-extrahepatic obstuctuion of bile flow
 Obstruction can be;
 Intrahepatic
 causes include;
     Primary biliary cirrhosis
     Primary sclerosing cholangitis
      Hepatic infiltration
      Pregnancy(benign recurrent intrahepatic
   Extrahepatic obstruction
    causes include;
      CA: pancreas, cholangicarcinoma
     Traumatic stricture
   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:
   Transfusion
   Intravenous (IV) drug use
   Multiple sexual partners
   Exposure to a person who is infected
   Colicky abdominal pain or fever suggests
    gallstone disease.
   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.
   Physical examination;
   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;
   Palmer erythema
   Dupuytren’s contractures
   Flapping tremors
   Parotid swelling
   Gynecomastia
   Spider nevi
   Testicular atrophy
   Examine the abdomen for;

   Distension and signs of free fluid(ascites)

   Hepatomegaly and tenderness

   Splenomegaly

   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
    aminotransferase [ALT])

   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
    autoimmune hepatitis
   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
 Advantages;
-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
   Disadvantages;

   Limited resolution

   Operator dependent

   May not detect common bile duct stones
    because of bowel gas
   Abdominal computed tomography (CT) scan
   Advantages;
   Better resolution than ultrasonography
   Provides good evaluation of the entire bile
   Can define the anatomy better than
    ultrasonography, especially if contrast agents
    are used
   Better for evaluating suspected malignancies
   Permits guided needle biopsies
   Disadvantages;

   More expensive and less portable than
   Requires radiation exposure
   Requires IV contrast medium for best results
   Less sensitive than ultrasonography for
    gallbladder stones
   Abdominal magnetic resonance imaging (MRI)
   Advantages;

   Requires no exposure to ionizing radiation
    (ie, safe in pregnancy)
   Permits guided needle biopsies (open MRI
    systems only)
   With special contrast agents, can evaluate bile
    and pancreatic ducts
   Disadvantages;

   Not universally available

   Cannot be used in most patients with metallic

   Requires IV contrast medium for best results

   Clinical experience is still somewhat limited
   Endoscopic retrograde
    cholangiopancreatography (ERCP)
   Advantages;

   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
   Disadvantages;

   Requires conscious sedation and radiation

   May cause pancreatitis and other

   Not always successful, especially after
    gastroduodenal surgery
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
Thank you

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