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Approach to Jaundice DR.Bilal Natiq Nuaman C.A.B.M. F.I.B.M.S. D.I.M. M.B.Ch.B. 2016 1

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• Jaundice or icterus is a yellowish discoloration of the skin sclerae and mucous membranes due to hyperbilirubinaemia. • It is a sign of either liver disease or less often a hemolytic blood disorder. 2

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1 st stage: 
 frenulum of tongue 1.5mg/dl 
 2 nd stage: 
 sclera of eye 2.5mg/dl 
 most important to exclude carotinemia 
 3 rd stage: 
 3.5mg/dl 3 Sequential sites of jaundice

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Spectrum of color change 4

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• Normal serum bilirubin level is less than 1 mg/dl. • In good light most clinicians will recognize jaundice when bilirubin levels exceeds 45 µmol/L 2.5 mg/dL. convertor factor 17 • Another sensitive indicator of increased serum bilirubin is darkening of the urine which is due to the renal excretion of conjugated bilirubin. Patients often describe their urine as tea- or cola-colored. • In the setting of recent onset severe hepatocellular damage as in acute viral hepatitis or toxic hepatitis the sclera may not show jaundice because staining of tissues by excess bilirubin takes 2 to 3 days. Therefore it is a golden rule to look at the color of urine and examine urine for bile pigments and the patient repeatedly on successive days for jaundice if a likely cause is suspected . 5

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Plasmodium falciparum malaria causes pre-hepatic hepatic and obstructive jaundice 10

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11 History taking of patient presenting with jaundice: focus on the onset and duration of the jaundice. When you notice that your eyes /skin had changed color How have things progressed since then. Acute onset days: • Gall stone disease choledocholithiasis cholangitis • acute hepatitis • Acute Budd-Chiari syndrome • Hemolysis Subacute onset weeks—months: • Pancreatic and hepatobiliary malignancy • Intrahepatic cholestasis eg drug-induced. autoimmune. infiltrative liver disease • Right-sided heart failure

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12 Recurrent episodes: • Gallstone disease • Disorder of bile transport e.g. Gilberts syndrome • malaria • G6PD deficiency • chronic active or alcoholic hepatitis. Ask about these associated symptoms: Fever: may occur in • cholangitis • viral hepatitis Or • alcoholic hepatitis.

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13 Causes of painful jaundice include Hepatitis alcoholic infective drug induced Wilson’s disease Biliary colic Pancreatitis Cholecystitis Liver metastasis and Budd–Chiari. Painful VS Painless jaundice

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14 Causes of painless jaundice are Hemolysis hyperbilirubinaemia Gilbert’s pancreatic or biliary malignancy and Hepatic cirrhosis e.g. alcoholic hemochromatosis primary biliary cirrhosis Drug-related or autoimmune cholestasis .

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15 Confusion: the presence of altered mental status strongly suggests a serious underlying cause such as • sepsis due to cholangitis. or • hepatic encephalopathy due to acute or chronic liver failure. • Other causes include intracranial haemorrhage as a consequence Of coagulopathy caused by liver failure hypoglycaemia due to liver failure or a post-ictal State following a seizure due to alcohol or substance withdrawal.

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16 Mucosal bleeding / bruising: ask specifically about gum bleeding. nosebleeds and easy bruising. • Aside from coagulopathy caused by liver failure. • other causes of mucosal bleeding and jaundice include disseminated intravascular coagulation DIC due to chloangitis and sepsis thrombocytopenia due to portal hypertension hypersplenism. thrombotic thrombocytoping purpura TTP. or severe malaria.

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17 Bock pain: is a feature of • viral hepatitis along with right upper quadrant pain and • severe hemolysis. Dark urine / pale stools: these are classically symptoms of obstructive jaundice which causes "pale stool".

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18 Pruritus: is a feature of all cholestatic processes including bile duct obstruction drug-induced and autoimmune. Weight loss: involuntary weight loss is associated with • pancreatic or hepatobiliary malignancy. • Patients with advanced chronic liver disease are also usually malnourished although their weight loss may be balanced by the development of ascites.

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19 Associated risk factors: Risk factors for viral hepatitis: • Needle and blood exposure—shared needles tattoos piercings. dental or medical care abroad • Sexual history—ask sensitively about sexual contacts. • Exposure to hepatitis A—exposure to individuals with viral illness • Document travel history in last 6 weeks. • Recent immunosuppression—patients who may be asymptomatic carriers of hepatitis B may develop liver failure due to viral reactivation after starting immunosuppressant therapy e.g. steroids chemotherapy. Risk factors for alcoholic hepatitis and acute liver failure: Alcohol intake—ask openly about alcohol intake. Many patients may under-report the amount Of alcohol they consume.

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20 Risk factors for cholestatic jaundice 1-Gallstones—ask about a history of gallstones and a past history of post-prandial right upper quadrant pain. Also ask about risk factors for gallstones such as • a haemolytic anaemia pigment stones • previous parenteral nutrition. • gastric bypass surgery or • use of somatostatin analogues such as Lanreotide for carcinoid syndrome or acromegaly. 2-Previous hepatic or biliary surgery—risk Of biliary strictures. 3-Previous pancreatitis may result in pancreatic pseudocyst formation which can compress the biliary tree. 4-History of sickle cell anaemia—associated with haemolysis and biliary disease due to pigment gallstones. 5-History of ulcerative colitis—associated with primary sclerosing cholangitis in 1—4 of cases .

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21 Medications • Do you toke painkillers or cold remedies containing paracetamol Have you recently started any new medications or over-the-counter OTC remedies • DO you drink herbal remedies. • Several drugs are associated with acute liver failure including paracetamol. Antituberculous medications and antiepileptics. • Herbal teas may also cause hepatic veno-occlusive disease and liver failure.

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22 Travel history: The incubation period Of hepatitis A virus infection is 4—6 weeks.Therefore document all areas visited in the preceding 2 months. Hepatitis B virus infection is also common prevalence up to 20 in South East Asia Eastern Europe and sub-Saharan Africa—ask specifically about travel to these areas. Additionally liver fluke infection Clonorchiasis may be acquired in South East Asia. These infections may cause biliary strictures resulting in jaundice and recurrent cholangitis.

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23 Relevant family history Ask about a family history of liver disease hepatitis Or blood disorders. Haemachromatosis Wilsons disease and Gilberts syndrome are familial as are several hemolytic anaemias such as sickle cell anaemia and G6PD deficiency.

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24 The most important initial step is to determine whether the jaundice is predominately caused by an elevation of unconjugated indirect or of conjugated direct bilirubin. If jaundice is primarily the result of unconjugated indirect bilirubin evaluation for hemolysis and other conditions with shortened red blood cell survival is required. In patients with elevated conjugated direct bilirubin the clinical challenge lies in determining whether biliary obstruction or impaired hepatic excretion is responsible

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Prehepatic jaundice 
 In hemolytic disorders the accompanying anemic pallor combined with jaundice may produce a pale lemon complexion. The stools and urine are normal in color. In hemolytic jaundice urine does not generally contain bile pigments since unconjugated bilirubin does not appear in urine acholuric jaundice. Causes Hemolysis sickle cell disease autoimmune hemolytic anemia Microbe-induced hemolysis malaria. Ineffective erythropoiesis e.g. megaloblastic anemias 26

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27 Hemolysis should be considered in the evaluation of unconjugated hyperbilirubinemia and evaluated by examination of the peripheral blood smear and in some cases the bone marrow smear To document excessive hemolysis suspect in patients with anemia : • Splenomegaly • reticulocytosis increased reticulocyte count • Elevated serum LDH

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Hepatic jaundice 
 Hepatocellular disease causes hyperbilirubinaemia that is both unconjugated and conjugated. Conjugated bilirubin is soluble and filtered by the kidney so the urine is dark brown. The stools are normal in color. There are stigmata of liver disease gynecomastiawastinghepatosplenomegaly 28

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Post-hepatic/ cholestatic obstructive jaundice 
 In biliary obstruction conjugated bilirubin in the bile does not reach the intestine so the stools are pale. Obstructive jaundice usually accompanied by pruritus generalized itch due to skin deposition of bile salts. 29

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