approach to the jaundiced patient(د/ أشرف الأباصير

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Dr.Ashraf Sobhy Al-Abasiry.MBBCh.MSc Internist,Primary Care Department Saad Specialist hospital Email : ashrafalabasiry@yahoo.com Approach to the Jaundiced Patient

Introduction : 

Introduction Jaundice is not a common presenting complaint in adults.when present, it may indicate a serious problem. Patients with jaundice may present with no symptoms at all (i.e., the condition is found accidentally).or they may present with a life-threatening condition. American Family Physician® > Vol. 69/No. 2 (January 15, 2004

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The wide range of possibilities is based on the variety of underlying causes and whether disease onset is quick or slow moving. A systematic approach is warranted to clarify the cause quickly so that treatment can begin as soon as possible. American Family Physician® > Vol. 69/No. 2 (January 15, 2004

Jaundice : 

Jaundice Yellowish colouration of sclera,mucous membrane & skin. Symptom not a disease. Literally, means yellow. Caused by high Bilirubin. Normal range 0.3-1.2 mg /dL Clinically obvious ≥ 2.5 mg /dL Definition:

Bilirubin : 

Bilirubin Bilirubin is formed by a breakdown product of heme rings. Approximately 80 % of the heme moiety comes from catabolism of red blood cells. The remaining 20 % resulting from ineffective erythropoiesis and breakdown of muscle myoglobin and cytochromes.

Causes of hyperbilirubinemia : 

Causes of hyperbilirubinemia ► Overproduction by reticuloendothelial system. ► Failure of hepatocyte uptake. ► Failure to conjugate or excrete. ► Obstruction of biliary excretion into intestine.

Pathophysiologic classification of Jaundice : 

Pathophysiologic classification of Jaundice

Pre-hepatic (Haemolytic) : 

Pre-hepatic (Haemolytic) Excessive haemolysis due to any cause: RBC disorder Hereditary spherocytosis. Sickle cell anaemia. Auto-immune Mismatched blood transfusion. Paroxysmal cold hemoglobinuria. Infective Sepsis. Malaria.

Pre-hepatic (Haemolytic) : 

Symptoms Weakness, Dark urine, Anemia, Icterus, , Splenomegaly. Lab UB without bilirubinuria. Fecal and urine urobilinogen. Hemolytic anemia. Hemoglobinuria (in acute intravascular hemolysis). Reticulocyte counts,LDH , Haptoglobin↓ Pre-hepatic (Haemolytic)

Hepatic Jaundice : 

Hepatic Jaundice Due to a disease affective hepatic tissue either congenital or acquired diffuse hepatocellular injury.

Hepatic Jaundice : 

(1)Congenital : *Congenital unconjucated hyperbilirubinemia: Decreased UDPGT activity (Gilbert’s syndrome). Hereditary absence or deficiency of UDPGT (Grigler-Najjar Syndrome). Type I Type II Hepatic Jaundice

Hepatic Jaundice : 

Hepatic Jaundice **Congenital conjucated hyperbilirubinemia: Dubin-Johnson Syndrome. Rotor syndrome.

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Hepatic Jaundice, (cont) (2) Acquried (Hepatocellular). ► Viral Infection. ► Drugs. ► Alcohol. ► Wilson’s disease. ► Hemochromatosis. ► Cirrhosis. ► Multiple hepatic metastasis. ► Hepatic congestion in cardiac failure.

Main features of hepatocellular jaundice : 

Main features of hepatocellular jaundice Symptom Weakness, loss appetite,dark urine. dark stools. Jaundice, hepatomegaly, Palmar erythema, Spider naevi. LAB LFTs  Both unconjugated and conjugated bilirubin. ↑ AST, ALT. ALP – normal or mild ↑. Urine bile pigments ↑.

Biliary Tract : 

Biliary Tract

Post-hepatic (Obstructive) : 

Post-hepatic (Obstructive) It is due to intra or extra hepatic obstruction of bile ducts. Extra-hepatic Gallstones. Carcinoma of the head of pancreas or CBD. Intra-hepatic: Primary Biliary Cirrhosis. Sclerosiing cholangitis. Drugs.

Main features : 

Main features Jaundice. Dark urine. Pale stool. Prurities. Absent Urobilinogen in urine Alkaline phosphatase ↑. cholesterol .

Primary Biliary Cirrhosis (PBC) : 

Primary Biliary Cirrhosis (PBC) ► Slowly progressive autoimmune liver disease. ► 90% females. ► Peak incidence in 40’s. ► Portal inflammation and autoimmune destruction of intrahepatic bile ducts.

Primary Biliary Cirrhosis (PBC) : 

Primary Biliary Cirrhosis (PBC) ►Insidious onset, Fatigue and pruritus most commonn symptoms. ►Pigmented xanthelasma on eyelids, keratoconjunctivities sicca,osteomalacia / osteoporosis. ►Hyperbilirubinemia, jaundice, cirrhosis late ►90-95% have antimitochondrial antibody ( AMA). ►↑ alkaline phosphatase, ↑ cholesterol.

Primary Sclerosing Cholangitis (PSC) : 

Primary Sclerosing Cholangitis (PSC) ► PSC is chronic biliary disease of unknown aetiology charachterized by inflammation, fibrosis and Progressive destruction of bile ducts of inrta & extra biliary system. ► The estimated prevalence of PSC is 20 to 60 cases per 1 million people. ► M:F = 2:1, third through fifth decades. ► 70% associated with inflammatory bowel disease, particularly ulcerative colitis.

Primary Sclerosing Cholangitis (PSC) : 

Primary Sclerosing Cholangitis (PSC) ► Clinically,PSC present asprogresive obstructive jaundice ,frequently associated with malaise,prurities,anorexia,& idigestion .some patients are diagnosed in the presymptomatic phase because of an elevated alkaline phosphatase level. ► The diagnostic test of choice for PSC is cholangiography typically an endoscopic retrograde cholangiogram (ERC). Occasionally, PTC when ERC is unsuccessful. (MRC) has also been used in the diagnosis of PSC. ► Liver biopsy often include the absence of intralobular bile ducts (ductopenia), bile duct proliferation, and periductal fibrosis with an onion-skin fibrosis and nodular fibrous scars

Primary Sclerosing Cholangitis (PSC) : 

Primary Sclerosing Cholangitis (PSC) ► Currently, no medical therapy has been shown to be clearly beneficial in PSC. ► Ursodeoxycholic acid (UDCA) has been shown in small studies to improve symptoms and biochemical tests. ► Up to 20% of patients with PSC will develop jaundice and/or cholangitis caused by a dominant stricture of the biliary tree, which can be treated with balloon dilatation with or without the placement of a biliary stent. ► Liver transplantation is effective for patients who have evidence of end-stage liver disease.

Approach to the jaundiced Patient : 

Approach to the jaundiced Patient

Evaluation of the Jaundiced Patient HISTORY : 

Evaluation of the Jaundiced Patient HISTORY The Following Aspects of the history should be covered. ►Duration of the illness . ►Recent outbreaks of jaundice . ►Intravenous drug abuse, recent injection,blood transfusion. ►Alcohol consumption .

Evaluation of the Jaundiced PatientHISTORY ( cont ) : 

Evaluation of the Jaundiced PatientHISTORY ( cont ) ►Drug Taken . ►Travel. ►Family History. ►Recent Surgery of Biliary Tract or carcinoma. ►Fever or Rigors.

Physical Examination : 

Physical Examination The physical examination should focus primarily on: ► Stigmata of chronic liver disease. ► Marks of itching . ► Charcot’s triad: fever + rigors + jaundice . ► Courvoisier’s Law: obstructive jaundice + palpable gallbladder = malignant cause.

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Certain findings suggest specific diseases such as ►Hyperpigmentation in hemochromatosis. ►A Kayser-Fleischer ring in Wilson's disease. ►Xanthomas in primary biliary cirrhosis.

Evaluation of the Jaundiced PatientLAB EVALUATION : 

Evaluation of the Jaundiced PatientLAB EVALUATION ►LFTs. ►Prothrombin&INR. ►Albumin. ►Viral serologies. ► CBC. ►Glucose. ►Acetaminophen level. ►Ammonia. ►Na-K-PO4, acid-base. ► ANA-ASMA-AMA. ► Quantitative Ig. ► Ceruloplasmin. ► Iron profile. ► Blood cultures.

Evaluation of the Jaundiced Patient : 

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.

Evaluation of the Jaundiced Patient : 

CT ► Better imaging of the pancreas and abdomen. ► is commonly used to identify hepatic masses, particularly small metastases, with an accuracy of about 80%. MRCP ► is more sensitive than CT or ultrasound in diagnosing common bile duct abnormalities, particularly stones. ►Imaging of biliary tree comparable to ERCP. Evaluation of the Jaundiced Patient

Evaluation of the Jaundiced Patient : 

Evaluation of the Jaundiced Patient ERCP Diagnostic: Calculi, tumours, strictures. Biopsy of pancreatic or distal CBD. Therapeutic Extract stones and drain bile. Stent to relieve obstruction.

Evaluation of the Jaundiced Patient : 

Evaluation of the Jaundiced Patient PTC Percutaneous transhepatic cholangiography is valuable when intrahepatic ductal dilatation is present. This procedure can be used to determine the location of biliary tract obstruction.

Liver Biopsy : 

Liver Biopsy Conditions in which needle biopsy is useful include: ► cirrhosis. ► chronic hepatitis. ► granulomatous hepatitis. ► tumors, undiagnosed hepatomegaly. ► cholestasis of unknown cause, infiltrative processes and miliary tuberculosis

JaundiceSummary : 

JaundiceSummary ► Patient’s history of great importance . ► Physical findings can narrow the differential diagnosis. ► Simple Laboratory Tests can focus evaluation. ► Ultrasound important if diagnosis not obvious.

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►Selected Laboratory tests confirms diagnosis and leads to successful treatment. ►Use treatment that is proven to be effective, is of no harm, and where cost is justified.

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Case (1) A 22 –year-old man is asymptomatic and on routine annual check up his serum bilirubin is 6mg/dl , and the unconjugated bilirubin level rises on fasting ,all other liver biochemistry is normal and there are no signs of liver disease.Reticulocyte count is normal.there is family history of jaundice.

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Answer : Gilbert’s syndrome

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Case (2) A 43-year-old woman complains of prurities.on examination she Has hepatomegaly but no jaundice.blood tests reveal a raised serum alkaline phosphatase and antimitochondrial antibodies positive. Pigmented xanthelasma are seen on eyelids.

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Answer : Primary Biliary Cirrhosis (PBC)

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Case (3) A 28- year- old woman present with jaundice.she has conjucated hyperbilirubinemia and liver biopsy shows melanin deposition.

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Answer : Dubin-Johnson Syndrome.

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Case (4) A 29-year-old hypertensive patient on methyldopa for control of high blood pressure .serum bilirubin is 5.5 mg/dl the serum unconjucated bilirubin is raised. Serum transferase,alkaline phosphatase.and albumin are normal.serum haptoglobins are low.

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Answer : Methyldopa- indused intravascular haemolysis

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Case (5) A 25-year-old man present with fever.He has mild jaundice and minor abnormalities of liver biochemistry. Peripheral blood shows atypical lymphocytes .5 days later he undergoes liver biopsy which shows that the sinusoids & portal tracts are infiltrated with large mononuclear cells but the liver architecture is preserved .A paul-Bunnell test is positive.

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Answer : ( Epstein-Barr Virus )

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Thanks..