jaundice a review

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WELCOME

JAUNDICE : 

JAUNDICE Presented by ----Dr Sibadatta das Guided by---Dr Anupama gupta Dept. of physiology P.G.I.M.S Rohtak

HISTORY : 

HISTORY Origin is unknown In 17th century the word was used for scolding “all appears yellow to an Icteric eye” (ittalian church literature) history of its technical study is also unknown 1950--- It was proved ,Billirubin is produced from degradation of haem,by applying labbeled glycine x

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Watson james– Billirubin is also produced from liver ,spleen ,etc., i.e. non Hb sources Israel & co worker– Billirubin assesment is the measurement of jaundice x

introduction : 

introduction Jaundice comes from the French word jaune, meaning yellow. Jaundice is nothig but Yellow discoloration of tissues from excess circulating bilirubin (>3.0 mg/dL). x

In reality : 

In reality Not a disease – a physical finding jaundice typically appears in a ‘top to bottom' progression (starting with the face, progressing toward the feet). BUT Resolves in a 'bottom to top' manner. x

BILIRUBIN : 

BILIRUBIN End product of haem protein metabolism (70-90)%---- Haem rest----- myoglobin, cyt p 450 x

Bilirubin Metabolism : 

Bilirubin Metabolism Senescent RBCs Bilirubin Bilirubin Diglucuronide RES Hepatocyte Bilirubin +Albumin Circulation UDP-glucuronyltransferase Unconjugated bilirubin Conjugated bilirubin UDP-glucaronyl Active transport Passive difusion Glutathion s transferase g Glutathion s transferase spleen (UGT1A1)

Bilirubin Metabolism : 

Bilirubin Metabolism Senescent RBCs Bilirubin Bilirubin Diglucuronide Bilirubin +Albumin UDP-Glucuronyltransferase Urobilinogen Urobilinogen Bowel ← Ampulla of Vater ← Bile Ducts ← Canaliculus bacteria MRP2 transport protein

Disease Targets : 

Disease Targets Bowel ← Ampulla of Vater ← Bile Ducts ← Canaliculus bacteria Senescent RBCs Bilirubin Bilirubin Diglucuronide RES Hepatocyte Bilirubin +Albumin Circulation UDP-Glucuronyltransferase Urobilinogen MRP2 transport protein

Where is the problem? : 

Where is the problem? Prehepatic Before the liver  hyperbilirubinemia  jaundice Hepatic Cholestasis From uptake into the hepatocyte to delivery into biliary canaliculi  cholestasis  hyperbilirubinemia  jaundice Posthepatic Cholestasis From canaliculi to small bowel  cholestasis  hyperbilirubinemia  jaundice

Prehepatic Targets : 

Prehepatic Targets Senescent RBCs Bilirubin Bilirubin Diglucuronide RES Hepatocyte Bilirubin +Albumin Circulation UDP-Glucuronyltransferase Urobilinogen Small Bowel ← Ampulla of Vater ← Bile Ducts ← Canaliculus Drugs

CAUSE OF PREHEPATIC JAUNDICE : 

CAUSE OF PREHEPATIC JAUNDICE 1.Hemolytic anemia a.Intracorpuscular defects b.Extracorpuscular defects 2.Decresed Hepatic uptake x

Intracorpuscular defects : 

Intracorpuscular defects -Hereditary spherocytosis -Thallasemia n other Hb-pathies -Porphyrias -G-6-PD Deficiency -PNH, etc. x

Extracorpuscular defects : 

Extracorpuscular defects -transfusion incompatibility -malaria n babesia -autoimmune hemolytic disorder -lead poisoning -megaloblastic anemia ,etc. x

Decresed Hepatic uptake : 

Decresed Hepatic uptake Drugs like ; Novobiocin,cholesterographic dyes, flavispedic acids, etc. Physiologic jaundice of new born x

Intrahepatic Targets : 

Intrahepatic Targets Senescent RBCs Bilirubin Bilirubin Diglucuronide RES Hepatocyte Bilirubin +Albumin Circulation UDP-Glucuronyltransferase Urobilinogen Small Bowel ← Ampulla of Vater ← Bile Ducts ← Canaliculus Urobilinogen Hepatocellular diseases

HEPATIC CAUSES : 

HEPATIC CAUSES 1.Hepatitis n Cirrhosis 2.Drugs:pregneninediol,chloramphenicol, gentamycin 3. Breast milk jaundice 4.Physiological jaundice 5. Lucy-driscoll syndrome 6. Criggler najjar syndrome I & II 7. Gillbert syndrome x

Extrahepatic Targets : 

Extrahepatic Targets Senescent RBCs Bilirubin Bilirubin Diglucuronide RES Hepatocyte Bilirubin +Albumin Circulation UDP-Glucuronyltransferase Urobilinogen Small Bowel ← Ampulla of Vater ← Bile Ducts ← Canaliculus Urobilinogen bacteria

POST HEPATIC CAUSES : 

POST HEPATIC CAUSES 1.Gall stone 2.Ca.Head of Pancreas 3.Dubin johnson syndrome 4.Rotor syndrome 5.BRIC Syndrome 6.PFIC –I (Byler’s disease) - II x - III

Clinical feature : 

Clinical feature Scleral icterus Whole body icterus

CORRELATED C\F : 

CORRELATED C\F PRE HEPATIC Mild transient Hyperbillirubinemia Anemia Myelgia,Fatigue HEPATIC Sustained Hyperbillirubinemia nausea vomitting weight loss x

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POST HEPATIC Sustained Hyperbillirubinemia Pruritus Dyspepsia Steatorrhoea with acholoric urine x

POST HEPATIC : 

POST HEPATIC Sustained Hyperbillirubinemia Pruritus Dyspepsia Steatorrhoea with clay stool & dark coloured urine Clay stool Dark urine

LAB DIAGNOSIS : 

LAB DIAGNOSIS BILIRUBIN conjugated Un-conjugated Urine urobillinogen Urine billirubin P P

management : 

management According to cause infection shd be treated iffectively exp;malaria etc enzyme induction can be done by phenobarbitol exp physiologic jaundice,criggler_najjar II, III etc. surgycal cases shd be operated promptly exp: gall stone , Ca panreas head etc. x

REFERENCE : 

REFERENCE Harrison 16th edi. Ganong 21st edi Harper 26th edi Samson’s wright 13th edi Fisher’s ‘’jaundice’’ 1st edi A.K.Jain Indu khurana Welender book of hepatology

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THANKS

R.ES : 

R.ES haem Haem oxygenase biliverdin Hb RBC globin Biliverdin reductase bilirubin

GENERAL CIRCULATION : 

GENERAL CIRCULATION bilirubin bilirubin-albumin complex albumin bilirubin albumin

LIVER : 

LIVER BILIRUBIN GLUTATHION-S- TRANSFERASE (LIGANDIN) BDG & BMG GLUCORONIL SULPH UDPGT