Approach to Jaundice
Prof khan Abul Kalam Azad
Professor of Medicine
Principal
PMCH
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Jaundice
Definition:
• Jaundice, also known as icterus
• It may be defined as the yellow discoloration of the
sclera, skin and mucous membranes due to elevation
in serum bilirubin level.
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• The term jaundice is from the French word
jaunisse, meaning "yellowish".
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• Bilirubin is formed from the catabolism of
haemoglobin and other haem- containing
compounds.
• Normal bilirubin level 0.2-1.2 mg/dl.
• Indirect -0.2-0.7 mg/dl.
• Jaundice becomes clinically apparent when S.
bilirubin level rises to about twice the upper
limit of normal or ≥ 2.5- 3.0 mg/dl
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Cont’d
• Bilirubin is deposited particularly in those
tissues which contain elastin.
• The sclera is rich in elastin
• Jaundice is the only condition causing yellow
sclera.
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• Other cause of yellow discoloration of the skin
but where the sclera remain normal are
1. Carotenaemia (carrots, mangoes)
2. Acroflavine
3. Fluoroscein
4. Picric acid ingestion.
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Sites to look for jaundice:
-Sclera (upper)
-Under surface of the tongue
-Palms of the hands
-Soles of the feet
-Skin (in general)
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Aetiology
Any disorder that affects
– Bilirubin production
– Uptake
– Conjugation
– Secretion by the hepatocytes
May result in hyper bilirubinaemia and
jaundice.
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Classification of Jaundice
Jaundice
Unconjugated Conjugated
↑Bilirubin production: ↓ Uptake and conjugation of
-Haemolytic anaemias bilirubin:
-Haemolytic reactions -Gilbert’s syndrome
-Ineffective erythropoiesis -Crigler-najjar syndrome
-Haematomas -Physiologic jaundice of the
newborn
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Conjugated
. Intra hepatic
Hepatocellular diseases -Cholestatic phase of v. hepatitis
-Viral hepatitis -Drugs & hormones (oral pills)
-Drugs and hepatotoxins -Pregnancy
-Alcoholic hepatitis -Primary biliary cirrhosis
-Ischaemia
-Metabolic disorders (Wilson’s disease,
haemochromatosis)
Extrahepatic
-Choledocholithiasis
--Bile duct stricture
Cholestasis --Ca head of the pancreas
--Sclerosing cholangitis
--portal lymphadenopathy
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Pathophysiologic classification of
Jaundice
◼ Hemolytic/ Pre hepatic Jaundice
◼ Hepatocellular/ Hepatic Jaundice
◼ Obstructive Jaundice(Cholestasis)/ Post
hepatic jaundice/ surgical jaundice
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Hemolytic Jaundice
• Pre-hepatic jaundice is caused by anything which
causes an increased rate of hemolysis
(breakdown of red blood cells).
• Unconjugated bilirubin comes from the
breakdown of the heme pigment found in red
blood cells' hemoglobin. The increased
breakdown of RBC leads to an increase in the
amount of unconjugated bilirubin present in the
blood and deposition of this unconjugated
bilirubin into various tissues can lead to a
jaundiced appearance
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Jaundice due to haemolysis is usually mild
because a healthy liver can excrete a bilirubin
load six times greater than normal before
unconjugated bilirubin accumulates in the
plasma.
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Classical triad of haemolytic jaundice
1. Mild Jaundice
2. Moderate anaemia
3. Huge splenomegaly
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Hepatic Jaundice
Due to a disease affective hepatic tissue
either congenital or acquired diffuse
hepatocellular injury
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Aetiology of Hepatocellular jaundice-
• Viral hepatitis, liver cirrhosis
• Drugs and hepatotoxins
• Alcoholic hepatitis
• Metabolic disorders eg- Wilson’s disease,
haemochromatosis
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Obstructive Jaundice
• Post-hepatic jaundice, also called obstructive
jaundice, is caused by an interruption to the
drainage of bile containing conjugated
bilirubin in the biliary system.
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Obstructive Jaundice
Pathogenesis
It is due to intra- and extra hepatic
obstruction of bile ducts
• intrahepatic Jaundice: Hepatitis, PBC, Drugs
• Extra Hepatic Biliary Obstruction: Stones,
Stricture, Inflammation, Tumors, (Ampulla
of Vater)
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Etiology of Obstructive Jaundice
a. Intrahepatic- Liver cell Damage/Blockage of
Bile Canaliculi
• Drugs or chemical toxins
• Dubin-Johnson syndrome
• Estrogens or Pregnancy
• Hepatitis-viral, chemical
• Infiltrative tumors
• Intrahepatic biliary hypoplasia or atresia
• Primary biliary cirrhosis
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Etiology of Obstructive Jaundice
b. Extrahepatic-
1. In the lumen-
✓stone in common bile duct
( choledocholithiasis)
✓ biliary ascariasis
2. In the wall-
✓ cholangiocarcinoma
✓ biliary stricture
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3. outside the wall-
✓ Carcinoma head of the pancreas
✓ enlarged lymph node
✓ periampullary carcinoma
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Clinical features and complications of
cholestatic jaundice
A. Cholestasis
a. Early features
• Jaundice
• Dark urine
• Pale stools
• Pruritus
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b. Late features
• Malabsorption (vitamins A, D, E and K):
✓weight loss,
✓Steatorrhoea (loose, pale, bulky, offensive
stools )
✓osteomalacia,
✓bleeding tendency
• Xanthelasma and xanthomas
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B. Cholangitis:
• Fever
• Rigors
• Pain (if gallstones present)
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Cholangitis is characterised by
‘Charcot’s triad’ of
1. jaundice,
2. right upper quadrant pain
3. fever
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Diagnostic approach
• The jaundiced patient represents a diagnostic
challenge initially approached with
– A careful history
– physical examination
– Appropriate laboratory studies.
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A. History-
• Age
• Sex
• Occupation
• Mode of onset of jaundice
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History- Cont’d
• Fever
• Abdominal pain
• Any symptoms like headache, anorexia, nausea
vomiting preceding jaundice.
• Dark urine, stool colour.
• itching
• Recurrent jaundice
• Medications presently using
• Drug abuse (i.v.drugs)
• Transfusion of blood and blood products
• Alcohol use.
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History- Cont’d
• Exposure to persons with jaundice.
• Sexual preference and activity
• Accidental purposeful needle sticks (dentist,
tattoing)
• Previous biliary tract surgery
• Family history of liver disease, jaundice
• Prior history of liver disease or abnomral liver
function test
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Physical Examination
• 1. General examination
– Appearance
– Anaemia
– jaundice
– Clubbing
– Leukonychia
– Oedema
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Physical Examination -Cont’d
• Skin
* Palmar erythema
*Purpura
*Scratch marks
*Spider angioma
*xanthoma/xanthalesmas
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• gynaecomastia
• hair loss.
• temperature
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Cont’d
• 2. Abdomen
-Hepatomegaly
Tender/nontender
-Splenomegaly
-Abdominal mass
-Ascites
-Caput medusae
-Abdominal scar
-Testicular atrophy
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Cont’d
3. Nervous system
– Any alteration in
• level of consciousness
• Behavior
• Sleep pattern
– Other feature of hepatic encephalopathy
– Kayser-Fleischer rings
4.Others
– Urine colour
– stool colour
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THANK YOU
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