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JAUNDICE. By Anfal Gadour. Objectives. Definition of Jaundice Bilirubin Metabolism Investigations Categories Common causes and management. What do you already know?. How would you define jaundice?

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JAUNDICE

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JAUNDICE

By Anfal Gadour


Objectives

  • Definition of Jaundice

  • Bilirubin Metabolism

  • Investigations

  • Categories

  • Common causes and management


What do you already know?

  • How would you define jaundice?

  • What is the difference between conjugated and unconjugated bilirubin?

  • How would you class the different causes of jaundice?

  • What would you ask about in the history?

  • What would you look for on examination?

  • What is corvorsiers law?

  • What are the most important investigations?


Jaundice (icterus)

  • Definition: Yellow discoloration of the skin and mucous membranes

  • Due to increased Bilirubin concentration in the body

  • Detectable when plasma levels are greater than 50 micromol/l (normal 3-17)


Bilirubin Metabolism

  • Haemoglobin

GLOBIN

FE 2+

LIVER

BILE

SI


Investigations

  • LFTS: Bilirubin, ALP, AST, ALT, GGT

  • USS abdo: GB, Cystic Duct, mass

  • ERCP/MRCP: Stone, Biliary system


Categories

  • Prehepatic

  • Hepatic

  • Posthepatic


Prehepatic

  • Due to Haemolysiscausing increased bilirubin production

  • Decreased uptake by liver

  • Decreased conjugation

  •  unconjugated bilirubin builds up in blood

  • Water insoluble – therefore doesn’t enter urine

  • Causes: Physiological (neonates), haemolysis, Gilberts syndrome


Hepatic/Hepatocellular

  • Hepatocyte Damage

  • Causes: hepatitis, alcoholic hepatitis, liver cirrhosis, liver metastases, rarer: haemochromatosis, AIH


Posthepatic

  • Obstructive jaundice

  • Common bile duct is blocked

  • Bilirubin overspills into blood – build up of conjugated bilirubin

  • Water soluble – excreted in urine – dark

  • Less conjugated bilirubin can reach the bowel – pale stools

  • If severe – pruritus

  • Causes: common bile duct stones, pancreatic cancer


Gallstones

  • Present in 10-20% of population

  • Cholesterol and mixed

  • Usually asymptomatic

  • Risk factors: 4F’s

  • Complications..


Biliary colic

  • Pain associated with temporary obstruction of cystic or CBD by a stone

  • Severe constant pain, subsides over several hours

  • Pain radiates to right shoulder. Vomiting

  • Examination normal

  • Diagnosis: hx, raised ALP and bilirubin. ABSENCE OF INFLAMMATORY FEATURES.

  • Manage: analgesia, elective cholecystectomy


Acute Cholecystitis

  • Stone in cystic duct or GB neck

  • Hx similar to biliary colic.

  • However, progresses to constant severe pain in RUQ

  • Fever, tenderness and guarding

  • Murphys sign

  • INFLAMMATORY FEATURES – rasied WCC, fever, deranged LFTS, USS

  • Manage conservatively: NBM, IV fluids, Analgesia, IV abx

  • Cholecystectomy


Ascending Cholangitis

  • Infection on biliary tree

  • Charcots triad – RUQ pain, Fever, Jaundice

  • Dark urine, pale stools, pruritus

  • Inv: raised WCC, Blood cultures, Deranged LFTS, USS, CT, ERCP

  • Manage: Fluid resus, Analgesia, IV abx, ERCP


Pancreatic cancer

  • Painless Jaundice

  • Older

  • Pale stools, dark urine

  • Weight loss

  • Palpable GB?

  • Usually head of the pancreas

  • Diagnosed on CT

  • Poor prognosis


  • Any Questions?


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