Jaundice
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Jaundice. Tad Kim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222. Overview. Normal Physiology Pathophysiology Broad Differential Diagnosis DDx of Obstructive Jaundice Work-up for “Medical” Jaundice Work-up if Obstructive Jaundice Treatment of Obstructive Jaundice.

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Jaundice

Jaundice

Tad Kim, M.D.

UF Surgery

[email protected]

(c) 682-3793; (p) 413-3222


Overview

Overview

  • Normal Physiology

  • Pathophysiology

  • Broad Differential Diagnosis

  • DDx of Obstructive Jaundice

  • Work-up for “Medical” Jaundice

  • Work-up if Obstructive Jaundice

  • Treatment of Obstructive Jaundice


Normal physiology

Normal Physiology

  • Bilirubin is from breakdown of hemoglobin

  • Unconjugated bilirubin transported to liver

    • Bound to albumin because insoluble in water

  • Transported into hepatocyte & conjugated

    • With glucuronic acid → now water soluble

  • Secreted into bile

  • In ileum & colon, converted to urobilinogen

    • 10-20% reabsorbed into portal circulation and re-excreted into bile or into urine by kidneys


Pathophysiology

Pathophysiology

  • Jaundice = bilirubin staining of tissue @ lvl greater than ~2

  • Mechanisms:

    • ↑ production of bilirubin

    • ↓ hepatocyte transport or conjugation

    • Impaired excretion of bilirubin

    • Impaired delivery of bilirubin into intestine

      • “surgically relevant jaundice” or obstructive jaundice

    • “Cholestasis” refers to the latter two, impaired excretion and obstructive jaundice


Broad differential diagnosis

Broad Differential Diagnosis


Ddx unconjugated bilirubinemia

DDx: Unconjugated bilirubinemia

  • ↑production

    • Extravascular hemolysis

    • Extravasation of blood into tissues

    • Intravascular hemolysis

    • Errors in production of red blood cells

  • Impaired hepatic bilirubin uptake(trnsport)

    • CHF

    • Portosystemic shunts

    • Drug inhibition: rifampin, probenecid


Ddx unconjugated bilirubinemia1

DDx: Unconjugated bilirubinemia

  • Impaired bilirubin conjugation

    • Gilbert’s disease

    • Crigler-Najarr syndrome

    • Neonatal jaundice (this is physiologic)

    • Hyperthyroidism

    • Estrogens

    • Liver diseases

      • chronic hepatitis, cirrhosis, Wilson’s disease


Ddx conjugated bilirubinemia

DDx: Conjugated Bilirubinemia

  • Intrahepatic cholestasis/impaired excretion

    • Hepatitis (viral, alcoholic, and non-alcoholic)

      • Any cause of hepatocellular injury

    • Primary biliary cirrhosis or end-stage liver dz

    • Sepsis and hypoperfusion states

    • TPN

    • Pregnancy

    • Infiltrative dz: TB, amyloid, sarcoid, lymphoma

    • Drugs/toxins i.e. chlorpromazine, arsenic

    • Post-op patient or post-organ transplantation

    • Hepatic crisis in sickle cell disease


Ddx obstructive jaundice

DDx: Obstructive Jaundice

  • This is the slide to remember for surgeons

  • Obstructive Jaundice– extrahepatic cholestasis

    • Choledocholithiasis (CBD or CHD stone)

    • Cancer (peri-ampullary or cholangioCA)

    • Strictures after invasive procedures

    • Acute and chronic pancreatitis

    • Primary sclerosing cholangitis (PSC)

    • Parasitic infections

      • Ascaris lumbricoides, liver flukes

  • Just remember top 5 (not parasites)


Initial evaluation history

Initial Evaluation: History

  • Jaundice, acholic stools, tea-colored urine

  • Fever/chills, RUQ pain (cholangitis)

    • Could lead to life-threatening septic shock

  • Reasons to have hepatitis or cirrhosis?

    • Alcohol, Viral, risk factors for viral hepatitis

  • Exposure to toxins or offending drugs

  • Inherited disorders or hemolytic conditions

  • Recent blood transfusions or blood loss?

  • Is patient septic or on TPN?

  • Recent gallbladder surgery? (CBD injury)


Initial evaluation physical exam

Initial Evaluation: Physical Exam

  • Signs of end stage liver disease (cirrhosis)

    • Ascites, splenomegaly, spider angiomata, and gynecomastia

  • Jaundice evident first underneath the tongue, also evident in sclerae or skin

  • Courvoisier’s sign = painless, but palpable or distended gallbladder on exam

    • Could indicate malignant obstruction


Screening labs

Screening Labs

  • NL LFT r/o hepatic injury or biliary tract dz

    • Consider inherited disorders or hemolysis

  • ↑Alk Phos moreso than AST/ALT implies “cholestasis” (intrahepatic vs obstruction)

    • ↑Alk Phos also seen in sarcoid, TB, bone

    • In this case, GGT is specific for biliary origin

  • Predominant ↑AST/ALT implies intrinsic hepatocellular disease

    • AST/ALT ratio > 2 in alcoholic hepatitis

  • ↓albumin or ↑INR c/w advanced liver dz


Subsequent labs

Subsequent Labs

  • If no concern for obstructive jaundice:

    • Viral (Hep B&C) serologies for viral hepatitis

    • anti-mitochondrial Ab (PBC)

    • anti-smooth muscle Ab (Auto-immune)

    • iron studies (hemochromatosis)

    • ceruloplasmin (Wilson’s)

    • Alpha-1 anti-trypsin activity (for deficiency)


Imaging for obstructive jaundice

Imaging for Obstructive Jaundice

  • RUQ Ultrasound

    • See stones, CBD diameter

  • CT scan

    • Identify both type & level of obstruction

  • ERCP

    • Direct visualization of biliary tree/panc ducts

    • Procedure of choice for choledocholithiasis

    • Diagnostic –AND- therapeutic (unlike MRCP)

  • PTC useul of obstruction is prox to CHD

  • Endoscopic Ultrasound or EUS


Treatment

Treatment

  • If Medical, then treat the etiology

  • If Obstructive Jaundice:

    • Should r/o ascending cholangitis, ABC/resusc

      • For cholangitis: IVF, IV Antibiotics, Decompression

    • Stones (remove stones vs stent vs drainage)

      • Done via ERCP or PTC or open (surgery)

    • Benign stricture (stent vs drainage catheter)

    • Cancer (Stent vs drainage +/- resect the CA)

  • The key principle is decompression, either externally(drainage) or internally(stenting) the duct open to allow better drainage


Take home points

Take Home Points

  • Above is a comprehensive approach

  • For surgery clerkship, all you need to know is:

    • 1. Broad categories (no specific diagnoses)

    • 2. The four DDx of obstructive jaundice

    • 3. H&P (ask about fevers/chills, jaundice, acholic stools, dark urine, weight loss for CA), r/o ascending cholangitis = emergency

    • 4. Labs (LFT: ?cholestatic, CBC w diff, BMP)

    • 5. Imaging (U/S, CT, MRCP, EUS)

    • 6. Therapy (ERCP vs PTC vs surgery)


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