Hospital Based Practice – Jaundice.

• Jaundice is yellow discolouration of the skin sclera and mucous membranes.

• Occurs when serum bilirubin > 30 μmol/L.
• Normal bilirubin metabolism is as follows.
o Erythrocytes are broken down in reticulo – endothelial system
o Biliverdin is released.
o Unconjugated (water insoiluble) bilirubin binds to albumin and is transported to the liver.
o Liver conjugates bilirubin with glucuronic acid
o Conjugated bilirubin excreted in bile into terminal ileum.
o Bacterial action on bilirubin converts it to urobilinogen
 Some recycled in enterohepatic circulation.
o Some enters systemic circulation, and excreted by the kidneys.
o Some remains in large bowel, oxidised to stercobilinogen and excreted in faeces.
• Jaundice can arise from.
o Increased haemolysis
o Disordered bilirubin excretion
o Reduced bilirubin excretion.

• Differential diagnosis
Pre – hepatic Hepatic Post – hepatic
Acute liver damage Chronic liver damage Intrahepatic Extrahepatic
obstruction opbstruction
• Haemolysis • Viral infections. • Inherited disease. • Gallstones • Primary biliary
• Inherited o Hepatitis o Primary • Carcinoma. cirrhosis
metabolic o EBV haemochromat o Bile duct • Alcohol
defects o CMV osis o Head of • Viral hepatitis
• Non – viral infections o Wilson’s pancreas • Drugs
o Leptospirosis disease o Ampulla of o COCP
• Drugs. o α–1 Vater • Pregnancy
o Paracetamol antitripsin • Sclerosing
o Alcohol deficiency.
cholangitis
• Alcohol
• Pregnancy • Benign stricture.
• Methorexate
• Shock o Post – ERCP
• Chronic infections • Pancreatitis
• Cryptogenic • Biliary atresia
• Autoimmune
hepatitis
• Metastatic
carcinoma
• Vascular
congestion.
o Budd – Chiari
o Right heart
failure

• Pre – hepatic jaundice is normally due to haemolysis.

• Hepatic jaundice also tends to cause some cholestasis.
o Pale stools
o Dark urine.
History
• Underlying cholestasis
o Itching
o Pale urine
o Dark stools
• Duration of illness.
o Viral hepatitis gives short history of
 Malaise
 Anorexia
 Myalgia
o Carcinoma likely if
 Elderly patient
 Prolonged history
 Weight loss
 Anorexia
• Abdominal pain.
o Biliary colic commonly due to gallstones.
 Episodice
 Colicky
 Right hypochondrium
o Pancreatic CA can cause pain that is.
 Dull
 Persistant
 Epigastric or central
 Radiating to back
• Signs of severe infection suggest cholangitis
o Fevers
o Rigors
• Take full recent drug history.
o Especially
 Paracetamol
 Alcoholl
 COCP
• Infectious contacts.
o Unsafe sex
o Injecting drugs
o Tattoos
o Seafood
o Anal sex.
• Recernt foreign travel
• Recent surgery.
o Halothane risk
o Surgery for known malignancy
o Biliary stricture due to ERCP
• Occupational history.
o Sewer workers at risk of leptospirosis
• Family history of recurrent jaundice.
o Inherited haemolytic anaemia
 o Gilbert’s syndrome.

Examination.
• The main points to determine in the examination of the jaundiced patient is.
o Is there any evidence of encephalopathy?
o Is this an acute on chronic problem?
o Are there signs of any specific disorder?

• Following factors suggest encephalopathy.

o Drowsiness.
 Eventually will progress to stupor and coma
o Slurred speech
o Asterixis.
 Flapping tremor of the outstretched hands.
o Seizures
o Constructive apraxia.
 Tested by asking patient to copy a 5 – pointed star.
o Hepatic fetor.

o Encephalopathy can arise as a result of.

 Fulminating hepatic failure
 Decompensation of chronic hepatic failure.
• Precipitating factors include.
o Constipation
o Vomiting and diarrhoea
o GI bleeding
o Intercurrent infection
o Alcohol
o Morphine
o Surgery
o Electrolyte imbalance.

• Signs of chronic liver disease include.

o Palamr erythema
o Signs of hypoalbuminaemia.
 Leuconychia
 Oedema
o Clubbing
o Dupuytren’s contractures.
 Particularly in alcoholic cirrhosis
o Spider naevi
 Greater than five in the distribution of the superior vena cava.
o Scratch marks.
 May suggests itching of cholestasis.
o Oestrogen excess
 Gynaecomastia.
 Loss of body hair
  Testicular atrophy
o Brusing.
 Disordered coagulation
o Hepatomegaly.
 May not be present in established liver disease.
o Signs of portal hypertension
 Splenomegaly
 Ascites
 Caput Medusae.

• Signs of specific diseases

o Xanthelasmata.
 Primary biliary cirrhosis
o Kayser – Fleischer rings.
 Wilson’s disease
o Hard, irregular hepatomegaly.
 Malignant metasteses
o Palpable gall bladder.
 Carcinoma of head of pancreas
 Courvoisier’s law.
o Parotid gland enlargement.
 Alcohol
o Needle marks or tattoos.
 Hepatitis B or C.

Investigations.
• First priority is to determine the type of jaundice that the patient has.
• Next priority is to determine which specific aeitiology.

Specimen Test Haemolysis Hepatocellular Cholestasis

Urine Urobilinogen Raised Normal or raised Decreased or absent
Conjugated bilirubin Absent Present Raised
Faeces Stercobilinogen Raised Normal or Decreased or absent
decreased
Serum Bilirubin Unconjugated Both unconjugated Conjugated
and conjugated
forms
Raised liver enzymes Normal AST, ALT Alkaline phophatase, GGT.

• Also do abdominal US to exclude biliary obstruction.

• Hepatic synthetic function can be monitored with.
o Serum albumin
 Will be altered by other inflammation.
o Prothrombin time.
 Important to check this before any invasive procedures are performed.

• Tests for specific aetiologies.

o Haemolysis screen.
o F
o Hepatocellular screen.
 Viral serology.
 • Hepatits A, B & C
• EBV
• CMV
 Autoantibody screen.
• Antimitochondrial antibodies
• Antinuclear antibodies.
 Ferritin.
• Haemochromatosis
 Serum caeruloplasmin
 Urinary copper excretion
 α1 – antitrypsin
 Liver biopsy.
• Definitive diagnostic test for intrinsic liver disease.

o Cholestasis screen.
 ERCP and percutaenous transhepatic cholangiography.
• Gives detailed information about bilary tree
• Also used for therpeutics, such as stent insertion.
 CT scan.
• Good imaging of pancreas, which is often poorly visualised on US
scan.
 MRCP & endoscopic US
• Modern techniques.
• Give accurate imaging of pancreas and biliary tree.