Evaluation of a patient

with Jaundice
Dr Yousif. A Qari
Assist prof. consultant
gastroenterologist
KAUH, Jeddah, Saudi Arabia
 Definition of Jaundice

Jaundice, as in the French jaune, refers to the

yellow discoloration of the skin.

It arises from the abnormal accumulation of

bilirubin in body tissues, which occurs when the
serum bilirubin level exceeds 3 mg/dL or 50
mmol/L.
 Laboratory Tests

Total and direct bilirubin assays

.
Conjugated Unconjugated
hyperbilirubinemia hyperbilirubinemia
 Causes Of Hyperbilirubinemia

UNCONJUGATED FORM

Hemolysis Uridine diphosphate

Glucose-6-phosphate glucuronosyltransferase
deficiency deficiencies

Pyruvate kinase deficiency Gilbert syndrome

Drugs Crigler-Najjar syndromes (I
and II)
Ineffective erythropoiesis
Miscellaneous causes

Drugs
Neonatal causes
Hypothyroidism
Physiologic abnormalities
Thyrotoxicosis
Lucy-Driscoll syndrome
Pulmonary infarct
Breast milk Fasting
 Causes Of Hyperbilirubinemia

CONJUGATED FORM

Congenital causes Cholestatic

Rotor syndrome
Primary biliary cirrhosis
Dubin-Johnson syndrome Primary sclerosing

Choledochal cysts cholangitis

Biliary obstruction
Familial disorders
Pancreatic disease

Benign recurrent
intrahepatic cholestasis Systemic disease

Cholestasis of pregnancy Infiltrative disorders

Hepatocellular defects Postoperative

Alcohol abuse complications

Viral infection Renal disease

Sepsis Drugs
Several questions must be answered initially

1. Is the elevated bilirubin conjugated or unconjugated?

2. If the hyperbilirubinemia is unconjugated, is it caused by

increased production

decreased uptake

impaired conjugation

3. If the hyperbilirubinemia is conjugated, is the problem

intrahepatic or

extrahepatic?

4. Is the process acute or chronic?

 Conjugated hyperbilirubinemia

Usually acquired disease

Intrahepatic or Extrahepatic (obstructive) cause.

Acute disease usually can be differentiated from chronic disease by the

patient's history, physical examination, and laboratory tests

clinical evaluation

xanthelasma,

spider angioma,

ascites,

hepatosplenomegaly.

Laboratory evidence of chronic disease

Hypoalbuminemia,

Thrombocytopenia,

uncorrectable prolongation of the prothrombin time.
 Cholestasis

Chronic cholestasis may arise from

Cirrhosis,
Primary sclerosing cholangitis,
Primary biliary cirrhosis,

Secondary biliary cirrhosis,

Carcinoma
Drugs.

Acute disease.

New-onset bilirubinuria
Fever
Right upper quadrant pain,
Tenderness,

Hepatomegaly,
Investigation of a patient with jaundice

History of presentation
Medication use
Past medical history
Physical examination
Evaluation of liver function tests
First evaluating a patient with hyperbilirubinemia

Quick assessment of the emergency of the situation

Fever, Asterixis
Leukocytosis Confusion
Hypotension Stupor

severe fulminant
Ascending
hepatocellular hepatocellular
cholangitis
dysfunction failure

Immediate
therapy
 History
Family history of liver disease

Alcohol and drug history

Sexual history

Transfusion history

Nutrition history

Exposure to

Environmental toxins

Persons with jaundice

Drugs (e.g., prescription, nonprescription, intravenous)

,
Outbreaks or epidemics in the community

Previous liver function tests are valuable

History of biliary or pancreatic disease.

 History
Shaking chills or fevers point toward cholangitis or bacterial
infection

Abdominal pain may indicate pancreatic disease, especially if

it radiates to the back

Right upper quadrant ache point toward Viral hepatitis

Weight loss, anorexia, nausea, and vomiting are not helpful

signs because most patients with hepatobiliary disease or
obstruction have anorexia and some weight

Pruritus can be associated with both intrahepatic cholestasis

as well as biliary obstruction.
 History

Age:
< 30 years acute parenchymal disease
> 65 years stones or malignancies
30 - 50 years chronic liver disease
Children and young adults viral hepatitis
 History
Sex:
Men are more likely to develop

Cirrhosis secondary to alcohol

Pancreatic cancer

Hepatocellular carcinoma,

Hemochromatosis

Women are more likely to have

Primary biliary cirrhosis

Gallstones

Chronic active hepatitis

 Physical Examination

Examination of the liver

Examination of spleen

Examination for evidence of stigmata of chronic liver disease

Palmar erythema
Dupuytren contracture
Abnormal nails
Parotid enlargement
Xanthelasmas

Gynecomastia
Spider nevi
Dilated veins.

Jaundice must be differentiated from

Hypercarotenemia
Uremic pigmentation
Picric acid ingestion
Quinacrine therapy
 Physical Examination

Shrunken, nodular liver may cirrhosis

Palpable mass abscess or malignancy

A liver span >15 cm fatty infiltration, congestion

other infiltrative diseases, or malignancy

Liver tenderness acute disease but is generally not

helpful

The presence of a friction rub or bruit malignancy.

 Physical Examination

Spider angioma
palmar erythema
distended abdominal veins indicate cirrhosis
jaundice
Ascites

Acute hepatitis
jaundice Cirrhosis
Ascites Malignancy
 Physical Examination

Infections
Splenomegaly
Infiltrative diseases

A palpable, distended gallbladder malignant biliary obstruction

Fulminant hepatic failure

Asterixis End-stage liver disease

Billiary colic
Fever Infection
 hyperbilirubinemia

LFT Hepatocellular Cholestatic

disease. disease.
Bilirubin levels Usually variable Usually high
Usually < 5mg/dL consistently > 5 mg/dL
Aminotransferases Variable, depending Mild to mod
on the underlying Usually < 400 IU/mL
disease
Alkaline Usually Normal - mild Usually > 3 times (N)
phosphatase
 Diagnosis

The alkaline phosphatase level

When normal extrahepatic obstruction is unlikely

When level is more than three times the normal

cholestasis or extrahepatic obstruction

When markedly elevated together with bilirubin, a

common bile duct stone should be excluded

An elevated level, but with a normal bilirubin may occur

in the presence of a partial extrahepatic or intrahepatic
obstruction
 Diagnosis

G-Glutamyltransferase

Elevated in patients with
Hepatobiliary disease,
Alcohol intake

Protein levels

Help to differentiate acute from chronic liver disease.
Elevated globulin with hypoalbuminemia supports the diagnosis of
cirrhosis

Prothrombin time

Hypercholesterolemia often is seen in patients with cholestasis

Urine tests
Bilirubin
Urobilinogen
 Diagnosis
Second-line tests for jaundice

5-nucleotidase
leucine aminopeptidase
antinuclear antibody
Anti smooth muscle antibody
Immunoglobulins
antimitochondrial antibody
hepatitis serologies
a1-antitrypsin
iron levels
Ceruloplasmin
a-fetoprotein
 Diagnosis

Radiological tests:

Ultrasonography

Stones

Billiary ductal dilatation

Tumour masses, lymph nods etc.

Organomegaly

AsciCtes

CT scan abdomen

Endoscopic Retrograde Cholangiopancreatography (ERCP)

Liver Biopsy
 Common Drugs Associated With
Hyperbilirubinemia
HEPATOCELLULAR CAUSES

Acetominophen Niacin
Alcohol Nifedipine
Amiodarone NSAIDs
Azulfidine Propylthiouracil
Carbenicillin Pyridium
Clindamycin Pyrazinamide
Colchicine Quinidine
Cyclophosphamide Rifampicin
Diltiazem Salicylates
Ketoconazole Verapamil
Methyldopa
 Common Drugs Associated With
Hyperbilirubinemia
CHOLESTATIC CAUSES
Amitriptyline 5-Flucytosine
Androgenic steroids (B) Fluoroquinolones
Atenolol Griseofulvin
Augmentin Haloperidol (D)
Azathioprine Labetolol
Bactrim (D) Nicotinic acid
Benzodiazeprines NSAIDs
Captopril Penicillins
Carbamazole Phenobarbital
Chlordiazepoxide (D)) Phenothiazines (D)
Clofibrate Phenytoin
Coumadin Tamoxifen
Cyclosporine Tegretol
Danazol (B) Thiabendazole (D)
Dapsone Thiazides
Disopyramide Thiouracil
Erythromycin Tolbutamide (D)
Estrogens (B) Tricyclics (D)
Ethambutol Verapamil
Floxuridine Zidovudine
B. bland or noninflammatory cholestasis: D. ductopenic cholestasis or vanishing bile duct syndrome.
Common Drugs Associated With
Hyperbilirubinemia

MIXED CAUSES

Acetohexamide Hydralazine
Allopurinol Lovostatin
Ampicillin Nitrofurantoin
Augmentin NSAIDs
Cimetidine Phenytoin
Dapsone Rifampicin
Disulfiram Thiouracil
Gold Tetracycline
Diagnosis of hyperbilirubinemia.

Patient's history

Physical examination

Laboratory tests