Presentation Jaundice

8/4/2019 Presentation Jaundice

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Definition

1.Jaundice is the yellowish staining of the skin and sclerae (the

whites of the eyes) that is caused by high levels in blood of the

chemical bilirubin.

Jaundice is not a disease but rather a sign that can occur in many

different diseases

The color of the skin and sclerae vary depending on the level of

bilirubin.bilirubin level is mildly elevated, they are yellowish.

bilirubin level is high, they tend to be brown.


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Bilirubin comes from RBC. When red blood cells getold, they are destroyed.

Hemoglobin, the iron-containing chemical in RBCthat carries oxygen, is released from the destroyed RBC

after the iron it contains is removed. The chemical that remains in the blood after the iron

is removed becomes bilirubin.


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There are several causes of jaundice. Jaundice may resultfrom various diseases or conditions that affect the liver.

Some common causes of jaundice are: Hepatitis A

Hepatitis B Hepatitis C Hepatitis D Liver cirrhosis Liver cancer Hepatitis E Hemolytic anemia Gilbert's syndrome (most common hereditary cause of

increased bilirubin,)

Dubin-Johnson syndrome(autosomal recessive disorder whichcauses an increase of conjugated bilirubin without elevationof liver enzymes)

Biliary atresia Malaria
http://www.mamashealth.com/liver/autohep.asp


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1) Too much of bilirubin being produced for the liver toremove from the blood.

2) a defect in the liver that prevents bilirubin from beingremoved from the blood, converted tobilirubin/glucuronic acid (conjugated) or secreted inbile

3) blockage of the bile ducts that decreases the f low of

bile and bilirubin from the liver into the intestines The decreased conjugation, secretion, or flow of bile

that can result in jaundice is referred to ascholestasis(not always result in jaundice).


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Increased production of bilirubin Acute inflammation of the liver Chronic liver diseases Infiltrative diseases of the liver Inflammation of the bile ducts

Blockage of the bile ducts Drugs Genetic disorders Developmental abnormalities of bile ducts

Jaundice of pregnancy


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Types of jaundice are:-

Hemolytic jaundice

Obstructive jaundice

Hepatocellular jaundice

Neonatal jaundice

Breastfeeding jaundice

Breast milk jaundice

Incompatibility jaundice (Rh or ABO blood group

problems


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Hemolytic jaundice(pre-hepatic jaundice) amount of bilirubin that is produced is too much

for the liver to process. It is called hemolytic jaundice because it caused

by excessive hemolysis(breakdown of RBC). Hemoylsis can have many causes, one of which is

hemolytic anemia Hemolytic anemia is a condition in which the RBC

are destroyed earlier than they should be.

-Since bilirubin is mainly formed by the breakdownof hemoglobin,too much breakdown of hemoglobin(RBC are

destroyed) leads to too much bilirubin.


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It is manifested by :

Unconjugated bilurubin in serum

Conjugated bilirubin in bile ,with increasedincidence of bilirubin gallstones

Increased fecal stercobilin and urinary levels.

Unconjugated bilirubin is not excreted in theurine.(acholuric jaundice)


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Pre-hepatic: The pathology is occurring prior theliver

caused by anything which causes an increased rate ofhemolysis(breakdown of RBC).

In tropical countries, malaria can cause jaundice in thismanner.

Certain genetic diseases(sickle cell anemia, and glucose

6-phosphate dehydrogenase)deficiency can lead toincreased red cell lysis and therefore hemolytic jaundice.

Commonly, diseases of the kidney, such as hemolyticuremic syndrome, can also lead to coloration.

Defects in bilirubin metabolism

Jaundice usually comes with high fevers.


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Hepatocellular jaundice

Decrease uptake ,conjugation,or excretion of

bilirubin by the liver. Is manifested by: Elevated conjugated and unconjugated bilirubin in serum

Excretion of bilirubin in urine(common)

Caused by liver failure or acute (sudden)hepatitis(inflammation of the liver).

Gilbert's syndrome(predominantly uncojugated)

Criggler-Najjar syndrome(predominantly

uncojugated)Dubin-Jonson syndrome(predominatly conjugated)

Rotor's syndrome (predominatly conjugated)


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Hepatic: The pathology is located withinthe liver

acute hepatitis, hepatotoxicity and alcoholic liverdisease.

Less common causes include primary biliarycirrhosis, Gilbert's syndrome(a genetic disorder

of bilirubin metabolism which can result inmild jaundice)

Crigler-Najjar syndrome, metastatic carcinoma

and Niemann-Pick disease.Jaundice seen in the newborn, known as neonatal

jaundice


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Obstuctive jaundice


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Is manifested by ; Increased conjugated bilirubin in serum Excretion of bilirubin in the urine Decreased in fecal and urinary urobilinogen levels,due to

failure of bilirubin to reach the intestine. Claycolured stool(complete biliary obstruction)Causes:

Liver cancer. Gallstones (stones in the gallbladder) Cholestasis(obtruction of biliary tract) Carcinoma of head of pancreas/ampulla/bile duct


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Post-Hepatic: The pathology is locatedafter the conjugation of bilirubin in the liver

obstructive jaundice, is caused by an interruption tothe drainage of bile in the biliary system

most common causes are gallstones in the commonbile duct, and pancreatic cancer in the head of the

pancreas.


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Group of parasites known as "liver flukes" live inthe common bile duct

The presence of pale stools and dark urine suggestsan obstructive or post-hepatic cause as normalfeces get their color from bile pigments.

Patients also can present with elevated serum

cholesterol, and often complain of severe itching.


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Newborn Jaundice Most babies have some jaundice during the first week of

life. The ordeal of birth can send many RBC to an early

retirement, and babies livers are often unprepared forthe load.

Before Moms milk comes in and stooling begins in

earnest, bilirubin accumulates more easily. Jaundice is even more common in premature babies.

Pathologic Jaundice occur in children or adults.

It arises for many reasons, including bloodincompatibilities, blood diseases, genetic syndromes,hepatitis, cirrhosis, bile duct blockage, other liverdiseases, infections, or medications.


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Neonatal jaundice is jaundice that begins withinthe first few days after birth.

Bilirubin levels in the blood become elevated inalmost all infants during the first few daysfollowing birth, and jaundice occurs in more thanhalf.

Few infants, the elevation and jaundice representsa normal physiological phenomenon and does notcause problems.

However high bilirubin levels in infancy isharmful: because it can cause bilirubinencephalopathy or kernicterus.


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During life in the uterus = RBC of the fetus contain atype of hemoglobin different from those present afterbirth.

When an infant is born = infant's body rapidly destroythe RBC containing the fetal-type hemoglobin andreplaces with RBC containing the adult-typehemoglobin.

This floods the liver with bilirubin derived from thefetal hemoglobin from the destroyed RBC.


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The liver in a newborn infant is not mature, and itsability to process and eliminate bilirubin is limited.

As a result of both the influx of large amounts ofbilirubin and the immaturity of the liver, bilirubinaccumulates in the blood.

Btw 2-3 wks

destruction of RBC ends,

the livermatures bilirubin levels return to normal.


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Breastfeeding jaundice In infants, jaundice can sometimes be worsened or caused

by breastfeeding.

Occurs between 4-7 after birth, but it can occur more than14 days after birth. An underactive thyroid can also cause jaundice to last for

more than 14 days after birth.How?

infant is not getting enough breast milk. If the infant does not get enough breast milk, the infant

does not grow as much not enough bilirubin leaves thebody and bilirubin level build up.(Bilirubin normally leaves the body when the infant grows

and body system start functioning) Can last for as long as 3-10 weeks.


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Incompatibility jaundice (Rh or ABO blood groupproblems)

There are two blood disorders that can lead tojaundice by causing a rapid breakdown RBC.

Rh incompatibility and ABO incompatibility.

usually observed 1-2 days after birth. Normal jaundice

usually occurs 3 -10 days after birth.


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Physiologic jaundice :-usually first appears when a baby is 2 or 3 days old

- jaundice peaks by day 4 and usually does notcontinue below the belly.

-The rate of bilirubin rises less than 5 mg/dL per day.

-The baby with physiologic jaundice should have no

other symptoms.Pathologic jaundice :-appears earlier, later, rises faster, reaches higher levels,lasts longer, or is accompanied by other symptoms(perhaps vomiting, dark urine, lethargy, weight loss,

abnormal body temperature )-first appears on day 4-6 is often caused by sepsis or aurinary tract infection


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1. Divided into three categories based on where

they start-before, in, or after the liver(prehepatic, hepatic and post-hepatic).

2. These two types of bilirubin are calledunconjugated (insoluble) and conjugated

(soluble). Jaundice often becomes visible on the face when

the bilirubin level is about 5 mg/dL.

It can be seen from the head down to the belly

when the bilirubin is about 15 mg/dL, and all theway to the soles of the feet at about 20 mg/dL.


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The list of signs and symptoms mentioned in various sources forJaundice include :

Yellow skinYellow eyesDark or reddish urineLoss of appetiteBitter taste in mouthFurry tongue

Pale fecesFoul-smelling fecesNauseaItching skinLethargy

Slow pulseConfusion


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Diagnosis


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History and physical examination

Masses (tumors) in the abdomen suggest cancerinfiltrating the liver (metastatic cancer) as the cause of the

jaundice. An enlarged, firm liver suggests cirrhosis

Blood tests

markedly greater elevations of unconjugated bilirubin

relative to elevations of conjugated bilirubin in the bloodsuggest hemolysis (destruction of red blood cells)

Ultrasonography

examination of the abdomen may disclose gallstones,tumors in the liver or the pancreas, and dilated bile ductsdue to obstruction (by gallstones or tumor).

Computerized tomography (CT or CAT scans)

particularly good for identifying tumors in the liver and thepancreas and dilated bile ducts


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Magnetic resonance imaging (MRI)

MRI scans can be modified to visualize the bile ducts better than CT scans(a procedure referred to as MR cholangiography), and, therefore, are better

than CT for identifying the cause and location of bile duct obstruction Endoscopic retrograde cholangiopancreatography (ERCP)

Endoscopic retrograde cholangiopancreatography (ERCP) providesthe best means for examining the bile duct.

For ERCP an endoscope is swallowed by the patient after he or she hasbeen sedated.

ERCP is particularly good at demonstrating the cause and location ofobstruction within the bile ducts. Liver biopsy

diagnosing inflammation of the liver and bile ducts, cirrhosis, cancer, andfatty liver.


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CT Scan


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X-Ray

re- epat c Hepatic Jaundice ost- epat c


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pJaundice

Hepatic Jaundice pJaundice

Total bilirubinNormal /

IncreasedIncreased Increased

Conjugated

bilirubinNormal

Normal /

DecreasedIncreased

Unconjugated

bilirubin

IncreasedNormal /

Increased

Normal

Urobilinogen IncreasedNormal /

Increased

Decreased /

Negative

Urine Color Normal Dark Dark

Stool Color Normal Normal Pale

Alkaline

phosphatase levelsnormal normal increased

Alanine transferase


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T


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Treatment The treatment of jaundice in adults and older children

will depend on the underlying condition that iscausing it.

After having a number of different tests to determinethe cause of jaundice, the appropriate treatment will

be recommended.


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1) Phototherapy

~ Bili lights


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therapeutic procedure performed on newborn orpremature infants to reduce elevated levels ofbilirubin.

placed under special lights known as billilights.The lights may be blue, green, or white.

Biliblanket

infant placed under a blanket that produces light,known as a biliblanket.

Lights are used because light helps to break down

bilirubinBreastfeeding ( stop or not )

Most doctors do not recommend stoppingbreastfeeding in infants that have jaundice.


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Biliblanket


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3) Immunoglobulins

immunoglobulins also known as antibodies

through the infant's veins to decrease the bilirubinlevel

4) Blood exchange transfusion

if the bilirubin levels get too high, a bloodexchange transfusion can be done,

infant's blood is exchanged with donated bloodthat does not contain a high level of bilirubin.

Extremely premature infants may need an urgentblood exchange transfusion if their bilirubin levelsget dangerously high


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Feed babies frequently and don't let them becomedehydrated.

With jaundice, the important thing to prevent iskernicterus a toxic levels of bilirubin accumulating

in the brain. Early identification and treatment of jaundice will

usually prevent kernicterus, whatever the cause.

Beyond this, jaundice is a symptom of otherproblems that have their own preventionstrategies.


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1. Can worsen and affect other parts of the body.2. In newborns, untreated jaundice can cause kernicterus.

3. Severe untreated jaundice leading to kernicterus may resultin the following:

mental retardation cerebral palsy deafness Death

4. Untreated biliary atresia leads to biliary cirrhosis, aprogressive, irreversible scarring of the liver, by about twomonths of age


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Presentation Jaundice