1 / 19

Jaundice

Jaundice . http://thestandard.org.nz/wp-content/uploads/2010/09/Dr-Nick-Riviera.png. Steven Smith. Objectives. Bilirubin Physiology Jaundice Definitions Jaundice Presentation History and examination Investigations & Interpretation Differential Diagnosis Approach to differential

adanne
Download Presentation

Jaundice

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Jaundice http://thestandard.org.nz/wp-content/uploads/2010/09/Dr-Nick-Riviera.png Steven Smith

  2. Objectives • Bilirubin Physiology • Jaundice Definitions • Jaundice Presentation • History and examination • Investigations & Interpretation • Differential Diagnosis • Approach to differential • Key diagnoses

  3. Bilirubin Metabolism Longmore M. Wilkinson I. Turmezei T. Cheung CK. Oxford Handbook of Clinical Medicine 8th edition

  4. Jaundice • Yellow pigmentation of the skin, sclerae and mucosae • Caused by excess circulating bilirubin • Normal serum bilirubin is 3 to 17 μmol/L • Detectable clinically when serum bilirubin is greater than 35μmolL-1

  5. Some Definitions • Prehepatic - excessive production of bilirubin • Hepatic - Pathology within hepatocytes • Post hepatic - Problem with biliary flow • Conjugated (direct)- Accumulation of conjugated bilirubin • Unconjugated (indirect)- Accumulation of unconjugated bilirubin • Obstructive - Lack of bile flow

  6. http://en.wikipedia.org/wiki/File:Jaundice08.jpg Patient presenting with jaundice

  7. History • Presenting complaint • Acute or chronic • Associated features • Pain (RUQ), Nausea +/- vomiting, Puritis (itch), Fever, Dark Urine, Diarhoea, Steatorrhoea, Weight loss, Night sweats, Loss of Appetite • Past medical History • Gallstones, Liver disease, Haemophilia, Recent transfusion, Ulcerative Colitis, Diabetes Mellitus, Emphysema • (Psychosis)

  8. History • Medications (including OTC & herbal) • Haemolysis • Cephalosporins – 3rd generation • penicillin • aspirin • Hepatitis • Paracetamol overdose • Rifampacin, isoniazid • Cholestasis • Antibiotics: beta-lactams (flucloxacillin) • Chlorpromazine 

  9. History • Social History • Alcohol consumption – units per week • IVDU • Unprotected sex/multiple partners • Foreign travel – malaria, hep A or E • Tattoos • Ethnic background & country of birth • Sickle cell • Thalassaemia & G-6-PDH deficiency • Family History • Jaundice, Liver disease, cancer or haemolytic anaemia.

  10. Examination • Signs of: • Chronic liver disease • Haemolysis • Biliary obstruction • Features indicative of specific disease • Kayser-Fleisher rings in iris • Bronzed tan • Cachexia • Murphy’s Sign

  11. Investigations • 1st Line • Bloods - FBC, LFT’s, U+E’s, Clotting, Amylase • Urinalysis – bilirubin • 2nd Line • Imaging – USS • Further Bloods - Blood film, Viral Serology Autoimmune screen, Ferritin and transferrin, Cu and Caeruloplasmin • 3rd Line • MRCP/ERCP • Liver biopsy – USS or CT guided

  12. Bloods – Liver enzymes • Bilirubin levels • Confirm hyperbilirubinaemia • >20% bilirubin conjugated – suggests obstruction to flow • ALT and AST • Raised if there is damage to hepatocytes • Normal level in serum = <40U/L • Very high in acute hepatocellular damage/necrosis • 8-20 fold above normal (ALT>AST) • Milder rise in chronic liver disease or extrahepatic obstruction • Alkaline Phosphatase and γ-GT • Released from damage to biliary epithelial cells • Alk phos also from bones with high turnover and placenta • γ-GT almost exclusive to biliary cells

  13. An Overview Differential Diagnosis http://www.flickr.com/photos/jeffpro/5084387279/

  14. Differential Diagnosis • 3 main problems • Increased bilirubin production • Intravascular haemolysis • Extravascular haemolysis • Decreased conjugation • Reduced hepatocyte uptake • Enzymatic problems • Decreased excretion • Can’t be excreted into bile canaliculi • Can’t pass through biliary tree Unconjugated Conjugated

  15. Differential Diagnosis

  16. Differential Diagnosis

  17. Differential Diagnosis

  18. http://i102.photobucket.com/albums/m83/lavopal/Jaundice-Hulk.jpghttp://i102.photobucket.com/albums/m83/lavopal/Jaundice-Hulk.jpg

  19. References • Oxford handbook Clinical Medicine • Oxford handbook for the foundation programme • Oxford cases in medicine and Surgery • Kumar and Clark • BMJ Best Practice

More Related