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  1. 1. AIMS: • define jaundice • recognise the associated symptoms of jaundice • look at the diseases which might cause jaundice • look at the management of obstructive jaundice
  2. 2. JAUNDICE: yellow pigmentation of the skin, sclera & mucosa due to increased plasma bilirubin Bilirubin levels: Normal levels are between: 3- 17 μmol/L Jaundice becomes apparent at: >35 μmol/L
  3. 3. Some Anatomy…
  4. 4. right lobe left lobe caudate lobe quadrate lobe POSTERIOR VIEW Fundus Body Cystic duct Hepatic duct Common bile duct GALLBLADDER
  5. 5. Bile The components of bile:  Water  Cholesterol  Lecithin (a phospholipid)  Bile pigments (bilirubin & biliverdin)  Bile salts (sodium glycocholate & sodium taurocholate)  Bicarbonate ions
  6. 6. Hb Unconjugated bilirubin Conjugated bilirubin Bile Hepatic jaundice Unconjugated bilirubin Stercobilin Urobilin Pre-hepatic jaundice Post-hepatic jaundice
  7. 7. - Type of bilirubin - uncongugated (insoluble) - conjugated (soluble) - Site of problem - pre-hepatic - hepatic - post-hepatic Classification of jaundice:
  8. 8. Pre-hepatic jaundice • Pre hepatic jaundice occurs when unconjugated (insoluble) bilirubin is produced in excess or not taken up by the liver. • It results in unconjugated hyperbilirubinaemia.  V ascular  I nfective/inflammatory  N eoplasia  T rauma  A utoimmune  M etabolic  E ndocrine  D rugs  I atrogenic  C ongenital Causes: Haemolytic anaemia Malaria Hereditary spherocytosis Autoimmune red cell destruction
  9. 9. Hepatic jaundice • Hepatic jaundice is caused by disorders of up-take or conjugation of bilirubin. • Results in conjugated and unconjugated hyperbilirubinaemia.  V ascular  I nfective/inflammatory  N eoplasia  T rauma  A utoimmune  M etabolic  E ndocrine  D rugs  I atrogenic  C ongenital Causes: Viral hepatitis Criger-Najjar, Gilbert’s syndrome, Dubin-Johnson syndrome, Rotor syndrome, Wilson’s disease, α1- Antitrypsin deficiency, Haemochromatosis Autoimmune hepatitis Liver mets, Hepatic carcinoma Budd-Chiari, Right heart failure Paracetamol, Anti-TB, Statins, MAO-I. Toxins: CCl4, fungi.
  10. 10. Post-hepatic jaundice (or ‘Obstructive’ or ‘Cholestatic’ jaundice) • Post-hepatic or obstructive jaundice occurs when bilirubin fails to reach the gut. • This results in conjugated bilirubinaemia.  V ascular  I nfective/inflammatory  N eoplasia  T rauma  A utoimmune  M etabolic  E ndocrine  D rugs  I atrogenic  C ongenital Causes: Aortic aneurysm Pancreatic cancer; Cholangiocarcinoma Choledocholithiasis (gallstones) Primary biliary cirrhosis, Primary sclerosing cholangitis Congenital biliary atresia Post-op strictures in bile duct Abx, Anabolic steroids, OCP, Chlorpromazine, Sulphonylureas
  11. 11. Taking a jaundice history Ask about:  Duration of jaundice  Associated pain  Previous episodes of jaundice  Chills, fever, systemic symptoms  Itching (‘pruritis’)  Exposure to prescribed, OTC and illegal drugs  Biliary surgery  Weight loss, anorexia  Colour of stools and urine  History of injections or blood transfusions  Contact with jaundiced patients  Occupation
  12. 12. On examination…  Palmar erythema, clubbing, leukonychia, gynaecomastia, Dupuytren’s contracture (chronic liver disease)  Scratch marks (itching)  Scars of previous surgery (strictures)  Irregular hepatomegaly (hepatic carcinoma)  Palpable gallbladder (carcinoma below cystic duct)  Abdominal masses (carcinomas; cysts in pancreas or gallbladder)
  13. 13. Investigations Blood tests  FBC  U&E  LFT  ALT  ALP  γGT  bilirubin  albumin  INR  Ca++  Antibodies Urine ■ Dipstick Radiology ■ Ultrasound (first-line in jaundice) ■ CT Other investigaions  ERCP  MRCP  PTC  Liver biopsy (last resort: 0.01% mortality)
  14. 14. Findings in obstructive jaundice The 2 most common causes of cholestatic jaundice are: • gallstones • pancreatic carcinoma  Increased ALP & γGT together are strongly indicative of cholestasis.  Bilirubin >19umol/L in blood & bilirubin in urine (must be conjugated)  High INR: absence of bile in intestine poor absorption of vitamin K  Ultrasound can identify both gallstones and pancreatic carcinoma (stones themselves or dilated bile ducts)  CT scan can identify tumours.
  15. 15. Management of obstructive jaunfice It is important to diagnose & manage obstructive jaundice quickly as secondary conditions such as biliary cirrhosis can develop. Depending on the diagnosis: • Conservative • Medical • Surgery: REMOVE BLOCKAGE
  16. 16. Case study: History & Exam  Mr Jones, 76, retired farmer PC/ ‘I have gone yellow’ HPC/ Yellow skin associated with itching. Has lost 1stone over last year and decreased appetite; has noticed pale stools. ROS/ CVS/RS, CNS: Migraines, MS: Rheum-arthritis PMH/ NIDDM, Duodenal ulcers for 5yrs, Inguinal hernia repair ’05. DH/ Omeprazole, rheum pills? FH/ Father died of cancer at 60, can’t remember what type. SH/ Lives with wife, independent in ADL, moderate drinker, non-smoker
  17. 17. O/E End-of-bed-o-gram: looks thin, muscle wasting Hands: nothing of note Face: yellow sclera and buccal membrane Neck: nothing of note Chest: nothing of note Abdomen: • Soft non-tender •RIF scar, 4cm, well healed • Palpable lump under costal margin •Scratch marks
  18. 18. Differential diagnosis  Cancer (weight loss, obstruction)  liver, gallbladder, pancreas  Gallstones (palpable gallbladder)  Aortic aneurysm (epigastric pain)  Gastric/ duodenal ulcers (epigastric pain)
  19. 19. Investigations Bloods  LFTs: raised conjugated bilirubin, γ-glutamyl transpeptidase and ALP levels indicate obstruction  INR of 3  Ca++ : check for bony mets Urine:  Dark coloured, raised bilirubin Radiology  Ultrasound or abdominal CT used to identify tumour.  ERCP to find site of obstruction
  20. 20. Diagnosis: Carcinoma of head of pancreas  Carcinoma of head of pancreas can obstruct the bile duct and often presents as painless obstructive jaundice.  Courvoisier's law defines the presence of jaundice and a painlessly distended gallbladder as strongly indicative of pancreatic cancer, and may be used to distinguish pancreatic cancer from gallstones.  Risk factors: smoking, alcohol, diabetes, male, >60y  Causes ~6500 deaths/year in UK
  21. 21. Management Conservative Talk to patient: pancreatic cancer has a poor prognosis partly because the cancer usually causes no symptoms early on, leading to metastatic disease at time of diagnosis. Medical Fluorouracil, gemcitabine, and erlotinib are the chemotherapeutic drug agents of choice. Surgery The Whipple procedure is the most common surgical treatment for cancers involving the head of the pancreas.
  22. 22. The Whipple Procedure
  23. 23. SummarySummary  Jaundice is a clinical sign in which there is yellow pigmentation of skin, sclera & membranes.  It is caused by hyperbilirubinaemia (>35umol/L).  Hyperbilirubinaemia can be caused by:  too much bilirubin production  defective bilirubin processing  impaired bilirubin passage from liver  gut  Obstructive jaundice requires rapid management and treatment.