approach to jaundice patient
TRANSCRIPT
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Approach to theJaundiced
Patient
By:Dr. Berhane Redae
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Introduction :
not a common presentingcomplaint in adults . whenpresent, it may indicate a serious
problem. Patients with jaundice may
present with no symptoms at allor they may present with a life-threatening condition
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variety of underlying causes.
Viral hepatitis
Alcoholic liver disease
Autoimmune hepatitis
Medication-induced liver disease
Common bile duct stones
Pancreatic cancer Primary Biliary Cirrhosis (PBC)
Primary Sclerosing Cholangitis (PSC)
A systematic approach is warranted toclarify the cause quickly so that treatmentcan begin as soon as possible
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Jaundice
Definition: Jaundice Yellowish colouration of
sclera,mucous membrane & skin.
It is Symptom not a disease.
Literally, means yellow.
Caused by high Bilirubin.
Normal range 0.3-1.2 mg /dL.
Clinically obvious 2.5 mg /dl.
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Bilirubin
Bilirubin is formed by a b/downproduct of heme rings.
Approximately 80 % of the
heme moiety comes fromcatabolism of red blood cells.
Remaining 20 % resulting fromineffective erythropoiesis andbreakdown of muscle myoglobinand cytochromes.
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Causes of hyperbilirubinemia :
Overproduction by reticuloendothelial
system.
Failure of hepatocyte uptake.
Failure to conjugate or excrete.
Obstruction of biliary excretion into
intestine.
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Pre-hepatic (Haemolytic):
Excessive haemolysis due to any cause:
RBC disorder
Hereditary spherocytosis.Sickle cell anaemia.
Auto-immune
Mismatched blood transfusion.
Paroxysmal cold hemoglobinuria.
Infective Sepsis.
Malaria.
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Hepatic Jaundice :
Hepatic Jaundice Due to a disease
affective hepatic tissue eithercongenital or acquired diffusehepatocellular injury.
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Post-hepatic (Obstructive) :
Post-hepatic (Obstructive) It is due tointra or extra hepatic obstruction ofbile ducts.
Extra-hepatic Gallstones. Carcinoma of the head of pancreas or
CBD.
Intra-hepatic: Primary Biliary Cirrhosis
. Sclerosiing cholangitis.
Drugs.
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Main features :
:Main features:
Jaundice.
Dark urine. Pale stool.
Prurities.
Absent Urobilinogen in urine. Alkaline phosphatase .
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Critical Questions in the Evaluationof the Jaundiced Patient
Acute vs. Chronic Liver Disease
Hepatocellular vs. Cholestatic
Biliary Obstruction vs. Intrahepatic Cholestasis
Fever Could the patient have ascending cholangitis?
Encephalopathy Could the patient have fulminant hepatic failure?
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Evaluation of the JaundicedPatient
HISTORY
The Following Aspects of the
history should be covered. Duration of the illness .Recent outbreaks of
jaundice . Intravenousdrug abuse, recentinjection,blood transfusion.
Alcohol consumption .
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Evaluation of the Jaundiced Patient
HISTORY ( cont )
Drug Taken .
Travel.
Family History.
Recent Surgery of Biliary Tractor carcinoma
. Fever or Rigors.
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PHYSICAL EXAM
BP/HR/Temp
Mental status
Asterixis
Abd tenderness
Liver size
Splenomegaly
Ascites
Edema
Spider angiomata
Hyperpigmentation
Kayser-Fleischerrings
Xanthomas
Gynecomastia
Left supraclavicularadenopathy(Virchows node)
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Physical Examination
The physical examination should focusprimarily on:
Stigmata of chronic liver disease
Marks of itching .
Charcots triad: fever + rigors +
jaundice .
Courvoisiers Law: obstructivejaundice + palpable gallbladder =malignant cause.
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Certain findings suggest specificdiseases such as:
Hyperpigmentation in
hemochromatosis.
A Kayser-Fleischer ring in Wilson's
disease.
Xanthomas in primary biliarycirrhosis.
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LAB EVALUATION
AST-ALT-ALP Bilirubin
total/indirect
Albumin INR
Glucose
Na-K-PO4, acid-base
Acetaminophen
level
CBC/plt Ammonia
Viral serologies ANA-ASMA-
AMA
Quantitative Ig
Ceruloplasmin Iron profile
Blood cultures
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Evaluation of the
Jaundiced Patient Ultrasound
More sensitive than CT forgallbladder stones.
Equally sensitive for dilatedducts.
Portable, cheap, no radiation,
no IV contrast.
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Evaluation of the Jaundiced Patient :
CT Better imaging of the pancreas andabdomen. is commonly used to identifyhepatic masses, particularly small
metastases, with an accuracy of about80%.
MRCP
is more sensitive than CT or ultrasoundin diagnosing common bile ductabnormalities, particularly stones.
Imaging of biliary tree comparable to
ERCP. Evaluation of the Jaundiced Patient
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ERCP
* Diagnostic:
Calculi, tumours, strictures.Biopsy of pancreatic or distal CBD.
* Therapeutic
Extract stones and drain bile.
Stent to relieve obstruction.
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PTC
Percutaneous transhepatic
cholangiography is valuable whenintrahepatic ductal dilatation ispresent. This procedure can be used
to determine the location of biliarytract obstruction.
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Liver Biopsy Conditions in which needle
biopsy is useful include:
cirrhosis.
chronic hepatitis.
granulomatous hepatitis
tumors, undiagnosed
hepatomegaly.
cholestasis of unknown cause,infiltrative processes and miliarytuberculosis
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JaundiceSummary
Patients history of greatimportance . Physical findings
can narrow the differentialdiagnosis.
Simple Laboratory Tests can
focus evaluation. Ultrasound important if
diagnosis not obvious.
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Selected Laboratory testsconfirms diagnosis and leads to
successful treatment.
Use treatment that is proven tobe effective, is of no harm, andwhere cost is justified.