jaundice
DESCRIPTION
this ppt was made by me for my colleagues by the request of Dr. Ahilan (Consultant Physician )TRANSCRIPT
HOW TO DIAGNOSE THE CAUSE OF JAUNDICE?
MIM.ILHAM4th Batch
FHCS,EUSL
Contents
• Bilirubin metabolism.• Causes of Jaundice• History• Examination• Special test.
Bilirubin metabolism.
Causes of Jaundice
Causes of Jaundice
• Increased bilirubin load (Haemolytic Jaundice)1. Hereditary spherocytosis2. Hereditary non spherocytic anaemia3. Sickle cell disease4. Thalassemia5. Acquired haemolytic anaemia6. Incompatible blood transfusion7. Severe sepsis8. Drugs
Causes of Jaundice
• Disturbed bilirubin uptake and conjugation of bilirubin
1. Viral hepatitis2. Hepatotoxins3. Cirrhosis4. Gilbert’s familial hyperbilirubinaemai (AD)5. Familial neonatal hyperbilirubinaemia6. Crigler-Najjar’s familial jaundice (Type1- AR, Type2-
AD)
Causes of Jaundice
• Disturbed bilirubin excretionExcess of conjugated serum bilirubin known as cholestasis
Intra hepatic (without mechanical obstruction)1. Cirrhosis2. Viral (chronic active) hepatitis.3. Drugs- chorpromazine, methyl testosterone4. Dubin-Johnson’s familial hyperbilirubinaemia(AR)5. Primary biliary cirrhosis6. Parenteral or enteral feeding with synthetic
nutrition
Causes of Jaundice
Extra hepatic cholestasis• Inside the duct1. Gallstones2. Foreign body eg- Broken T-tube, parasites
(Hydatid,liver fluke, round worms)• In duct wall1. Congenital atresia2. Traumatic stricture3. Sclerosing cholangitis4. Tumor of the bile duct
Causes of Jaundice
• Outside duct1. Carcinoma of head of the pancreas2. Carcinoma of the ampulla3. Pancreatitis4. Lymph node metastases
History
Age:• Young age- Hepatitis is common• Old age- Malignancy (CA) is common
History
PC:• Jaundice (Yellowish discoloration of
sclera+mucus membrane+Skin) • Exclude other causes for yellow discolouration*Carotenaemia (Only skin, mainly palm and sole are orange color) in eating carrot,mango,papaya and hypothyroidism*Antimalarial drugs*Vit-B12 deficiency
History
HPC & Systemic Rvw• Jaundice1. Sudden onset- Gall stones OR Viral hepatitis2. Gradual onset- Cirrhosis, Pancreatic CA OR
Porta hepatis metastases3. Progressive- Malignant obstruction4. Fluctuaing- Stones in the CBD, CA of the
duodenal papilla OR repeated hemolytic episodes.
History
• Pain:1. Painless- Viral hepatitis (Dragging subcostal ache due
to hepatic enlargement)2. Pailess+Fluctuating- intermittent obstruction by
gallstone OR necrosing ampullary CA3. Painless+Progressive- Malignant obstruction of CBD4. Painful- Gallstones OR Pancreatic CA Biliary colic- right subcosatl pain radiating beneath the costal margin to shoulder bladeModerate boring pain passing through to back- Chronic pancreatitis OR pancreatic tumor
History
• Fever:1. Fever with chills- Extra hepatic cholestasis with
cholangitis due to bile duct stone,Liver abscess and leptospirosis
2. Fever without chills- Viral hepatitis, Drug induced hepatitis
• Pruritus:Results from the irritation of cutaneous nerves by retained bile saltCholestatic jaundice
History
• Weight loss-Progressive weight loss- MalignancyAlso in chronic hepatocellular damage.• Anorexia and fatigueEarly signs of hepatitis(This is due to production of cachexin and TNF)
History
• Colour of the urine and stool
Pre hepatic Hepatic Post hepatic
Urine colour Normal Dark Dark
Stool colour Normal Normal Pale
History
Contact history:1. Contact with jaundice patients from work
mates, family- hygienic habits such as toilets, drinking water, taking meals from out side (HepA & HepB)
2. Contact Hx of muddy water in leptospirosis
History
Obstetric Hx:• Ask about LRMP and calculate POA• Benign intra hepatic cholestasis is common in
pregnancy period
History
PMHx• Viral hepatitis• History of transfusion of blood OR blood
products (HepB & HepC)• Recent parenteral injection (HepB & HepC)• Amoebic dysentery• Jaundice following febrile illness- some
congenital haemolytic anaemia may be triggered by febrile illness eg- G6PD deficiency
History
• Recurrent left hypochondrial pain due to splenomegaly eg- Hereditary spherocytosis
• Recurrent foot ulcer eg- some form of chronic haemolytic anaemia such as sickle cell disease
• Hx of breast cancer and bowelcancer• SLE and other connective tissue disorders (Hx
suggestive of joint pain, skin rash)
History
PSHx• Previous difficult biliary surgery suggest –
traumatic stricture OR a residual stones in the CBD
• Post operative jaundice1. Resorption of haematomas,haemoperitonium,
haemolysis of transfused erythrocyte2. Impaired hepatocellular function- halogenated
anaesthetics, sepsis
History
DRUG Hx:• Smilar to pre-hepatic jaundice- rifampicin,
methyldopa• Intra-hepati jaundice- ethanol (cirrhosis ),
paracetamol, halothane, methyldopa, barbiturates
• Post-hepatic jaundice- isoniazid, chlorpromazine• Antileprosy drugs and Antipsychotic drugs• OCP,Saliclate,Sulfonamide , MAOi
History
Family Hx:• FHx of jaundice+anaemia+splenectomy- Hereditary spherocytosis• FHx of jaundice+anaemia- congenital
hyperbilirubinaemias• Consanguinity of parents- Inherited congenital
haemolytic anaemia eg- G6PD deficiency• Neuropsychiatry llness+jaundice- Wilson’s
disease
History
Social Hx:• Hx of Alcohol consumption in Units for years-Chronic alcohol liver disease Hepatocellular CA jaundiceCirrhosis and pancreatic CA• Toddy consumption- Amoebic liver abscess• Sexual promiscuity and unprotected sexual behavior-
HepB transmission• Occupational Hx- Sheep farmers OR allied workers- Hydatid infestationWorking at chemical enviorment eg-CCl4
Examination
General:• Depth of jaundice:Lemmon yellow- haemolytic jaundiceOrange- hepatocellular causeDeep mahogany hue- Prolonged obstructive jaundice
Examination
• Anaemia:Suggestive of Haemolytic,malignant OR cirrhotic causes
Examination
• Liver failure
Examination
• Supraclavicular node enlargement- Metastatic CA• Skin-Scratches and xanthomas in chronic cholestasis
Examination
• Pyrexia- Cholangitis, Viraemia and hepatic involvement eg-Infectious mononucleosis, septicaemia and haemolysis and hepatic abscess
Examination
Abdominal Ex:• Scars: previous surgery of biliary tree
Examination
• Caput medusaeDilated periumblical vein indicatye portal HT and cirrhosis
Examination
• Site of tenderness:Tenderness over the gall bladder indicate biliary inflammation
Examination
• Gall bladderA palpable gall bladder in the presence of the jaundice means that janundice is unlikely to be due to a stone (Courvoisier’s sign). CA of head of the pancreas must be suspected
Examination
• Liver:1. Palpable large nodule of large proportion-
metastatic malignancy2. Small nodules- cirrhosis3. Slightly enlarged smooth live chronic
cholestasis4. Tender liver- viral hepatitis and liver abscess
Examination
• Spleen:Splenomegaly may be evident of congenital haemolytic anaemia
Examination
• Abdominal massHard and irregular abdominal mass suggestive of malignancy.• AscitesDue to abdominal malignancy or liver failure
Examination
• Rectal ExColour of the stoolPresence of a primary malignancy or metastatic deposit in the pouch of douglas