JAUNDICEJAUNDICE

Definition• Is a yellowish

pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood).

Pathophysiology

Pre-hepatic

Hepatic

Post-hepatic

Entero-hepatic Circulation

Etiology1.Unconjugated hyperbilirubinaemia• Pre-hepatic- increases the load of bilirubin to be metabolized by the liv

er 2.Conjugated hyperbilirubinaemia• Hepatocellular-damages or reduces the activity of the transferase enzyme

or hepatocyte • Post-hepatic-also called obstructive jaundice, is caused by an interrupti

on to the drainage of bile in the biliary system

Etiology• Pre-hepaticHemolytic anemias;Polycythemia; Shortened red cell life as a result of immaturity

or transfused cells ;Drug induced (antimalarias);G-6PD;etc.• HepatocellularViruses:Hepatitis(A,B,C,D,E);CMV,EBV;Drugs;Autoimmune Hepatitis;Wilson's Dise

ase;Right Heart Failure;Drug induced(Paracetamol, Isoniazid,rifampicin,pyrazinamide); etc.

• Post-hepaticExtrinsic obstruction of the bile duct ;Biliary atresia;Common bile duct gallstones;

Drugs induced (steroids,flucloxacilin);etc.

Common Causes In Older Children• Infection-eg. Viral (Hepatitis

A,B,C,D,E),EB,Malaria,Leptospira• Autoimmune eg. SLE,Kawasaki• Infiltrative eg.Malignancy• Metabolic eg. Wilson,CF• Narrow or obstructed bile ducts• Toxin & drugs eg.Acetaminophan

I MET 3

History Taking• ID/CC: Age, sex, symptom• HoPI:-Elaborate the symptoms1. Onset (sudden or progressively)?• sudden (Infection .)• proggressive ( Obstrustion above hepatobiliary duct, chornic hem

olysis eg.Thalassaemia ,chronic hepatitis etc.)2. Asso: symptoms- Fever, LOA, Pallor, Stool & urine

colour,vomiting,abdo;pain, rash, arthralgia3. if there is any aggravating factor (bloods transfusion, intake of food

/ drugs).4. Exposures to epidemic areas?

History Taking cont:

Sleep—quantity, quality, disturbances (restlessness),

History Taking• PMH:• Pregnancy—gravida/para status, maternal age, duration, exposures

(medications,alcohol, tobacco, drugs, infections, radiation); complications (bleeding,

gestational diabetes, hypertension, etc.), problems with past pregnancies• Labor and delivery—length of labor, rupture of membranes, fetal

movement, medications, presentation/delivery,mode of delivery, assistance (forceps, vacuum), complications, Apgars

• Neonatal—birth height/weight, abnormalities/injuries, length of hospital stay, complications (respiratory distress,cyanosis, anemia, jaundice, seizures, anomalies, infections), behavior

• Infancy—temperament, feeding, family reactions to infant• Illnesses/hospitalizations/surgeries/accidents/injuries—dates,

medications/interventions, impact on child/family• Past medical illness • Medicatioion/Drug H/O—past (antibiotics, especially), present, reactions• Allergies—include reaction• Immunizations—up to date, reactions• Family history—relatives, ages, health problems, deaths (age/cause),

miscarriages/stillbirths/deaths of infantsor children• Social history—parents’ education and occupation, living arrangements,

pets, water (city or well), lead exposure(old house, paint), smoke exposure, , risk-taking behaviors,school/daycare

Physical Examination

Physical Examination

• General— Lethargic, Tired, Hydration status,Malnutrition,Jaundice,Concious level,Weight,Height

• Hand-Pallor,Cyanosis,Leuconychia(hypoalbuminaemia?),Clubbing,Liver palms,Aneamia,Hepatic Flap

• Skin—Bruising,Scratch marks, Spider Naevi • Eyes—Jaundice,Pallor• Nose— Flaring nostrils

• Mouth—Cyanosis,Ulcer• Throat—Oropharynx (red, moist, injection, exudate)

• Lymph—Lympoedema(Cervical, axillary, inguinal)• Legs-Edema(Pretibial/Medial malleolus)

Physical Examination• Abdomen1. Inspection-Distention,Scar,Prominent veins 2. Palpation-Hepatomegaly(Hepatitis,Cirrhosis?),Spleenomegaly(H

emolysis?),Tenderness,Gallbladder(Murphy?),Kidneys.3. Percussion-Liver,Spleen,Shifting dullness(Ascites?)4. Ausculation- Bowel sounds.

For extra Eamination• Respiratory（ Pulmonary Edema?)—Rate, Grunting,Basal Crac

kles? Sputum?• Cardiovascular(Heart Failure?)—Heart rate,Gallop Rhythnm?

Investigation• Full blood count (RBC,Retic )• Liver function tests(ALT, AST,GGT, AKP,T&DP,TB,UCB,CB)1. TB+UCB = pre-hepatic2. TB+UCB+CB =hepatic3. TB+CB = post-hepatcic• Coagulation profile –PT,INR• Ultrasound (In adavanced MRCP,ERCP)• Urine FEME,• Urine for leptospiral Ag• Renal function test• Stool test • Genetic Test (G-6PD ,Thalasseamia)• Serology Test for viruses(Hepatitis A,B,C,D,E)• Serology Test for Autoimmune• Coomb's test• Liver biopsy

Table of Diagnosis TestFunction test Pre-hepatic Jaundice Hepatic Jaundice Post-hepatic Jaundice

Total bilirubin Normal / Increased Increased Increased

Conjugated bilirubin Normal Increased Increased

Unconjugated bilirubin

Normal / Increased Increased Normal

Urobilinogen Normal / Increased Increased Decreased / Negative

Urine Color Normal Dark (urobilinogen + conjugated bilirubin)

Dark (conjugated bilirubin)

Stool Color Normal Normal/Pale Pale

Alkaline phosphatase levels

Normal Increased Increased

Alanine transferase and Aspartate transferase levels

Normal Increased Increased

Conjugated Bilirubin in Urine

Not Present Present Present

References• Goljan, Edward F., Rapid Review

Pathology 2nd edition. Pg. 368–369. 2007.

• First Aid For The Pediatric Clerkship Pg.9-10• Oxford Handbook Of Clinical Medicine Pg.2

50-251• Nelson's Pediatrics 18th edition• Essential Nelson• Current Paed: