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DR : RAMY A. SAMY
M.D. / lecturer of internal medicine
Dr_ramisami@fmed.bu.edu.eg
Jaundice
• Definition
• Causes
• History
• Investigation-Imaging
• Clinical Cases
Definition
Normal Physiology
• Bilirubin is from breakdown of hemoglobin
• Unconjugated bilirubin transported to liver
– Bound to albumin because insoluble in water
• Transported into hepatocyte & conjugated
– With glucuronic acid → now water soluble
• Secreted into bile
• In ileum & colon, converted to urobilinogen
– 10-20% reabsorbed into portal circulation and
re-excreted into bile or into urine by kidneys
Jaundice
Pathophysiology
• Jaundice = bilirubin staining of tissue @ lvl
greater than ~2
• Mechanisms:
– ↑ production of bilirubin
– ↓ hepatocyte transport or conjugation
– Impaired excretion of bilirubin
– Impaired delivery of bilirubin into intestine
• “surgically relevant jaundice” or obstructive
jaundice
– “Cholestasis” refers to the latter two, impaired
excretion and obstructive jaundice
What causes jaundice?
Category Definition
Pathology occurs
Pre-hepatic
prior to the liver
- mature cells or
- precursors (ineffective erythropoiesis).
- haemolysis, or
- as a result of the metabolism of blood
following internal haemorrhage, e.g. into
a soft tissue injury or fracture.
9
Prehepatic Jaundice
• Ineffective erythropoiesis occurs in conditions such as:
10
Prehepatic Jaundice
• Jaundice occurs because the conjugating capacity of the
liver is saturated,
11
KEY POINTS
Prehepatic jaundice is most commonly
Caused by haemolytic disease
12
Hepatic Jaundice
• Congenital disorders of bilirubin transport lead to
jaundice because of:
- defective uptake, reduced conjugation
or impaired excretion of bilirubin.
14
Hepatic Jaundice
• When hyperbilirubinaemia is caused by impaired
conjugation of bilirubin;
15
Hepatic Jaundice
• Serum bilirubin may be unconjugated or conjugated, as
glucuronyl transferase and intracellular transport may be
defective.
16
KEY POINTS
Jaundice due to hepatocyte dysfunction may be
caused by selective transport defects
of generalized cell dysfunction
17
Cholestatic Jaundice
• Cholestatic jaundice results from interference to biliary
flow between the sites of secretion by the hepatocyte
and drainage into the duodenum.
18
Cholestatic Jaundice
• Intra- and extra-hepatic cholestasis can be differentiated by;
- ultrasound examination or
- Hepatitis,
- Hepatic cirrhosis
19
Cholestatic Jaundice
• Some drugs may cause intrahepatic cholestasis such as:
20
Cholestatic Jaundice
• Jaundice is due to impaired excretion and
accumulation of conjugated bilirubin which can
be filtered by the kidney and appear in urine.
22
Obstructive Jaundice
• Common
– Common bile duct stones
– Carcinoma of the head of pancreas
– Malignant lymph nodes at the porta hepatis
• Infrequent
– Ampullary carcinoma
– Pancreatitis
– Liver secondaries
• Rare
– Benign strictures - iatrogenic, trauma
– Recurrent cholangitis
– Mirrizi's syndrome
– Sclerosing cholangitis
– Cholangiocarcinoma
– Bilary atresia
– Choledochal cysts
Jaundice
Pregnancy
Jaundice
33
• Clinical Case 1
• 50 year old female
• Acute, severe pain in RUQ
• Nausea and vomiting
• Calls GP – pethidine pain relief
• Next few days notices dark urine and pale stools
• Her husband comments she has a pale yellow tinge
Emergency admission