HUEVOS, HAZIEL M.

SURGERY CLERK 12/03/21

Physiologic Jaundice
Physiologic jaundice in a neonate is mild and transient and occurs because the metabolism of bilirubin
in the neonatal period leads to an increased bilirubin load. Specifically, it involves an increased
production of bilirubin due to a higher mass of red blood cells with a decreased lifespan in the neonate,
a decreased bilirubin clearance from a deficiency of the uridine diphosphate glucuronosyltransferase
(UGT) enzyme, which in the newborn has the activity of about 1% of the adult liver, and an increased
enterohepatic circulation.

Physiologic jaundice usually occurs on days 2 to 4, resolves in two weeks. Physiologic jaundice never
occurs in the first 24 hours.

Pathologic Jaundice
The causes of pathologic unconjugated hyperbilirubinemia are also due to increased bilirubin
production, decreased bilirubin clearance, and increased enterohepatic circulation. Some of the
etiologies are:
Immune-mediated hemolysis such as ABO and Rhesus incompatibility;
Non-immune mediated causes of hemolysis such as cephalhematoma, red blood cell
membrane defects like hereditary spherocytosis and elliptocytosis, enzyme defects like
glucose-6-phosphate dehydrogenase (G6PD) deficiency and pyruvate kinase;
Disorders of UGT function or production such as in Crigler-Najjar syndrome, where there is
either an absence of UGT activity (type 1) or low UGT activity (type 2), and Gilbert syndrome
where there is a mutation of the UGT1A1 gene.

Pathologic jaundice may occur in the first 24 hours of life and is characterized by a rapid rate of rising in
the bilirubin level more than 0.2 mg/dl per hour or 5 mg/dl per day.

Cholestasis
Cholestasis is defined as stagnation or a marked reduction in bile secretion and flow. It can be due to a
functional impairment of the hepatocytes in the secretion of bile and/or due to an obstruction at any
level of the bile tree. Clinically, cholestasis leads to retention of the constituents of bile in blood and
manifests as pruritus and malabsorption of fat and fat-soluble vitamins.

Surgical causes of cholestasis

• Choledocholithiasis- presence of stones within the common bile duct preventing bile flow.
• Choledochal cysts- congenital cystic dilatation of the biliary duct causing bile to back up in the liver.
• Biliary atresia- obliteration of the extrahepatic biliary duct system, resulting in obstruction to bile flow.
• Cholangiocarcinoma- malignancy of the bile duct system anywhere from the liver to the ampulla of Vater.
• Mirizzi syndrome- common hepatic duct obstruction caused by extrinsic compression from an impacted
stone in the cystic duct or infundibulum of the gallbladder.

Nonsurgical causes of cholestasis

• Viral hepatitis- a viral infection that causes liver inflammation and damage and may be acute or chronic.
• Alcoholic hepatitis- progressive inflammatory liver injury associated with long-term heavy intake of ethanol.
• Cholestasis of pregnancy- a condition that slows or stops normal flow of bile during the 2nd or 3rd trimester.
• Sickle cell intrahepatic cholestasis- sickling within the hepatic sinusoids leading to vascular stasis
• Primary biliary cholangitis- chronic disease in which the small bile ducts in the liver become injured and
inflamed and are eventually destroyed.