Jaundice

Bagus Setyoboedi
Department of Child Health
Medical School Airlangga University - Dr. Soetomo
Hospital Surabaya - Indonesia

Accumulation of yellow pigment in the skin

and other tissues (Bilirubin)

Bilirubin Metabolism

Bilirubin formation

Transport of bilirubin in plasma

Hepatic bilirubin transport

Hepatic uptake

Conjugation

Biliary excretion

Enterohepatic circulation

Bilirubin Metabolism

Classification
Pre-hepatic
(Increase bilirubin load)
Increase breakdown of hemoglobin

Hepatic
(Reduce conjugation or excretion)
Reduce uridine diphosphate
glucuronosyltransferase (UDPGT) activity
Hepatocellular dysfunction

Post-hepatic
(Reduce excretion outside the liver or increase
reabsorption)
Biliary tract obstruction
Increase enterohepatic circulation

Pathophysiologic classification

Hemolytic Jaundice

Hepatic Jaundice

Obstructive Jaundice (Cholestasis)

Congenital Jaundice

Hemolytic Jaundice
Overproduction
Hemolysis (intra and extra vascular)

inherited or genetic disorders

acquired immune hemolytic anemia

(Autoimmune hemolytic anemia)

nonimmune hemolytic anemia

(paroxysmal nocturna Hemoglobinruia)

Ineffective erythropoiesis

Overproduction may overload the liver with UB

Symptoms
weakness, Dark urine, anemia,
Icterus, splenomegaly

Lab

UB without bilirubinuria
fecal and urine urobilinogen
hemolytic anemia
hemoglobinuria (in acute intravascular hemolysis)
Reticulocyte counts

Serum / blood:
bilirubin (micormoles/l) 50-150; normal range 3-17
AST I.U. < 35; normal range <35
ALP I.U. <250; normal range <250
gamma GT I.U. 15-40; normal range 15-40
albumin g/l 40-50; normal range 40-50
reticulocytes(%) 10-30; normal range <1
prothrombin time (seconds) 13-15; normal range 13-15

urinary changes:
bilirubin: absent
urobilinogen: increased or normal
faecal changes: stercobilinogen: normal

Obstructive Jaundice
it is due to intra- and extra hepatic obstruction of bile
ducts

intrahepatic Jaundice: Hepatitis, PBC, Drugs

Extra Hepatic Biliary Obstruction: Stones, Stricture,

Inflammation, Tumors, (Ampulla of Vater)

Intrahepatic-Liver cell Damage/Blockage of Bile Canaliculi

Drugs or chemical toxins

Dubin-Johnson syndrome

Estrogens or Pregnancy

Hepatitis-viral,chemical

Infiltrative tumors

Intrahepatic biliary hypoplasia or atresia

Primary biliary cirrhosis

Extrahepatic-Obstructive of bile Ducts

Compression obstruction from tumors
Congenital choledochal cyst
Extrahepatic biliary atresia
Intraluminal gallstones
Stenosis-postoperative or inflammary

Hepatic Jaundice

Due to a disease affective hepatic tissue

either congenital or acquired diffuse
hepatocellular injury

 Impaired or absent hepatic conjugation of

bilirubin

decreased GT activity (Gilberts syndrome)

hereditary absence or deficiency of UDPGT (GriglerNajjar Syndrome)

Familiar or hereditary disorders

Dubin-Johnson Syndrome
Rotor syndrome

Acquired disorders

hepatocellular necrosis
intrahepatic cholestasis
(Hepatitis, Cirrhosis, Drug-related)

SUMMARY

Have the patient had an isolated elevation of

serum bilirubin?

SUMMARY

Is the bilirubin elevation due to an increased

unconjucated or conjucated fraction?

SUMMARY

Is the hyperbilirubinemia hepatocellular or

cholestatic?

SUMMARY

If cholestatic,is it intra-or extrahepatic?