YEAR 2: PBL 2

JAUNDICE
ANATOMY OF EXTRAHEPATIC BILIARY
SYSTEM
NORMAL STOOLS

1. The stool appears brown, soft, and well-formed in

consistency.
2. The stool does not contain blood, mucus, pus, undigested
meat fibres, harmful bacteria, viruses, fungi, or
parasites.
3. The stool is shaped like a tube.
4. The pH of the stool is 7.0-7.5.
5. The stool contains less than 0.25 grams per decilitre (g/dL)
[less than 13.9 milimoles per litre (mmol/L)] of sugars
called reducing factors.
6. The stool contains 2-7 grams of fat per 24 hours (g/24h).
 Bristol Stool Chart

Type 1 and 2: Constipation

Type 3 and 4: Normal
Type 5, 6 ,7: Diarrhea
STOOL COLOUR AND INDICATIONS
URINALYSIS THROUGH GROSS VISUAL EXAMINATION
Pale Light Yellow, Light Yellow, Red Orange
Dark Amber, Dark Transparent
Yellow
Normal Medical Foods- Foods-
Conditions- Beets, blackberries, Carrot, vitamin c
Diabetes insipidus rhubarb
Drugs-
Drugs- Rifampin,
Propofol, phenazopyridine
chlorpromazine,
thioridazine, Ex-lax

Medical
Conditions-
UTI, nephrolithiasis,
hemoglobinuria
(rhabdomyolysis),
porphyrias
 Green Blue Purple Brown
Foods- Drugs- Medical Food-
Asparagus Methylene blue, condition- Fava beans
indomethacin, Bacteriuria in
Drugs- amitryptyline, patients with Drugs-
Vitamin B, triamterene, urinary catheters Levodopa,
methylene blue, cimetidine, (Purple urine bag metronidazole,
propofol, promethazine syndrome) nitrofurantoin,
amitriptyline primaquine,
Medical chloroquine,
Medical condition- methocarbamol,
condition- Blue diaper senna
UTI syndrome
(tryptophan Medical
malabsorption) conditions-
Gilbert syndrome,
tyrosinemia,
hepatobiliary
disease
 Black White Cloudy

Medical conditions- Drugs- Special conditions-

Alkaptonuria, malignant Propofol Cellular debris, casts,
melanoma crystals, bacteria,
Medical conditions- significant proteinuria,
Chyluria, pyuria, vaginal discharge,
phosphate crystals sperm, and prostatic
secretions

*Other Tests In Urinalysis

1. Chemical Examination / Urine Dipstick
2. Microscopic Examination / Urine Sendiment
ANOREXIA
 Definition: Decrease or loss of appetite

 Causes:
• Chronic liver disease
• COPD
• Pregnancy
• Hepatitis
• Cholelithiasis
• Cancer
• Hypothyroidism
• Chronic kidney failure
• Heart failure
• Medications
 ASTHENIA
Definition:Clinical sign or symptom manifested as debility,
or lack or loss of strength and energy

Causes:
 Hypotension
 Hypothyroidism

 Hypoglycemia

 Pregnancy
 Anemia

 Congestive heart failure

 Medications
DIFFERENTIAL DIAGNOSIS
 Hepatitis
 Budd-Chiari syndrome
 Pancreatitis
 Cholelithiasis
 Congestive Heart Failure
 Abdominal aortic aneurysm
 Nephrolithiasis
 Renal cancer
 Fitz-Hugh and Curtis syndrome
 Pregnancy
MURPHY’S SIGN
 MURPHY’S SIGN
 As the patient takes a deep breath in, gently palpate in
the lowermost right anterior rib cage of the abdomen at
the midclavicular line.
 If the acutely inflamed gallbladder contacts the
examining fingers, pain will be evoked with the arrest of
inspiration.
POSITIVE MURPHY’S SIGN
 Often indicates acute cholecystitis
 The patient experiences pain or tenderness
sufficient to cause an abrupt halt in inspiration
(normally occurs toward the end of inspiration).
NEGATIVE MURPHY’S SIGN

 It is identified when the patient comfortably

inspires a deep breath. In this case, the
diaphragm pushes the non-inflamed gallbladder
into the palpating hand without causing any
discomfort or pain.
 may suggest pyelonephritis, and ascending
cholangitis.
PITFALLS WHILE ELICITING A
MURPHY’S SIGN
 If positive sign is elicited on right side, the
left side should also be evaluated on similar
lines to avoid false positive Murphy’s sign.
 Incorrect placement of the examiner’s
fingers can lead to false negative results.
Hence knowledge of correct method is
mandatory before attempting to elicit
Murphy’s sign
 JAUNDICE

The clinical syndrome associated with elevation of the

serum bilirubin level above the normal level of 1 mg/dL.

Direct bilirubin level : 0 to

0.3mg/Dl
Total bilirubin: 0.3 to
1.9mg/dL
COMMON CAUSES OF JAUNDICE

• Hepatitis
• Alcoholic liver disease
• A blockage of a bile duct by a gallstone or tumour
• A toxic reaction to a drug
• Inflammation of the bile duct
• Hemolytic anaemia
COMMON SYMPTOMS OF JAUNDICE
 a yellow tinge to the skin and the whites of the
eyes, normally starting at the head and spreading
down the body
 pale stools
 dark urine
 itchiness
INVESTIGATION
 HISTORY:
 AGE
 TEMPORAL PATTERN: (onset, progressive)
 ASSOCIATED SYPTOMS AND SIGNS: (abdominal pain, dark colored urine,

pale stools)
 RISK FACTORS:
 Past medical history (previous abdominal surgeries, gallstone or liver disease)

 Drug history (alternative medication, liver-toxic drugs)

 Family history (coagulopathy, inherited diseases)

 Social history (IV drug abuse, alcohol-intake, unprotected sexual intercourse, travel

history)
HISTORY OF PRESENTING ILLNESS
• Right upper abdominal discomfort after meals- for
the past 2 years.
• Developed pruritis.
• Yellowish discoloration of eyes.
• Pale stools- for the last 1 week.
• Dark urine.
• Generalized weakness & fatigability.
• Reduced appetite.
LABORATORY TESTS:
 LIVER Function test: • Urinalysis:
 ALT ( Alanine aminotransferase) • Urine bilirubin
 AST( Aspartate aminotransferase)
• Serum Analysis
 ALP ( Alkaline phosphatase)
 Bilirubin( conjugated, unconjugated)
 Albumin
 GGT (Gamma-glutamyl transferase)
 Prothrombin time(PT)
 Urine bilirubin
 ALT ( ALANINE AMINOTRANSFERASE)
 Enzyme found mostly in liver and kidney cells
 Smaller amounts are in the heart and muscles
 Healthy individuals: ALT levels in the blood are low
 Liver damage: ALT is released into the blood, before more obvious signs of liver
damage occur, such as Jaundice.
 This makes ALT a useful test for early detection of liver damage .

 Tested in conjunction with AST

 ALT and AST increase during liver damage, although ALT is more specific for
the liver and, in some cases, may be the only one of the two to be increased.
 An AST/ALT ratio may be calculated to aid in distinguishing between different
causes and severity of liver injury and to help distinguish liver injury from
damage to heart or muscles.
 AST( ASPARTATE AMINOTRANSFERASE)
 Enzyme found in cells throughout the body
 Mostly in the heart and liver and to a lesser extent in the kidneys
and muscles.
 Healthy individuals: AST levels in blood are low,
 Liver or Muscle Damage: AST is released into the blood
 This makes AST a useful test for detecting or monitoring liver
damage.
 AST, however, is not specific for the liver and may be increased
in conditions affecting other parts of the body.
ALP ( ALKALINE PHOSPHATASE)

 Enzyme found in several tissues throughout the body.

 The highest concentrations of ALP are present in cells
that comprise the bone and liver.
 Liver disease or bone disorders: ALP levels in blood
are high
 In the liver, ALP is found on the edges of cells that
join to form bile ducts, tiny tubes that drain bile from
the liver to the bowels, where it is needed to help
digest fat in the diet.
BILIRUBIN(CONJUGATED, UNCONJUGATED)

 Bilirubin is an orange-yellow pigment, a waste product primarily

produced by the normal breakdown of heme.
 A small amount (approximately 250 to 350 milligrams) of
bilirubin is produced daily in a normal, healthy adult.
 Normally, small amounts of unconjugated bilirubin are released
into the blood, but virtually no conjugated bilirubin is present.
 Both forms can be measured or estimated by laboratory tests,
and a total bilirubin result (a sum of these) may also be reported.
 If Bilirubin level increases = person will have jaundice
 The pattern of bilirubin test results can give the health
practitioner information regarding the condition that may be
present
ALBUMIN
 Albumin is a protein made by the liver. It makes
up about 60% of the total protein in the blood and
plays many roles.
 Two important causes of low blood albumin
include:
 Severe liver disease: since albumin is produced by the
liver, its level can decrease with loss of liver function;
however, this typically occurs only when the liver has
been severely affected.
 Kidney disease
 GGT (GAMMA-GLUTAMYL TRANSFERASE)

 Enzyme found in many organs throughout the body

 Highest concentrations found in the liver.
 Liver or bile duct damage: GGT levels increase in blood
 GGT is usually the first liver enzyme to rise in the blood
when any of the bile ducts that carry bile from the liver
to the intestines become obstructed, for example, by
tumors or stones. This makes it the most sensitive liver
enzyme test for detecting bile duct problems.
 PROTHROMBIN TIME(PT)

 The liver produces proteins involved in the clotting

(coagulation) of blood; the PT measures clotting function and,
if abnormal, may indicate liver damage.

 Measures the number of seconds it takes for a clot to form in a

person's sample of blood. The PT is often performed with a
PPT and together they assess the amount and function of
proteins called COAGULATION FACTORS that are an
important part of proper blood clot formation.
 URINE BILIRUBIN

 A urinalysis is a group of physical, chemical, and microscopic tests.

The tests detect and/or measure several substances in the urine, such
as by-products of normal and abnormal metabolism, cells, cellular
fragments, and bacteria.

 A complete urinalysis consists of three distinct testing phases:

 Visual examination: evaluates the urine's color and clarity
 Chemical examination: tests chemically 9 substances that provide valuable
information about health and disease and determines the concentration of the
urine
 Microscopic examination: identifies and counts the type of cells, casts,
crystals, and other components such as bacteria and mucus that can be present
Other laboratory examinations
1.Urinalysis
1.If positive for bilirubin → Patient has conjugated jaundice.
2.Findings confirmed with serum testing.

2.Serum analysis
1.Includes complete blood count (CBC)
2.Bilirubin levels are also checked.
 NON-LABORATORY TESTS
 Abdominal ultrasound
 MRI (magnetic resonance imaging) scan, often including MRCP
(magnetic resonance cholangiopancreatogram, to visualize the
pancreas and bile ducts)
 CT (computed tomography) scan
 Endoscopic retrograde cholangiopancreatography (ERCP, a direct
imaging of the pancreas and bile ducts)
 Liver biopsy
 ABDOMINAL ULTRASOUND
• More sensitive than CT for
gallbladder stones and other
pathology of gall bladder.
• Sensitive for dilated ducts
(Dilation of the extrahepatic
(>10 mm) or intrahepatic (>4
mm) bile ducts suggests
biliary obstruction).
• Portable, cheap, no radiation.
• But it is operator dependent.
 MAGNETIC RESONANCE
CHOLANGIOPANCREATOGRAPHY (MRCP)
• Noninvasive test to visualize the
hepato biliary
Tree.
• Entire biliary tree and pancreatic
duct can be seen.
• Best for Intra Hepatic
stones and
CHOLEDOCHAL CYST.
• SINGLE BEST FOR
CHOLANGIOCARCINO
MA.
• MRCP is better to determine
the extent and type of tumor as
 CT SCAN

• Main role in malignant conditions

mainly for localization of
primary tumors and metastasis.
• Best for Pancreatic
Carcinoma(Highly sensitive for
lesion >1mm).
• Mainly done when ultrasound fail or
when there is ductal dilation on
ultrasound.
• Also to find level and cause of
obstruction
• And in malignant conditions.
ENDOSCOPIC RETROGRADE CHOLANGIOGRAM
(ERCP)
• Its an invasive
procedure and COMPLICATIONS
has therapeutic • Pancreatitis
potential. • Cholangitis
• Hemorrhage
• Used to
• Sepsis
examine
pancreatic duct
and bile duct . CONTRAINDICATIONS
• Bile duct stones • Unfav anatomy
• Pseudocyst
can be
• Rec a/c pancreatitis
diagnosed and
removed by
ERCP.
 PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM (PTC)

• PTC is indicated when

percutaneous intervention is
needed and ERCP either is
inappropriate or has failed.
• Can be used to drain
biliary obstructions.
SUMMARY:
• Non invasive tests
(US, CT, MRI)

• Invasive (ERCP,
PTC, EUS)
CHOLELITHIASIS
 GALLBLADDER

 Pear-shaped sac at the fossa

of inferior surface of liver
 Concentrates and stores bile
secreted by the liver
 Cholecystokinin produced by
intestinal mucosa during
digestion causes gallbladder
to contract and release bile
 BILE

Water, electrolytes
 Emulsifies fat to and bicarbonate
Bilirubin
enhance Proteins
absorption
 Components: Phospholipids

Cholesterol Bile salts

and
acids
CHOLELITHIASIS

 Gallstones
 Types:
1. Cholesterol stone
2. Pigment stones
(Bilirubin stones)
 CHOLESTEROL STONE
 Concentration of cholesterol exceed the solubilizing capacity of bile
 Cholesterol can no longer remain distributed and crystallizes out of solution
 Cholesterol precipitation:

1. Supersaturation
2. Insufficient salts/acids/phospholipids
3. Hypomobility of gallbladder (stasis)
 Morphology:
1. Consist of 50% - 100% cholesterol
2. Pure cholesterol stones = Pale yellow
3. Increasing portions of calcium carbonate, phosphates and bilirubin =
Gray-white to black discoloration
4. Ovoid and firm
5. Occur separately
6. Faceted surface due to apposition
7. Most are radiolucent
8. Sufficient calcium carbonate = Radiopaque
 PIGMENT STONE
 Presence of unconjugated bilirubin in the biliary tree
 Due to hemolytic anemia and infections of biliary tract
 Precipitates are primarily insoluble calcium bilirubinate salts
 Black pigmented stones
 Radiopaque
 If brown pigmented stones, sign of infection
 Often stones ventured outside and into bile duct
 Bacteria (E.Coli) produce hydrolytic enzymes (hydrolyze conjugated bilirubin
and phospholipids)
 RISK FACTORS
1. Advancing age
2. Female > Male
3. Obesity
4. Inborn disorders of bile acid metabolism
5. Dyslipidemia syndrome
6. Rapid weight reduction
HOW TO REMOVE GALLSTONES?
URSODIOL
 MOA :
 -decreases biliary cholesterol by suppressing
hepatic synthesis of cholesterol.
 -reduces the rate of intestinal absorption of
cholesterol.
 -permits gradual solubilization of cholesterol
from gallstones, resulting in their eventual
dissolution.
 Adverse effects:-nausea,diarrhea
 -headache,dizziness
 -mild itching, rashes
 -hair loss
 -cold symptoms such as stuffy nose, sneezing,
sore throat
 -leukopenia
 -thrombocytopenia
Indications:
 - treat small gallstones in people who cannot have

gallbladder surgery,
 - to prevent gallstones in overweight patients undergoing

rapid weight loss.

 Contraindications:
 - patients with calcified cholesterol stones, radiopaque stones
or radiolucent bile pigment stones.
 - patients with bile acid agents hypersensitivity.
SURGERY
 Cholecystectomy-1) OPEN 2) Laparoscopic
(keyhole)
 cholecystectomy
 oral dissolution therapy
 Extracorporeal shockwave lithotripsy (ESWL)
 Endoscopic retrograde cholangiopancreatography
(ERCP) with biliary endoscopic sphincterotomy
(BES)
 Biliary stenting
LIFESTYLE MODIFICATIONS
-Avoid these foods:
 Foods high in cholesterol

 Refined sugars

 Beans

 Onions or bell pepper

 Fried foods

 Foods high in saturated fat ie. butter, fatty meats, whole

milk
-go on a diet and lose weight too quickly
Recommendation:
 Foods high in fiber
 Nuts

 Fresh fruits and vegetables

 Wine. Just 1 to 2 glasses daily can lower the risk

 Healthy oils. Olive oil, fish oils

*Rowachol(plant based treatment), Lecithin(soy

lecithin)