APPROACH TO A PATIENT WITH

JAUNDICE
Presenters
1. MATOVU DAVID KAYIZA
2. KANG BYEONGHYEON
Tutor: DR. SEMITALA FRED
 OUTLINE

Definition
Symptoms of Jaundice
Metabolism of bilirubin
Etiology of jaundice
Evaluating a patient with Jaundice
Investigating a patient with jaundice
Management and prevention
Complications of jaundice
 Definition

• Jaundice/icterus is a yellowish pigmentation of the Sclera, skin, tissues, and

body fluids caused by abnormally high blood levels of bilirubin
(hyperbilirubinemia).
• Jaundice is usually detectable clinically when the plasma bilirubin exceeds
50 μmol/L.
• Jaundice in adults can be an indicator of significant underlying disease.

Figure 1 – Yellowing of the sclera

 Symptoms associated with Jaundice
o Yellow tinge on the skin and in the whites of the eyes
o Vomiting
o High fever
o Dark colored urine
o Loss of appetite
o Pale colored stool
o Abdominal pain (especially in the liver region)
o General body weakness
o Weight loss
o swelling of the abdomen due to the accumulation of fluid
Metabolism of bilirubin
 Etiology of jaundice

• Etiology can be classified into;

1. Pre-hepatic
2. Hepatocellular
3. post-hepatic
 PRE-HEPATIC JAUNDICE

This is due to excessive red cell breakdown which overwhelms the liver’s
ability to conjugate bilirubin.
This causes an unconjugated hyperbilirubinemia.
Causes
• Haemolytic anaemia
• Gilbert’s syndrome
• Criggler-Najjar syndrome
 Hepatocellular/ intrahepatic jaundice
 There is dysfunction of the hepatic cells.
The liver loses the ability to conjugate bilirubin
 In cases of liver cirrhosis there is compression of the intra-hepatic
portions of the biliary tree which causes some degree of biliary obstruction
This leads to both unconjugated and conjugated bilirubin in the blood,
termed a ‘mixed picture’.
 Hepatocellular/ intrahepatic jaundice….
Causes;
• Alcoholic liver disease
• Viral hepatitis
• Iatrogenic, e.g. acetaminophen
• Hereditary haemochromatosis
• Autoimmune hepatitis
• Primary biliary cirrhosis or primary sclerosing cholangitis
• Hepatocellular carcinoma
 Post-hepatic Jaundice

This is due to obstruction of biliary drainage.

The bilirubin that is not excreted will have been conjugated by the liver
The result is a conjugated hyperbilirubinaemia.
• Causes;
• Gallstones
• Cholangiocarcinoma
• Pancreatic cancer
• Drug induced cholestasis
• Abdominal masses like lymphomas
Post-hepatic causes of Jaundice
 Evaluation of a patient with Jaundice

• History
 Changes in urine color (Hyperbilirubinemia can cause urine to darken before jaundice is visible)
 Important associated symptoms include fever, prodromal symptoms (eg, fever, malaise, myalgias)
 Changes in stool color
 Pruritus
 Steatorrhea
 Abdominal pain (note location, severity, duration, and radiation)
 Important symptoms suggesting severe disease include nausea and vomiting, weight loss, and possible
symptoms of coagulopathy (eg, easy bruising or bleeding, tarry or bloody stools).
 Review of systems

• Systems review should seek symptoms of possible causes, including;

 Weight loss and abdominal pain (cancer)

 Joint pain and swelling (autoimmune or viral hepatitis, hemochromatosis,

primary sclerosing cholangitis and sarcoidosis)
 Past medical history
 This should identify known causative disorders, such as hepatobiliary disease (eg,
gallstones, hepatitis and cirrhosis)

 Disorders that can cause hemolysis (eg, hemoglobinopathy, G6PD deficiency)

 Disorders associated with liver or biliary disease, including inflammatory bowel

disease, infiltrative disorders (eg amyloidosis, lymphoma, sarcoidosis, TB and
HIV)

 Drug history should include questions about use of drugs or exposure to toxins
known to affect the liver and about vaccination against hepatitis.
 Surgical history should include questions about previous
surgery on the biliary tract (a potential cause of strictures).

 Social history should include questions about risk factors for

hepatitis, amount and duration of alcohol use, injection drug
use, and sexual history.

 Family history should include questions about recurrent,

mild jaundice in family members and diagnosed hereditary
liver disorders.
 PHYSICAL EXAMINATION
GENERAL EXAM
• Assess the JACCOLD
• Vital signs (BP, PR, RR, Temp)
SYSTEMIC EXAM
 GIT
 CNS
 CVS
 RS
 GUS
 SKIN
 PHYSICAL EXAMINATION

 Patient should be examined in bright day light.

 Assessment of patients’ nutritional status
 Temporal & proximal muscle wasting suggest – pancreatic cancer or cirrhosis.
 Pruritus is common in cholestatic jaundice (obstructive jaundice) due to the
deposition of bile salts in the skin
 Xanthomas: yellowish deposits of cholesterol under the skin, particularly
around the eyelids (xanthelasma – suggest obstructive jaundice.
 Stigmata of chronic liver diseases
Stigmata (signs) of chronic liver diseases
 Abdominal examination
Should focus on size and consistency of liver
Splenomegaly – suggest hemolytic anemia
Ascites may present or not
Severe right upper quadrant tenderness with respiratory arrest on
inspiration – cholecystitis
Ascites + jaundice – cirrhosis or malignancy with peritoneal spread
Enlarged left lobe of liver felt below the xiphoid with an enlarged
spleen – suggest cirrhosis.
Enlarged tender liver – viral or alcoholic hepatitis.
Grossly enlarged nodular liver – malignancy.
Investigation of jaundice
 Laboratory Investigations

Serum Bilirubin with fractionation (Direct/conjugated vs. indirect/unconjugated)

 Laboratory Investigations…..
Liver function tests(LFTs)
Aminotransaminases (Aspartate transaminase (AST) and Alanine
transaminase (ALT))
• Normal AST is 0-40 IU/L
• Normal ALT is 0-55 IU/L
• AST is present in cells of liver, heart, skeletal muscle, kidney, pancreas and brain
• ALT is present mostly in the liver
• Damage hepatic cells causes elevated serum AST and ALT
Laboratory Investigations….
 Laboratory Investigations
Liver function tests(LFTs)
Cholestatic enzymes (Alkaline phosphatase (ALP) and Gamma-Glutamyl
Transferase(GGT)

• Normal ALP is 20-140 IU/L

• Normal GGT is 0 to 30 IU/L (Normal values can vary due to age and sex)
• ALP is present primarily found in the liver, bones, intestine, and kidneys
• GGT is an enzyme found throughout the body, but it is mostly found in the liver.
• Cholestatic/Obstructive jaundice is characterized by a relatively greater elevation of
ALP and GGT than the aminotransferases
 Laboratory Investigations

Liver function tests(LFTs)

Albumin and Prothrombin time (PT)

These help assess functionality of the liver/Liver failure
Low albumin levels signify a chronic liver disease like cirrhosis
 Laboratory Investigations cont’d

 Urinalysis to assess for urine bilirubin (Bilirubin must be absent in urine)

 Complete blood count to assess for anaemia (type, severity, haemolysis?) and any infection

 Liver biopsy in cases of liver masses on radiological examinations

 Other tests for specific liver diseases e.g. Viral hepatitis serological tests
 Radiological investigations

• Imaging with ultrasonography or computed tomography can differentiate

between extrahepatic obstructive and intrahepatic parenchymal disorders.
• 1. Abdominal ultrasound
• 2. Abdominal CT scan
• 3. Endoscopic retrograde cholangiopancreatography(ERCP)
• Procedure to diagnose and treat problems in the liver, gallbladder, bile ducts, and
pancreas

• 4. Magnetic resonance cholangiopancreatography (MRCP)

• Special type of MRI exam that produces detailed images of the hepatobiliary and
pancreatic systems, including the liver, gallbladder, bile ducts, pancreas and pancreatic
duct.
 Management

 Treatment depends on cause.

 Once diagnosis is made of underlying cause, treatment is directed to address
that particular condition.
 Treatment may consist of expectant management at home with rest
 Medical treatment with IV fluids, medications, antibiotics or blood transfusions
may be needed
 If drug or toxin is the cause, these may be discontinued
 Surgical treatment in cases of obstructed jaundice
 Complications of Jaundice

 Kernicterus; but this is rare in adults

 Kernicterus is a type of brain damage that can result from high levels of
bilirubin in blood
 Other conditions that cause yellow skin

 Hypercarotenemia
 Uremic pigmentation
 Picric acid ingestion
 Quinacrine therapy
 Prevention
 Avoid heavy alcohol

 Vaccination of hepatitis B

 Take medication for hepatitis as recommended by the doctor

 Chemoprophylaxis for malaria for foreigners visiting endemic areas

 Case Scenario

• Case: A 21-year-old woman, known SCD patient, not on Hydroxyurea, presents with
yellowing of the eyes and skin, joints pain and chest pain for 3 days. The chest pain
was associated with difficulty in breathing. There is no past surgical history. She takes
Fansidar 3 tabs per month. She doesn’t drink alcohol or smoke. She reported tea-
colored urine. She presented in the Sickle cell clinic accompanied by her mother and
one of her sister and admitted immediately for transfusion and further management.
 Case Scenario

• O/E: Sick looking young woman, J+ A++ Co Co Oo Lo D+

• PA: The abdomen is of normal fullness. The spleen is palpable beneath the
costal margin (5 cm.) and tender. There is no rebound tenderness, shifting
dullness or hepatomegaly. Resonant percussion note. Normal bowel sounds.

• SKIN: slightly Icteric

 Case Scenario

• LABORATORY FINDINGS
• CBC
• White blood cell count: 14,000 cells/mm3
• Hemoglobin 6.6 g/dL; normal MCV and MCHC
• Platelets 160,000/mm3
 Case Scenario
• LABORATORY FINDINGS
• Chemistries
• AST 35 U/L
• ALT 40 U/L
• Total Bilirubin 3.2 mg/dL
• Indirect 2.2mg/dl
• Direct 1.0mg/dl
• ALP 100 U/L
• GGT 30 IU/L

• Urinalysis
• Bilirubinuria positive
 Case scenario....

•IMPRESSION???
Thank you