dr. Darmadi, M.

Ked(PD), SpPD

Division of Gastroenterohepatology, Department of Internal

Medicine, Faculty of Medicine, Universitas Sumatera Utara
 Definition
 Jaundice : yellowish discoloration of the skin, sclera,
and mucous membranes due to hyperbilirubinemia
and deposition of bile pigments

 Serum bilirubin level

Normal serum bilirubin level : 0.3-1 mg/dL
Conjugated : 0.1-0.3 mg/dL
Unconjugated : 0.2 – 0.7 mg/dL

 If bilirubin :
>1 mg/dL : hyperbilirubinemia
>2 – 2.5 mg/dL : start diffusing into tissues
>2.5 / > 3 mg/dL : clinically jaundice detectable
 Cholestasis/conjugated hyperbilirubinemia:
 direct (conjugated) serum bilirubin >1 mg/dL
(if total bilirubin <5 mg/dL)
 direct bilirubin level >20% of total bilirubin
(if total bilirubin >5 mg/dL)

 Jaundice is not a disease, but a sign that

can occur in many different diseases.
Sites to be examined

Upper bulbar Palate

conjunctiva Base of tongue (especially soft palate)
(contains elastin which has
affinity for bilirubin)

Palms and soles General skin surface

 Bilirubin
Metabolism
X Carotenoderma
 Carotene deposition (exceed 250 µg/dL) mainly
in the stratum corneum, in sweat and in sebum.

 Pigment is concentrated on the palms, soles,

forehead, and nasolabial folds

 Can be distinguished from jaundice by the spring of

the sclerae

 Etiology : high β‐carotene intake, hypothyroidism

Classification
Pre-Hepatic
Jaundice
Hemolytic
1.Intrinsic
a. Enzyme defect
b. Hemoglobinopathies
c. Membrane abnormalities
2.Extrinsic
a. Immune
b. Traumatic
c. Infection / Toxin
d. Sequestration
Enzyme defects
 Glucose-6-Phosphate Dehydrogenase Deficiency
G6PD: regeneration of glutathione, protects agains
oxidative stress
Lack of G6PD  hemolysis during oxidative stress

 Pyruvate Kinase Deficiency

Hemoglobinopathies
 Thalassemia : autosomal recessive
 Hypochromic microcytic anemia, anisocytosis,
poikilocytosis, target cell
 Hepatomegaly, splenomegaly
 Paroxysmal Nocturnal Hemoglobinuria
 Ongoing intra & extravascular hemolysis, classicaly at
night

 Urine : hemosiderinuria (Rous test)

 Specific test :
Screening test: Sucrose water test
Definitive test: Ham test (acid hemolysis)
Sucrose Water Test
Ham Test
Membrane abnormalities
Hemolytic
1.Intrinsic
a. Enzyme defect
b. Hemoglobinopathies
c. Membrane abnormalities
2.Extrinsic
a. Immune
b. Traumatic
c. Infection / Toxin
d. Sequestration
Extrinsic

Immune : Autoimmune, transfusion, reaction

drugs (eg. Dapsone)
Traumatic: Microangiopathic hemolytic
anemia, burns
Infection/Toxin: Malaria, sepsis, snake bites,
hypotonic solution
Sequestration: hypersplenism
 Autoimmune hemolysis
 Warm Type
Usually IgG antibodies
+IgG or IgG and C3
Hemolysis primarily extravascular
Responsive to steroids/ splenectomy
 Cold Type (antibodies bind best at 30o or lower
Most commonly IgM mediated
-IgG, only C3
RBC lysis in vascular
Poorly responsive to steroid, splenectomy; responsive to
plasmapheresis
 Diagnosis Pre-Hepatic Jaundice
History taking PE
Pale, symptoms of anemia Pale yellow discoloration
Repeated transfusion, family
history of transfusion Anemic conjunctiva
Systemic symptom (eg. Splenomegaly
fever)
Drugs
 Anemia
Reticulocytosis
LDH ↑

High total bilirubin

Indirect > Direct
Liver function tests:
-AST/ALT normal
-ALP normal

Urine bilirubin (-):

-albumin not filtrated
-indirect bilirubin : water insoluble

Stercobilinogen in faeces ↑
Urobilinogen in urine ↑
Classification
Conjugation failure:
Indirect bilirubin ↑
Transport failure:
Direct bilirubin ↑

Hepatic
Jaundice
Etiology
Infection
Viral Hepatitis :
HAV, HBV, HCV,
Hepatocelluler
HDV, HEV Liver cirrhosis
carcinoma
Other viruses:
EBV, CMV, HSV

Drugs: Alcoholic Acute heart

PCT, PZA hepatitis failure

Autoimmune Wilson disease

hepatitis
 Hemolysis (-)
High total bilirubin
Indirect ≈ Direct
Impaired liver function tests:
-AST/ALT ↑/ ↑ ↑
-ALP, GGT slight ↑

Stercobilinogen in faeces ↓ 
pale
Urobilinogen in urine ↓

Urine bilirubin (+):

-direct bilirubin : water soluble

Fecal fat level

Acute
Hepatitis
Liver cirrhosis
Classification
Transport failure to
duodenum:
Direct bilirubin ↑

Post-Hepatic
Jaundice
Intraluminal:
Choledocholithiasis,
Parasitic infections
Mural:
Cholangiocarcinoma,
sclerosing cholangitis
Extraluminal:
Ca head of pancreas,
periampullary carcinoma

Etiology
Post-Hepatic
Jaundice
Diagnosis Post-Hepatic Jaundice
History taking PE
Dark-colored urine Yellow green discoloration
Clay-colored stool
Pruritus Orange yellow
Steatorrhea
Weight loss RUQ pain
Fever + ascites

Abdominal pain,
vomiting
 Hemolysis (-)
High total bilirubin
Indirect < Direct
Impaired liver function tests:
-AST/ALT ↑
-ALP, GGT ↑↑

Fecal stercobilinogen↓↓/ (-) 

pale
Urine urobilinogen↓↓/(-)

Urine bilirubin (+):

-direct bilirubin : water soluble

Fecal fat level

Radiological Investigation
 Plain radiographs : limited utility as frequently
calculi are not visualized because few are
radiopaque

 Ultrasonography : most sensitive technique for

visualizing the biliary system, particularly the
gallbladder, common bile duct, intrahepatic biliary
duct

 CT scan
Acute cholecystitis +
cholelithiasis
Intrahepatic cholestasis
ERCP (Endoscopic Retrograde
Cholangiopancreaticography)
 Diagnostic:
Tumors
Gallstones that form in the gallbladder and
become stuck in the ducts
Inflammation due to trauma or illness such as
pancreatitis
Scarring of the ducts (sclerosis)
Pseudocysts
 ERCP (Endoscopic
Retrograde
Cholangiopancreaticography

)
Therapeutic:
Stone removal
Stent placement
Balloon dilation
Tissue sampling
 MRCP (Magnetic resonance
cholangiopancreatography)
 To visualized the hepatobiliary tree
 It helps in detecting biliary and pancreatic duct stones,
strictures, or dilatation within the biliary system,
surrounding structures such as pseudocyst, masses
Endoscopic ultrasound
Diagnostic Approach
Treatment of Jaundice
GENERAL
Treatment depends on the underlying cause
Need careful fluid balance to correct dehydration
Correction of electrolyte imbalance
Parenteral vitamin K + FFP
Preoperative biliary decompression (ERCP)
Surgery to correct blockage
Administration of antibiotic, antiviral, or
antiparasitic drugs
Treatment of pre-hepatic
jaundice
 Treat primary cause of hemolytic anemia
 Immune related hemolysis
Corticosteroids, folic acid (to sustain
erythropoiesis)
 Parasitic infections
Antimalarial drugs
 Transfusion
For acute, severe hemolytic crises
 Splenectomy
 Treatment of hepatic causes
 Treat the underlying disease
 Supportive care
 Pegylated interferon: chronic Hepatitis B and C
 Steroid / immunosuppressant  Autoimmune
hepatitis, Alcoholic hepatitis
 Resection/ TACE/ RFA/ Sorafenib  HCC
 Liver transplant
Treatment of post-hepatic
jaundice
 ERCP, Surgery
 Choledocholithiasis – cholecystectomy
 Carcinoma of head of pancreas – whipple resection
 Ca gallbladder – whipple resection, but if unoperable 
stenting
 Choledochal cyst : excision of the cyst with
reconstruction of extrahepatic biliary tree
 Stricture : endoscopic stenting. Standard care is
surgery by roux-en-y choledocojejunostomy
THANK YOU