Gastrointestinal System >
Jaundice
“Jaundice (aka icterus) is a yellowing of the skin and sclera due to high bilirubin levels”
Risk Factors
- Alcohol
- Trave
- Drugs
- Pain (Gallstones)
- Weight loss (Malignancy)
- Parenteral exposure (Transfusion, IVDA, Tattoos, Sexual)
Aetiology
Pre-hepatic, Hepatic, Post-hepatic set of causes
Pathophysiology
- Pre-Hepatic:
- Excess/premature red cell destruction (unconjugated hyperbilirubinaemia):
- Haemolysis (e.g. infection malaria, sickle cell anemia/thalassaemia)
- Haematoma
- Decreased bilirubin conjugation (Gilbert´s syndrome, Cringler-Najjar syndromes types I and II, physiological neonatal jaundice)
- Excess/premature red cell destruction (unconjugated hyperbilirubinaemia):
- Hepatic:
- Impaired canalicular excretion of conjugated bilirubin (Dubin-Johnson syndrome, Rotor syndrome)
- Hepatocellular:
- Viruses – Hep. A, B, C, D, E, EBV, CMV, HSV
- Drugs/Toxins – Alcohol, Anabolic steroids, Paracetamol overdose,…; Environmental toxins e.g. vinyl chloride
- Autoimmune – Autoimmune hepatitis, primary biliary cirrhosis, primary sclerosing cholangitis
- Metabolic – Wilson´s disease, Haematochromatosis
- Post-Hepatic:
- Benign:
- Choledocholithiasis (most common)
- Parasite
- Malignant:
- Pancreatic carcinoma
- Cholangiocarcinoma
- Gallbladder carcinoma
- Ampullary carcinoma
- Porta hepatis lymph nodes
- Benign:
Clinical Presentation
- Right upper quadrant tenderness, guarding and rigidity
- Severe right upper quadrant tenderness with Murphy´s Sign
- Charcot´s triad: pyrexia, jaundice and pain suggest cholangitis
- Courvoisier´s law: palpable gallbladder in the presence of jaundice is suggestive of pancreatic carcinoma
Investigations
- LFT: Bilirubin, ALT, Alkaline Phosphatase, Albumin, total protein and albumin
- Imaging: U/S, CT, MRCP, ERCP
Pre-Hepatic | Heptaic | Post-Heptaic | |
---|---|---|---|
Type of bilirubin elevated | Unconjugated | Both conjugated and unconjugated | Conjugated |
Serum bilirubin – Van den Bergh test | Indirect positive | Biphasic | Direct positive |
Urine – Conj. Bilirubin – Urobilinogen – Bile salt | Absent +++ Absent | ++ + early, obst. -dec + | +++ Absent ++ |
Urine colour | Normal – Acholuric | Dark – Choluric | Dark – Choluric |
Stool colour | Dark brown colour | normal / decreased | Clay coloured stools |
AST & ALT | Normal | Very high | Increased |
ALP Levels | Normal | 2-3 times increased | 10-12 times increased |
Management
- Pre-Hepatic: prevent rapid haemolysis
- Hepatic: aim of treatment is to prevent any further liver damage occurring
- Post-Hepatic: often surgery to unblock the bile system