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)

• 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

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