“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-HepaticHeptaicPost-Heptaic
Type of bilirubin elevatedUnconjugatedBoth conjugated and unconjugatedConjugated
Serum bilirubin – Van den Bergh testIndirect positiveBiphasicDirect positive
Urine
– Conj. Bilirubin
– Urobilinogen
– Bile salt

Absent
+++
Absent

++
+ early, obst. -dec
+

+++
Absent
++
Urine colourNormal – AcholuricDark – CholuricDark – Choluric
Stool colourDark brown colournormal / decreasedClay coloured stools
AST & ALTNormalVery highIncreased
ALP LevelsNormal2-3 times increased10-12 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

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