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Jaundice

Jaundice. Bilirubin Metabolism. Pre-hepatic Hepatic Post-hepatic. Bilirubin Metabolism: Pre-Hepatic. Bilirubin is formed in reticuloendothelial system as breakdown product of hemaglobin. Heme group  biliverdin  bilirubin Bilirubin is insoluble in water, bound to albumin.

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Jaundice

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  1. Jaundice

  2. Bilirubin Metabolism • Pre-hepatic • Hepatic • Post-hepatic

  3. Bilirubin Metabolism: Pre-Hepatic Bilirubin is formed in reticuloendothelial system as breakdown product of hemaglobin. Heme group biliverdin bilirubin Bilirubin is insoluble in water, bound to albumin. Bilirubin circulates in the blood before uptake by the liver. Pre-hepatic jaundice = if not taken up by the liver/produced in excess, unconjugated bilirubin is deposited in extra-hepatic tissues. Kernicterus in newborns

  4. Bilirubin Metabolism: Hepatic • Bilirubin is taken up into hepatocytes and conjugated to glucuronic acid = bilirubin diglucuronide > bilirubin monoglucuronide > secreted into bile • The glucuronide conjugated form of bilirubin is water soluble and is excreted into bile. • Hepatic jaundice = disorders of bilirubin uptake or conjugation

  5. Bilirubin Metabolism: Post-Hepatic • Glucuronide-conjugated bilirubin degraded to urobilinogen. • Urobilinogen pathway: • may be reabsorbed by the gut and returned to the liver • converted to urobilin > reabsorbed into plasma for excretion by kidneys • May be acted upon by bacterial enzymes within the gut to form the bile pigment stercobilinogen > stercobilin>brown color of feces • Obstructive jaundice = failure of bilirubin to reach the gut > light colored stool, dark urine.

  6. DDX

  7. DDX: Conjugated Hyperbilirubinemia Intrahepatic Cholestasis (impaired excretion) Functional, obstructive Hepatitis (viral, alcoholic, and non-alcoholic) Primary biliary cirrhosis or end-stage liver dz Sepsis and hypoperfusion states TPN Pregnancy Infiltrative disease: TB, amyloid, sarcoid, lymphoma Drugs/toxins i.e. chlorpromazine, arsenic Post-op patient or post-organ transplantation Hepatic crisis in sickle cell disease

  8. DDX: Obstructive Jaundice Extrahepatic Cholestasis (obstructive jaundice) Choledocholithiasis Cancer/Neoplasm: Pancreatic CA Cholangiocarcinoma (rare) Gallbladder CA Ampullary adenoma/adenocarcinoma Duodenal adenoma/adenocarcinoma Metastatic CA (and adenopathy of porta hepatis) Strictures after invasive procedures Acute and chronic pancreatitis Primary sclerosing cholangitis (PSC) Parasitic infections

  9. Evaluation: History Fever/chills, RUQ pain (cholangitis) Use of alcohol Hepatitis risk factors Inherited disorders including liver diseases and hemolytic conditions H/O blood transfusion TPN use H/O abdominal surgery Travel history Use of drugs or herbal medications Exposure to toxic substances

  10. Evaluation: PE Look for jaundice: under tongue, conjunctiva, skin (>1.5mg/dL) Signs of end stage liver disease (cirrhosis): ascites, splenomegaly, spider angiomata, and gynecomastia Hyperpigmentation (hemochromatosis) Kayser-Fleischer ring (Wilson’s disease) Courvoisier’s sign = painless, palpable/distended gallbladder on exam (think of CA)

  11. Evaluation: Labs CBC – infection, anemia LFTs Bilirubin (total/direct/indirect) AST, ALT (AST/ALT) Predominant increase in AST/ALT implies intrinsic hepatocellular disease Alk Phos, GGT ↑Alk Phos also seen in sarcoid, TB, bone In this case, GGT is specific for biliary origin INR/albumin CA 19.9 AFP

  12. Evaluation: Additional Labs Further specific labs. Serologic tests for viral hepatitis Antimitochondrial antibodies (for primary biliary cirrhosis) Anti-nuclear anti-smooth muscle (sm), and liver-kidney microsomal (LKM) antibodies (for autoimmune hepatitis) Serum levels of iron, transferrin, and ferritin (for hemochromatosis) Serum levels of ceruloplasmin (for Wilson's disease) Measurement of alpha-1 antitrypsin activity (for alpha-1 antitrypsin deficiency)

  13. Imaging for Obstructive Jaundice RUQ U/S: Stones, wall thickening, edema, CBD diameter/obstruction MRCP ERCP Direct visualization of biliary tree & pancreatic ducts Procedure of choice for choledocholithiasis Diagnostic & therapeutic PTC When ERCP not possible CT scan: identification and description of obstruction Endoscopic U/S: visualization of the common bile duct without the hindrance of overlying bowel gas

  14. Treatment Start with ABCs & resuscitation If obstructive jaundice: Ascending cholangitis: IVF, ABX, decompression (medical emergency) Stones: remove using ERCP or surgery Benign stricture: stent vs. drainage catheter Cancer: Stent vs. drainage +/- resection of CA Primary goal = decompression

  15. Take Home Points Jaundice DDX is extensive DDX starting point: pre-hepatic, hepatic, post-hepatic Obstructive jaundice: choledocholithiasis, tumors, PSC, pancreatitis, stricture, parasites Ascending cholangitis is an emergency that must be identified and treated promptly Imaging: U/S, EUS, CT, ERCP, MRCP Treatment of obstructive jaundice: decompression

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