TBL - Jaundice and Hepatitis

jaundice / hepatitis

jaundice

Jaundice is a yellowish colouration of the tissue resulting from the deposition of bilirubin

This only happens in the presence of serum hyperbilirubinemia, and is a sign of either

·         Liver disease

·         Hemolytic disorder (less commonly)

The degree of bilirubin elevation can be estimated by PE.

Sclera icterus = at least 51micromol/L (3mg/dL)

May be even green in colour if long-standing (oxidation of bilirubin to biliverdin)

Differential of yellow skin

·         Caretenoderma

·         Quinacrine

·         Phenol exposure

Increased bilirubin occurs when there is an imbalance between the production and clearance of bilirubin.

It may result from

·         Over-production of bilirubin

·         Impaired…

o    Uptake

o    Conjugation

o    Excretion

·         Regurgitation of unconjugated / conjugated bilirubin from damaged hepatocytes / bile ducts.

Initial steps in jaundice patient evaluation

History taking

Some presentation of jaundice are quite characteristic, and such history presentation should warrant a confirmatory  investigations.

·         Fever + nausea + Anorexia (even cigarettes also does not want)

o    Suggestive of viral hepatitis

§  Comfirmation by HepA IgM, Hep B surface antigen, Hep C IgM etc.

·         Pruritis + dark urine + pale stools

o    Suggestive of cholestasis

§  Check by bilirubin study (urobilinogen,

§  Alkaline phosphatase

§  Ultrasound of bile ducts

·         Fatty food triggers colicy pain

o    Suggestive of bile stone causes

§  Ultrasound

§  ERCP

·         Progressive jaundice + fever + chills + rigors (Charcot’s triad)

o    Stone obstructive cholangitis

§  ERCP

§  Ultrasound

·         Jaundice + fever + Conjuctivitis + muscle aches + passage of small and dark urine

o    Leptospirosis

§  Darkfield microscopy

·         Recurrant mild jaundice which worsen with fasting / fever

o    Gilbert syndrome

·         Hematemesis + easy brising, mental confusion, inverted sleep pattern after severe illness like CHF, Shock etc

o    Liver insufficiency causing hepatic encelopathy

§  Liver function tests

Physical examination

Physical examination is often useful, after a sufficient history has been taken from the patient.

History and physical exam should come hand in hand, to provide a solid Differential Diagnosis for us to proceed onto the investigations.

Investigations

·         Full blood count

o    To rule out hemolytic causes

o    Leucocyte – bac. infection

·         Liver biochemistry

o    To rule out hepatocellular causes

·         Bilirubin study

o    Conjugated hyper bilirubinemia

§  Hepatocellular origin

o    Unconjugated
hyper bilirubinemia

§  Over production,

§  Impared hepatic intake

§  Impared conjugation

·         Viral Markers

o    hepatitis viruses

o    EBV

o    CMV

·         Serum alpha-fetoprotein

o    Hepatocellular carcinoma,

o    Germ cell tumors

o    metastatic cancers of the liver.

·         Serum Albumin:

o    low level indicative of chronic liver disease.

·         Prothrombin Time:

o    sensitive indicator of chronic liver disease. Will be prolonged. Vitamin K deficiency must be excluded.

·         Aspartate Aminotransferase:

o    increased in hepatic necrosis, MI, muscle injury, CCF

·         Alkaline Phosphatase:

o    increased in cholestasis(intra/extrahepatic), metastasis of liver, cirrhosis.

·         Ȣ-Glutamyl Transpeptidase:

o    increases with alcohol consumption and drugs i.e. phenytoin

imaging

·         Ultrasound Imaging

o    Bile duct imaging

o    Gallstones?

o    Hepatic mets?

o    Pancreatic mass?

·         CT Scan

o    Abdominal malignancy?

o    Masses in abdomen?

·         Endoscopy (ERCP)

o    Bile duct opening

o    Bile duct obstruction

algorhythm of jaundiced patient (from Harrison 16th ed)