What is the description of jaundice and how does it present?
Accumulation of bilirubin in the skin
- pigmentation - yellow/orange
- significant itch
Where is jaundice often most noticeable?
Sclera of the eye
Why does jaundice occur?
Mainly due to haem metabolism:
- haem converted into biliverdin, then bilirubin
- necessary to allow conjugation in the liver
- followed by excretion from liver cells into the biliary tree, forming bile
- this is why bile is the colour that it is
- if the liver has any metabolic problems, then bilirubin cannot be conjugated and distributed into the kidneys and intestines
- instead it is passed into the blood and the skin which gives the yellow ‘jaundiced’ appearance
What is another cause of jaundice beside liver malfunction?
Gall stones which cause obstruction of bilirubin once it has been conjugated in the liver
What are the 3 classifications of jaundice?
- Pre-hepatic - increased haem load (e.g. incorrect blood transfusion, anything causing destruction of red blood cells)
- autoimmune, spleen, abnormal RBCs - Hepatic - liver cell failure
- cirrhosis, hepatitis - Post-hepatic
- biliary, Gall bladder and pancreatic disease
What are clinical features of jaundice?
- Conjugated bilirubin is excreted in the urine and faeces
- colour changes with cause of jaundice
- pale stool and dark urine suggest post hepatic cause (conjugated bilirubin causing jaundice)
- normal in haemolytic excess bilirubin is unconjugated
What causes pre hepatic jaundice?
- Jaundice due to factors before liver metabolism
- usually excessive quantities of red blood cell breakdown products
. Haemolytic anaemia
. Post transfusion (bad match)
. Neonatal (maternal RBC induced)
What are causes of hepatic jaundice?
- Due to liver failure
- cirrhosis
- drug induced liver dysfunction
- prevents metabolism of RBC breakdown products
Why doesn’t hepatic jaundice affect urine colour?
Unconjugated bilirubin cannot be passed into the kidneys
What causes post hepatic jaundice?
Obstruction to bile flow
- intrahepatic biliary system
. Primary biliary sclerosis
Extrahepatic biliary system - Gall bladder . Gall stones - common bile duct . Pancreatic carcinoma . Cholangiocarcinoma
Where do gall stones form and what can they cause?
- Form within gall bladder
- Can cause inflammation
- Can block the biliary tree - obstructive jaundice
- Can move out to the biliary tree
What is acute cholecystitis?
Inflammation of the gall bladder
What are symptoms of gall bladder inflammation?
- Pain in shoulder tip
- Abdominal pain right side
- radiates to the back - Pain brought on by eating fatty food
- stimulates bile release by contraction of the gall bladder - Usually gall stones
- rarely cholangiocarcinoma (bile duct cancer)
What methods can be used to image a jaundiced patient?
- Ultrasound
- detects dilated bile channels within the liver
- also dilated biliary tree - Radiographs
- show radiopaque gall stones - ERCP
- endoscopic retrograde cholangiopancreatography
- contrast of biliary tree
What are causes of pancreatic disease other than cancer?
- Pancreatitis and cystic fibrosis
- need oral pancreatic enzyme supplements in CF
- aetiological role of alcohol in chronic pancreatitis
What condition is often a consequence of chronic pancreatic disease?
Diabetes
How do we manage pre hepatic jaundice?
Identify cause of excess red blood cell breakdown/elevated haem levels in blood
How is post hepatic jaundice managed?
- Remove obstruction
- gall stones via ERCP
- gall stones via lithotripsy (ultrasound)
- force open channel with stent
How can gall stone recurrence be prevented?
- Remove gall bladder (cholecystectomy)
- Prevent build up of bile acid
- ursodeoxycholic acid
- low calorie and low cholesterol diet - Prevent bile acid reabsorption from the GIT
- colestyramine
What is the cause of neonatal jaundice?
- Increased haem breakdown
- birth trauma
- ABO and thesis incompatibility - Poor liver function in neonate
- worse if <37 weeks gestation
What is a major risk of neonatal jaundice ?
Risk of kernicterus
- brain damage from bilirubin
How is neonatal jaundice managed?
Photo therapy under blue light to break down bilirubin
