Jaundice

Jaundice

Jaundice

Overview

Normal Physiology
Pathophysiology
Broad Differential Diagnosis
DDx of Obstructive Jaundice
Work-up for Medical Jaundice
Work-up if Obstructive Jaundice
Treatment of Obstructive Jaundice

Jaundice

Normal Physiology
Bilirubin is from breakdown of hemoglobin
Unconjugated bilirubin transported to liver
Bound to albumin because insoluble in water

Transported into hepatocyte & conjugated

With glucuronic acid now water soluble

Secreted into bile

In ileum & colon, converted to urobilinogen
10-20% reabsorbed into portal circulation and
re-excreted into bile or into urine by kidneys

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Pathophysiology
Jaundice = bilirubin staining of tissue @ lvl
greater than ~2
Mechanisms:
production of bilirubin
hepatocyte transport or conjugation
Impaired excretion of bilirubin
Impaired delivery of bilirubin into intestine
surgically relevant jaundice or obstructive
jaundice
Cholestasis refers to the latter two, impaired
excretion and obstructive jaundice

Jaundice

Broad Differential Diagnosis

production

transport or
conjugation

Impaired
excretion

Biliary
obstruction

Unconjugate Unconjugate Conjugated

Conjugated

Hemolysis

Gilberts

Rotors

CH/CBD stone

Transfusions

Crigler-Najarr

DubinJohnson Stricture

Txfusion rxn

Neonatal

Cancer

Cancer

Sepsis

Cirrhosis

Cirrhosis

Chronic
pancreatitis

Burns

Hepatitis

Hepatitis

PSC

Hgb-opathies

Drug inhibition Amyloidosis

Pregnancy

Jaundice

DDx: Unconjugated bilirubinemia

production
Extravascular hemolysis
Extravasation of blood into tissues
Intravascular hemolysis
Errors in production of red blood cells

Impaired hepatic bilirubin uptake(trnsport)

CHF
Portosystemic shunts
Drug inhibition: rifampin, probenecid

Jaundice

DDx: Unconjugated bilirubinemia

Impaired bilirubin conjugation
Gilberts disease
Crigler-Najarr syndrome
Neonatal jaundice (this is physiologic)
Hyperthyroidism
Estrogens
Liver diseases
chronic hepatitis, cirrhosis, Wilsons disease

Jaundice

DDx: Conjugated Bilirubinemia

Intrahepatic cholestasis/impaired excretion
Hepatitis (viral, alcoholic, and non-alcoholic)
Any cause of hepatocellular injury

Primary biliary cirrhosis or end-stage liver dz

Sepsis and hypoperfusion states
TPN
Pregnancy
Infiltrative dz: TB, amyloid, sarcoid, lymphoma
Drugs/toxins i.e. chlorpromazine, arsenic
Post-op patient or post-organ transplantation
Hepatic crisis in sickle cell disease

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DDx: Obstructive Jaundice

This is the slide to remember for surgeons
Obstructive Jaundice extrahepatic
cholestasis
Choledocholithiasis (CBD or CHD stone)
Cancer (peri-ampullary or cholangioCA)
Strictures after invasive procedures
Acute and chronic pancreatitis
Primary sclerosing cholangitis (PSC)
Parasitic infections
Ascaris lumbricoides, liver flukes

Just remember top 5 (not parasites)

Jaundice

Initial Evaluation: History

Jaundice, acholic stools, tea-colored urine
Fever/chills, RUQ pain (cholangitis)
Could lead to life-threatening septic shock

Reasons to have hepatitis or cirrhosis?

Alcohol, Viral, risk factors for viral hepatitis

Exposure to toxins or offending drugs

Inherited disorders or hemolytic conditions
Recent blood transfusions or blood loss?
Is patient septic or on TPN?
Recent gallbladder surgery? (CBD injury)

Jaundice

Initial Evaluation: Physical Exam

Signs of end stage liver disease (cirrhosis)
Ascites, splenomegaly, spider angiomata, and
gynecomastia

Jaundice evident first underneath the

tongue, also evident in sclerae or skin
Courvoisiers sign = painless, but palpable
or distended gallbladder on exam
Could indicate malignant obstruction

Jaundice

Screening Labs
NL LFT r/o hepatic injury or biliary tract dz
Consider inherited disorders or hemolysis

Alk Phos moreso than AST/ALT implies

cholestasis (intrahepatic vs obstruction)
Alk Phos also seen in sarcoid, TB, bone
In this case, GGT is specific for biliary origin

Predominant AST/ALT implies intrinsic

hepatocellular disease
AST/ALT ratio > 2 in alcoholic hepatitis

albumin or INR c/w advanced liver dz

Jaundice

Subsequent Labs
If no concern for obstructive jaundice:
Viral (Hep B&C) serologies for viral hepatitis
anti-mitochondrial Ab (PBC)
anti-smooth muscle Ab (Auto-immune)
iron studies (hemochromatosis)
ceruloplasmin (Wilsons)
Alpha-1 anti-trypsin activity (for deficiency)

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Imaging for Obstructive Jaundice

RUQ Ultrasound
See stones, CBD diameter

CT scan
Identify both type & level of obstruction

ERCP
Direct visualization of biliary tree/panc ducts
Procedure of choice for choledocholithiasis
Diagnostic AND- therapeutic (unlike MRCP)

PTC useul of obstruction is prox to CHD

Endoscopic Ultrasound or EUS

Jaundice

Treatment
If Medical, then treat the etiology
If Obstructive Jaundice:
Should r/o ascending cholangitis, ABC/resusc
For cholangitis: IVF, IV Antibiotics, Decompression

Stones (remove stones vs stent vs drainage)

Done via ERCP or PTC or open (surgery)

Benign stricture (stent vs drainage catheter)

Cancer (Stent vs drainage +/- resect the CA)

The key principle is decompression, either

externally(drainage) or internally(stenting)
the duct open to allow better drainage

Jaundice

Take Home Points

Above is a comprehensive approach
For surgery clerkship, all you need to
know is:
1. Broad categories (no specific diagnoses)
2. The four DDx of obstructive jaundice
3. H&P (ask about fevers/chills, jaundice,
acholic stools, dark urine, weight loss for CA),
r/o ascending cholangitis = emergency
4. Labs (LFT: ?cholestatic, CBC w diff, BMP)
5. Imaging (U/S, CT, MRCP, EUS)
6. Therapy (ERCP vs PTC vs surgery)