APP R O A C H T O
J A U N D IC E D P A T IE N T
, MRCSI
DR ABDALLAH HAWARI, MD
VASIVE SURGEON
GENERAL AND MINIMALLY IN
PATO BI LI ARY – PANCREAT IC SURGEON
HE
• Definition
• Epidemiology
• Pathophysiology
• Etiology
• Presentation
• Examination
• Investigation
• Management
NORMAL BILIRUBIN METABOLISM
• Bilirubin is generated from heme products, primarily senescent red blood cells.
• A small portion is derived from myoglobin and maturing erythroid cells.
• Within the reticuloendothelial system, heme is oxidized to biliverdin, which is then
converted to bilirubin.
• Heme is initially broken down into a green biliverdin by
heme oxygenase.
• which is then broken down into the orange bilirubin by biliverdin
reductase
NORMAL BILIRUBIN METABOLISM
• Unconjugated bilirubin forms a tight but reversible bond with albumin in
circulation.
• Circulating bilirubin is bound to albumin, which protects many organs from the
potentially toxic effects.
• The bilirubin-albumin complex enters hepatic sinusoidal blood, where it enters the
space of Disse through the large sinusoidal [Link] bilirubin-albumin
complex is disassociated in this space.
NORMAL BILIRUBIN METABOLISM
• It is passively taken into the hepatocytes undergoes glucuronidation (where it is
conjugated to glucuronic acid) and at this point has become conjugated bilirubin .
• This conjugated fraction is secreted into the biliary system and emptied into the gut.
• Colonic bacteria metabolize the majority of the bilirubin to urobilinogen and
stercobilin.
• Stercobilin is excreted in the stool (causing the stool to turn brown).
• urobilinogen is reabsorbed and excreted in the urine.
• The remaining conjugated bilirubin is deconjugated and reenters the portal circulation
to be taken up again by the hepatocytes (enterohepatic circulation).
DEFINITION
• Yellowish discoloration of the skin , sclerae and mucous membrane
due to hyperbilirubinemia .
• Normal bilirubine level 0.3 -1.3 mg/dl .
• Manifested when serum bilirubine level > 3 mg/dl .
• Beside to a raise in the serum bilirubine level , yellowness of the skin
can be due to carotenaemia ( excess in diet ) or , use of druge
quinacrine .
• It is not a
disease , rather it
is a sign of many
diseases
CAUSES OF JAUNDICE
Pre-Hepatic Hepatocellular Post-Hepatic
•Alcoholic liver disease
•Viral hepatitis •Intra-luminal causes, such as
•Iatrogenic, e.g. medication gallstones
•Haemolytic anaemia •Hereditary •Mural causes, such as
•Gilbert’s syndrome haemochromatosis cholangiocarcinoma, strictures,
•Criggler-Najjar •Autoimmune hepatitis or drug-induced cholestasis
syndrome •Primary biliary cirrhosis or •Extra-mural causes, such as
primary sclerosing pancreatic cancer or abdominal
cholangitis masses (e.g. lymphomas)
•Hepatocellular carcinoma
• TEA COLOUR URINE DUE
BILIRUBINUREA
CLAY COLOUR STOOL (( PALE STOOL ))
CLINICAL PRESENTATION OF JAUNDICE PATIENT
HISTORY TAKING
SYSTEMATIC APPROCH
• Sequential site of jaundice
• 1st stage:FRENULUM OF THE TONGUE ( > 1.5mg /dl )
• 2nd stage : sclera of the eye ( 3 mg/dl )
• 3rd stage : skin ( > 3.5 MG /DL )
• Yellow sclera : should be examined at
day light .
• Gentile lower eye lid traction
SPECTRUM OF COLOR CHANGES
• PALE YELLOW: haemolytic jaundice where bilirubin not exceed 5mg/dl
• ORANGE YELLO: in hepatic mild to moderate jaundice
• YELLOW GREEM : in complete obstructive jaundice / chronic jaundice
• Kayser fleischer ringe
XANTHALASMA
• Parotid glands
enlargement
LEUKONYCHIA AND CLUBBING FINGERS
PULMER ERYTHEMA AND MUSCLE WASTING
DUBYTRINE CONTRACTURE
ASTREXIA (( FLAPPING TREMOR ))
• Constructional apraxia refers to the inability of
patients to copy accurately drawings or three-
dimensional constructions.
• Itching : look for
scratch markes
PURPURA AND ECHYMOSIS
• Spider naevi
• TATOO
• Xanthomas
CAPUT MEDUSAE
• Ascites
• Gynecomastia
TESRTICULAR ATROPHY
LAB TESTS
BLOOD TESTS
POST HEPATIC JAUNDICE
PREHEPATIC JAUNDICE HEPATIC JAUNDICE
Total serum bilirubin Normal / increased Increased Increased
Conjugated bilirubin Normal Increased Increased
Unconjugated bilirubin Normal / increased Increased Normal
Urobilinogen Normal / increased Decreased Decreased / negative
Dark (urobilinogen, conjugated
Urine color Normal[38] Dark (conjugated bilirubin)
bilirubin)
Stool color Brown Slightly pale Pale, white
Alkaline phosphatase levels Increased Highly increased
Normal
Alanine transferase and aspartate
Highly increased Increased
transferase levels
Conjugated bilirubin in urine Not present Present Present
RADIOLOGICAL STUDY
ABDOMINAL ULTASOUND
• NONE INVASIVE
• CHEAP AND EASLY AVALABEL
• SENSITIVE FOR LIVER LESION
• DIAGNOSTIC OF GALL BLADDER STONE
• INTRA AND EXTRA HEPATIC BILIARY TREE EVALUATION
• SIZE OF THE LIVER
• ASCITIC FLUID
• CAN BE USE AS GAIDANCE FOR THERAPUTIC PROCEEDURE
ABDOMINAL ULTRASOUND
MAGNATIC RESONANCE PANCREATICO-
CHOALANGIORAPHY (( MRCP ))
ENDOSCOPIC RETROGRADE PANCREATICO-
CHOLANGIOGRAPHY (( ERCP ))
INTRA-OPERATIVE CHOLANGIOGARPHY (( IOC))
C T SCAN STUDY
C T SCAN AND MRCP
CHOLANGIOCARCINOMA
PERCUTANOUS TRANSHEPATIC CHOLANGIOGRAPHY
PERCUTANOUS TRANSHEPATIC DRAINAGE
• T- TUBE
CHOLANGIOGRAM
ENDOSCOPIC ULTRASOUND
• LESION DETECTION
• FINE NEEDLE ASPIRATION FOR
CYTOLOGY AND DIAGNOSIS
• THERAPUTIC GAIDANCE FOR
DRAINAGE OF CYSTS
