Jaundice

Jaundice

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  Jaundice Jaundice TadKim, M.D. UF Surgery [email protected] (c) 682-3793; (p) 413-3222
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  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
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  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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  Jaundice 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
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  Jaundice Broad DifferentialDiagnosis ↑production ↓transport or ↓conjugation Impaired excretion Biliary obstruction ↑ Unconjugate ↑ Unconjugate ↑ Conjugated ↑ Conjugated Hemolysis Gilbert’s Rotor’s 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
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  Jaundice DDx: Unconjugatedbilirubinemia • ↑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
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  Jaundice DDx: Unconjugatedbilirubinemia • Impaired bilirubin conjugation – Gilbert’s disease – Crigler-Najarr syndrome – Neonatal jaundice (this is physiologic) – Hyperthyroidism – Estrogens – Liver diseases • chronic hepatitis, cirrhosis, Wilson’s disease
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  Jaundice DDx: ConjugatedBilirubinemia • 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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  Jaundice DDx: ObstructiveJaundice • 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)
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  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)
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  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 • Courvoisier’s sign = painless, but palpable or distended gallbladder on exam – Could indicate malignant obstruction
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  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
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  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 (Wilson’s) – Alpha-1 anti-trypsin activity (for deficiency)
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  Jaundice Imaging forObstructive 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
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  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
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  Jaundice Take HomePoints • 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)