Clinical round By Dr. Ehab M. Oraby Jaundice Clinical round By Dr. Ehab M. Oraby

Definition Yellowish discoloration of: Tissues  ex. Sclera and palate except brain. Body fluids urine and stool except CSF, tears and saliva. Definition Dr. Ehab M. Oraby

Pathophysiology: Destruction of RBCs  release of HB  Haeme + Globin Haeme  iron + bilirubin (in unconjugated form = water insoluble). Conjugation occurs in liver (bilirubin becomes water soluble). Pathophysiology: Dr. Ehab M. Oraby

Secretion of conjugated form of bilirubin to biliary tract then to GIT  stool coloration. Some of conjugated bilirubin absorbed from GIT to circulation  renal excretion. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Hemolytic Anemia: Young age. Congenital or Acquired. Attacks of “crisis” ++ Hemolysis  ++ unconjugated bilirubin, ++ conjugation, ++ conjugated bilirubin  dark stool & normal urine. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Hemolytic Jaundice: Anemia (chronic with periodic exacerbations). During attacks  diffuse abdominal pain + bony pains + fever with rigors. Splenomegaly. Gall stones “pigment stones”. Leg ulcers. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Hepatocellular Jaundice: Any age. Mostly viral hepatitis  cirrhosis. Others: drug induced hepatitis. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Hepatocellular Jaundice: Liver fail to conjugate bilirubin + fail to properly secrete conjugated fraction to biliary tree  ++ blood level of conjugated bilirubin and bile salts. Conjugated bilirubin  jaundice + excreted in urine  dark urine. Bile salts in blood  pruritus. Stool is normal. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Hepatocellular Jaundice: Other stigmata of LCF: gynecomastia, spider naevi, palmar erythema, ascites and lower limb edema Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Obstructive Jaundice: Failure of bile drainage  ++ blood level of conjugated bilirubin and bile salts  jaundice, dark urine, pale clay stool and pruritus. Obstruction is either calcular or malignant. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Calcular obstruction: Females, Middle age. By gall stone impacted in ampulla of vater. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Calcular obstruction: Intermittent jaundice + pain “biliary” + fever. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Calcular obstruction: Gall Bladder is non-palpable except in cases with: double impaction or strategic impaction. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Re Calcular obstruction: Intermittent Females, Middle age. By gall stone impacted in ampulla of vater. Intermittent jaundice + pain “biliary” + fever. Gall Bladder is non-palpable except in cases with double impaction or strategic impaction. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Malignant Obstruction: Males, old age. By: Pancreatic head tumors Malignant LN in porta hepatis Bile duct cancer”cholangiocarcinoma”. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Malignant Obstruction: Painless except late. Epigastric pain referred to back  patient position is leaning forward. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Malignant Obstruction: Jaundice is progressive except: in cases with peri-ampullary carcinoma. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: Malignant Obstruction: Gall Bladder is palpable “courvoiser law” except in cases with: double pathology “cancer + gall stone” or malignant LN ???coming from cancer Gall Bladder. Pathophysiology: Dr. Ehab M. Oraby

Pathophysiology: ReMalignant Obstruction: Males, old age. By: Pancreatic head tumors Malignant LN in porta hepatis Bile duct cancer”cholangiocarcinoma”. Painless except late. Epigastric pain referred to back  patient position is leaning forward. Jaundice is progressive except in cases with peri-ampullary carcinoma. Gall Bladder is palpable “courvoiser law” except in cases with double pathology “cancer + gall stone” or malignant LN ??? coming from cancer Gall Bladder. Pathophysiology: Dr. Ehab M. Oraby

Dr. Ehab M. Oraby

Examination General examination Look Fascies Complexion Body built and position Vital signs Regional survey Examination Dr. Ehab M. Oraby

Examination Local abdominal examination: Inspection: General look: Movement with respiration Contour Scars Dilated veins Pigmentation Specific look: Subcostal angle Linea alba Umbilicus Hair distribution Hernial orifices Examination Dr. Ehab M. Oraby

Examination Palpation: Superficial palpation Deep palpation: Liver Gall Bladder Spleen Lymph Nodes swelling Examination Dr. Ehab M. Oraby

Examination Percussion: Auscultation: Liver Gall Bladder Spleen Ascites Swelling Auscultation: Venous hum with portal hypertension Examination Dr. Ehab M. Oraby

Anatomical Pathophysilogical Functional Diagnosis Dr. Ehab M. Oraby