1. Khalid Bzeizi

2.  Jaundice, also known as icterus, is a yellowish discoloration of the Skin,Sclera and Mucus membranes caused by hyperbilirubinemia.  Typically, the concentration of bilirubin in the plasma must exceed 1.5 mg/dl (> 40.0 mmol/L), three times the usual value of approximately 0.5 mg/dl (17 mmol/L.), for the coloration to be easily visible.

3. 85% from old RBC, the rest from non haem proteins Hb is degraded to Haem and globin Iron is extracted from Haem Rest is converted to bilirubin (porphorin metabolism) Bilirubin travels to liver bound to albumin

5.  Hyperbilirubinemia is due to:  Excess bilirubin production Haemolytic  Impaired uptake by hepatocyte Hep/cellular.  Failure of Conjugation Hep/cellular.  Impaired secretion of conj.bil. Hep/cellular.  Impaired bile flow. Obst.Jaundice

7. SpherocytosisThalassemiaSickle cell disease Gilbert Syndrome (Defect in bilirubin transfer) Crigler-Najjar Syndrome

11.  Clinical Features  Jaundice not typically severe   Increased unconjugated plasma bilirubin  Increased urobilinogen in urine  AP. ALT, AST - normal

12. 1ry Biliary CirrhosisViral HepatitisPregnancyToxic Drugs

13.  Viral hepatitis  Hepatitis B  Hepatitis C  Alcoholic Liver (ALD)  Autoimmune liver disease:  Autoimmune hepatitis  Primary Biliary Cirrhosis (PBC)  Inherited conditions  Haemochromatosis  Wilson’s Disease  Alpha1-Antitrypsin Deficiency (AATD)  Non-alcoholic steato- hepatitis (NASH)  Budd-Chiari syndrome  Cryptogenic 13

14. 14 Conventional Drugs Natural Substances Acetaminophen, Alpha-methyldopa Vitamins, Hypervitaminosis A Amiodarone, Dantrolene, Diclofenac Niacin, Cocaine, Mushrooms Disulfiram, Fluconazole, Glipizide Aflatoxins, Herbal remedies Glyburide, Isoniazid, Ketaconazole Senecio, crotaliaria, Labetalol, Lovastatin, Nitrofurantoin Pennyroyal oil, Chapparral, Thiouracil, Troglitazone, Trazadone Germander, Senna, Herbal mix.

15. 15  Anabolic steroids (testosterone, norethandrolone)  Antithyroid agents (methimazole)  Azathioprine (Immunosuppressive drug)  Chlorpromazine HCI (Largactil)  Clofibrate, Erythromycin estolate  Oral contraceptives (containing estrogens)  Oral hypoglycemics (especially chlorpropamide)

16.  Bile duct  In the lumen of the common bile duct  (gallstones  In the wall of the duct 1. Benign stricture 2. Cholangiocarcinoma  Pressing in/on the bile duct 1. Pancreatitis 2. Pancreatic cancer 3. Lymph node enlargemeny 4. Periampullary carcinoma

17.  Asymptomatic  Gallstones can cause Chronic Cholecystitis Acute Biliary Colic Jaundice Cholangitis & Septicemia Acute pancreatitis Biliary fistula Mirrizi Syndrome + Gallstone ileus

18. Clinical Picture Jaundice Weight loss Recent Onset of DM Itching

19.  It is very important to distinguish between adenocarcinoma Head, Body, Tail & Periampullary Tumours because of different prognosis Periampullary 5 y survival 40 % Cancer Head <5 %

20. The commonest Malignancy (3- 4% of all GIT Cancers). Disease of old age Gallstones present in 75-90% Carcinoma Of Gallbladder Cholangiocarcinoma Intrahepatic (minor hepatic ducts-Multicentric) Proximal (Rt, Lt Hepatic ducts-Hilar Conf.- Proximal CHD) Middle : (Distal CHD, Cystic duct & its conf. with CBD) Distal : (Periampullary Tumours) Bile Duct Cancer

21.  C/P Painless, Progressive Jaundice, Itching Rarely with Incresd S.Amylase Or Grey stool.  Includes Cancer Of:  The Ampulla Of Vater  Distal CBD  The duodenum.  Prognosis: Stage dependant: T1,2 Very good 30-50% 5y.survival after surgery.

22. MalignantBenign Iatrogenic Sclerosing Cholangitis

23.  Malabsorbtion  Fat (steatorrhoea) Fat soluble vitamins (DEKA)  Jaundice – Bilirubin, No bilirubin metabolites in stool – Pale  Itch – Bile salts  Sepsis, cholangitis, Charcots triad  ? Renal failure (Hepato-renal syndrome)  Bleeding - High INR

24.  1. Jaundice  2. Intermittent chills / fever or rigors  3. Abdominal pain  Charcot’s triad indicats cholangitis, this causes severe sepsis and may result in liver abscess formation

26.  Pale stools  Dark Urine  Itch ?  Pain  Intermittent, or progressive  Drugs  Surgery (anaesthetics)  Blood transfusion, inoculations  Family History

27.  Important Aspects Of Patient History  Any Abdominal Pain, Weight Changes And / Or Fever  Injections  Alcohol Abuse.  Blood Transfusion  Contact with Jaundiced patient.  Travel to Endemic Area.  Sexual Activity.

28.  General: Stigmata Of Liver Disease & Weight Loss.  Neck: Enlarged L.Ns & Virchow L.N.  Abdomen: Prominent ant.abd.wall veins. Enlarged Liver, Spleen Palpable Abdominal mass. Ascites 1-Spider Naevi 2-Palmar Erythema 3-Finger Clubbing 4-Leuchonychia 5-Gynecomastia 6-Ascites

29. Lab. Workup:  Urinalysis  CBC  Liver blood tests: AST, ALT, GGT, ALP & Albumin  Fractionanted bilirubin.

30.  Ultrasound (Abdominal ultrasound)  X-ray ( Plain abdominal film)  C.T  C.T + PET  PTC  ERCP  MRCP

36.  Liver Biopsy