1. TUTORIALTUTORIAL Presented by Dr. Abdulrhman M Kamel Collaborators : Dr.Mohammed Sofi ( Internal Medicine ) Dr.Nemier Khalied ( Anatomy ) Dr.Muhab ( Pharmacolgy )

2. CASE 1 Mr. Ali is 31 years old teacher came to KSMC complained of Rt hypochondruim pain=(liver) and yellowish discoloration of skin and sclera for 3 days associated with low grade fever and no itching. On Examination, patient looked ill, not pale but jaundiced BP100/70 RR14 / min Pulse 85 beats / min Low grade fever: VIRAL infec

3. Investigations CBC Results Normal range RBCs 5.2 *10 6 ( 4.8-5.5*10 6 ) PCV 47% ( 37%- 47%) MCV 86 (82-95 fl) MCH 27 (26 -33pg) MCHC 33 (32 -36 g/dl) WBCs 8.5* 10 3 (4.2-11* 10 3 ) Neutrophil 3.4 * 10 3 ( 1.5-5 * 10 3 ) Lymphocyte 5 * 10 3 (1.5 – 3* 10 3 ) Platelets 345*10 5 (150-400*10 5 ) Reticulocyte Count O.7 % Less than 1% Type of anemia

4. LFT Results Normal range Total bilirubin 3.5 ( less than 2mg/dl ) Direct Bilirubin 0.2 ( less than 0.3mg/dl ) Indirect bilirubin 1.9 ( less than 1 mg/dl ) Mr.Ali admitted for further investigations and management. Indirect high = hepatic cause

5. 1) What is the most likely diagnosis ?hepatic jaundice 2)What are the evidence that support your diagnosis 3) Justify the following Yellowish discoloration of the skin = bilirubin Hepatomegaly = congestion= inflammatory process, increase size Non itchy 4)What are the further investigation may be requested? 5)Outlines the plan of management.

6. Anatomy of biliary system Common site for gallbladder stone

7. Entrohepatic circulation

8. bile salts [95%] are reabsorbed from terminal ileum mechanism of absorption: active transport. Bile salt are returned to liver by hepatic portal system. Only 5% of bile salt are lost in the feces per day. This circulation occur 2 times per min Site of synthesis: liver Site of Storage: gallbladder Site of Action : duodenum

9. LABORATORY INVESTIGATIONS IN TYPES OF JAUNDICE مافيه شي مهم

10. CASE 2 A 10 years old received sulfonamides as prophylaxis for recurrent UTI although he was previously healthy and nourished, he became progressively ill,pale and jaundiced. The CBC reveled sever anemia. There was FH of similar condition 1.What is the most likely cause of the jaundice ? Hemolytic anemia, G6P dehydrogenase deficiency 2. Describe the CBC in such patients. High Reticulocyte Count, anemia parameter is low RBCs -PCV -MCV –MCH-MCHH

11. CASE 3 A 40 years old fat female presented with intolerance to the fat food,pain on the Rt side of the abdomen yellowish decoration and passages of clay colored stool. 1)what is the most likely diagnosis : obstructive jaundice 2) Justify the change on the stool color : no bile passing intolerance to the fat food : no bile secreted Common cause obstructive jaundice: stone, tumor Also it has itching

12. Gallstones are also associated with certain medical conditions including: 1-Diabetes 2-Liver disease 3-Crohn's disease 4-Blood disorders like sickle-cell anaemia 5-Stomach surgery - gallstones are more common if you have had surgery to remove part of your stomach Gall bladder Stone

13. Final notes Bile reabsorbed by active transport and act 2 time in one meal Most important indicator for hemolysis is retekolocyte Hypochondria pain is liver cause Hepatomegaly : inflammation*hepatitis* Hepatocellular carcinoma Congested *** itching with jaundice is obstructive jaundice ****

14. Reticulocyte Count Cholestasis is any condition in which the flow of bile from the liver is slowed or blocked.bile = obstrucibe jaundice no bile passing stone, tumor