1. Jaundice

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4. Definition 4 Jaundice ， or icterus ， is a yellowish discoloration of tissue resulting from the deposition of bilirubin. The presence of scleral icterus indicates a serum billirubin exceeds 40 μmol/L (~2.5 mg/dL) Scleral icterus difficult to identify in fluorescent lighting.

5. Van den Bergh method the normal serum bilirubin concentration usually is < 1 mg/dL(17 μmol/L). Up to 30% (0.3 mg/dL) of the total may be direct- reacting (conjugated) bilirubin. Total serum bilirubin are between (0.2 and 0.9 mg/dL) in 95% of a normal population Formation of bilirubin occurs in reticuloendothelial cells primarily in the spleen and Iiver. 5

6. Bilirubin metabolism 6

7. Lipid soluble, unconjugated bilirubin is always bound to albumin in the serum. Delta bilirubin/Delta Fraction/Biliprotein: Albumin- Linked (covalently) conjugated bilirubin fraction formed when hepatic excretion is impaired and accumulate in serum. Its half-Iife like albumin (12-14 days) rather than the short half-Iife of bilirubin (4 h) Any bilirubin found in the urine is conjugated. The presence of bilirubinuria implies the presence of Liver disease. 7

8. Site : skin, sclera & underneath the tongue A sensitive indicator of increased serum bilirubin is darkening of the urine. Differential diagnosis : Carotenoderma ， Drug: Quinacrine Excessive exposure to phenols. Carotenoderma : Carrots ， leafy vegetables ， squash, peaches ， and oranges. Involving palms ， soles ， forehead ， and nasolabial folds. Sparing sclera. 8

9. Types Prehepatic / Hemolytic jaundice Hepatocellular jaundice Post hepatic / Obstructive/ Cholestatic jaundice 9 Hyperbilirubinemia may result from Overproduction of bilirubin Impaired uptake, conjugation or excretion of bilirubin Regurgitation of unconjugated or conjugated bilirubin from damaged hepatocytes or bile ducts.

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11. Questions ? Isolated elevation of serum bilirubin? Unconjugated or conjugated fraction? Is accompanied by other liver test abnormalities? Is the disorder hepatocellular or cholestatic? If cholestatic,is it intra or extra hepatic? Answered with a thoughtful history, physical examination ， and interpretation of laboratory and radiologic tests and procedure 11

12. Classification: Unconjugated Hyperbilirubinemia 12

13. Classification : Mainly Conjugated Hyperbilirubinemia 13

14. History Onset and duration of jaundice; Exposure to possibly contaminated foods; Use of herbal or other drugs (e.g. Anti TB) Possible recent surgery, parenteral transfusions, intravenous drug use, tattooing and sexual activity. Recent travel history; exposure to people with jaundice; Occupational exposure to hepatotoxins; alcohol consumption; 14

15. History cont... Urine and stool color Prodromal symptoms (e.g. fever, malaise and myalgia) Fever with/without chills (e.g. Enteric fever) Pruritus Steatorrhea Weight loss Abdominal pain (location, severity, duration and radiation) 15

16. Past medical history Hepatobiliary disease: gallstones, hepatitis, cirrhosis Disorders that could cause hemolysis: hemoglobinopathy, G6PD deficiency. Infiltrative disorders: amyloidosis, lymphoma, sarcoidosis, AIDS. Vaccination against HAV/HBV 16

17. History cont... Surgical history: previous surgeries on the biliary tract ( a potential cause of strictures.) Social history: risk factors of hepatitis, amount and duration of alcohol use, injection drug use and sexual history. Family history: should include hereditary/acquired liver disorders/HCC/cirrhosis, autoimmune disease, metabolic syndrome in family. 17

18. Physical examination General examination: Nutritional status, cachexia and lethargy, enlarged lymph nodes, oedema, asterixis including mental status assessment. Vital signs are reviewed for fever and signs of systemic toxicity Abdominal examination should focus on Size and consistency of the liver ， Spleen Ascites Men: testicular atrophy and gynecomastia. 18

19. Physical examination cont... Presence of any accompanying signs and symptoms Arthralgias ， Myalgias ， Rash ， Anorexia ， Weight loss ， Abdominal pain ， Fever ， Pruritus ， and Changes in the urine and stool. 19

20. Physical examination cont... Stigmata of chronic liver diseases Spider nevi, Palmar erythema ， Gynecomastia ， Caput medusae, Dupuytren's contractures ， Parotid gland enlargement ， and Testicular atrophy 20

21. Spider nevi 21

22. Spider nevi 22

23. Palmar erythema 23

24. Caput medusae 24

25. Caput medusae 25

26. Caput medusae 26

27. Dupuytren's contracture 27

28. Algorithm for Jaundice patient 28

29. Laboratory Tests Other than routine blood tests: Total and direct serum bilirubin Alanine aminotransferase [ALT], Aspartate aminotransferase [AST], Alkaline phosphatase [ALP] Ultrasound: More sensitive than CT for GB stones. Equally sensitive like CT for dilated ducts Prothrombin time Albumin 29

30. Laboratory Tests cont... MRCP: Imaging of biliary tree comparable to ERCP Non invasive CT: Better imaging of the pancreas and abdomen ERCP: Therapeutic intervention for stones Brushing and biopsy for malignancy Endoscopic ultrasound (EUS): Distal CBD, biopsy Liver biopsy 30

31. Pre-hepatic jaundice is characterised by an isolated raised bilirubin level In hepatocellular pattern ALT/AST out of proportion to ALP. Hepatocellular jaundice can be due to acute or chronic injury Cholestatic jaundice ALP out of proportion to ALT/AST Cholangitis is characterised by ‘Charcot’s triad’ of jaundice, right upper quadrant pain and fever. 31

32. Can we prevent Jaundice? It's not possible to prevent all causes of jaundice. Some precautions to minimize your risk: Avoid open/non brand Foods. Consume packed foods and water. Avoid OPEN foods in streets, avoid alcohol Vaccination against hepatitis A or B Avoid saloons for shaving Consult dentists for good medical practice etc. 32

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34. Thank You 34