1. Approach to a patient with jaundice
Dr Ali Tumi

2. Jaundice
Yellow discoloration of skin & sclera due to excess serum bilirubin. >40umol/l, (3mg/dl)
Conjugated & Unconjugated types
Obstructive & Non Obstructive (clinical)
Pre-Hepatic, Hepatic & Post Hepatic types
Jaundice - Not necessarily liver disease *

3. Bilirubin Metabolism Blood Conjugated & Unconjugated
Urine – Urobilinogen
Stool – Stercobilin

5. Common Causes of Jaundice
Pre Hepatic (Acholuric) - Hemolytic
Unconjugated/Indirect Bil, pale urine
Hepatic – Viral, alcohol, toxins, drugs
Liver damage - unconjugated
Swelling, canalicular obstruction - Conjugated
Post Hepatic (Obstructive) – Stone, tumor
Conjugated/Direct Bil, High colored urine,

6. Critical Questions in the Evaluation of the Jaundiced Patient
Acute vs. Chronic Liver Disease
Hepatocellular vs. Cholestatic
Biliary Obstruction vs. Intrahepatic Cholestasis
Fever
Could the patient have ascending cholangitis?
Encephalopathy
Could the patient have fulminant hepatic failure?

7. Evaluation of the Jaundiced Patient HISTORY
Pain
Fever
Confusion
Weight loss
Sex, drugs, R&R
Alcohol
Medications
pruritus
malaise, myalgias
dark urine
abdominal girth
edema
other autoimmune dz
HIV status
prior biliary surgery
family history liver dz

8. Evaluation of the Jaundiced Patient PHYSICAL EXAM
BP/HR/Temp
Mental status
Asterixis
Abd tenderness
Liver size
Splenomegaly
Ascites
Edema
Spider angiomata
Hyperpigmentation
Kayser-Fleischer rings
Xanthomas
Gynecomastia
Left supraclavicular adenopathy (Virchow’s node)

9. Cirrhosis Clinical Features

10. Yes
Yes
Treat

11. Evaluation of the Jaundiced Patient LAB EVALUATION
AST-ALT-ALP
Bilirubin – total/indirect
Albumin
INR
Glucose
Na-K-PO4, acid-base
Acetaminophen level
CBC/plt
Ammonia
Viral serologies
ANA-ASMA-AMA
Quantitative Ig
Ceruloplasmin
Iron profile
Blood cultures

12. Evaluation of the Jaundiced Patient
Ultrasound:
More sensitive than CT for gallbladder stones
Equally sensitive for dilated ducts
Portable, cheap, no radiation, no IV contrast
CT:
Better imaging of the pancreas and abdomen
MRCP:
Imaging of biliary tree comparable to ERCP
ERCP:
Therapeutic intervention for stones
Brushing and biopsy for malignancy

13. New Onset Jaundice Viral hepatitis Alcoholic liver disease
Autoimmune hepatitis
Medication-induced liver disease
Common bile duct stones
Pancreatic cancer
Primary Biliary Cirrhosis (PBC)
Primary Sclerosing Cholangitis (PSC)

14. Jaundiced Emergencies
Acetaminophen Toxicity
Fulminant Hepatic Failure
Ascending Cholangitis

15. Jaundice Unrelated to Intrinsic Liver Disease
Hemolysis (usually T. bili < 4)
Massive Transfusion
Resorption of Hematoma
Ineffective Erythropoesis
Disorders of Conjugation
Gilbert’s syndrome
Intrahepatic Cholestasis
Sepsis, TPN, Post-operation

16. HBV Serology + - HBSAg HBcAb IgM IgG HBSAb Acute HBV Resolved HBV
Chronic HBV
HBV vaccinated

17. Jaundice

18. Jaundice

19. Yellow hands on top, red palms underneath - a sign of liver damage

20. Ascitis in Cirrhosis

21. Ascitis in Cirrhosis

22. Gynaecomastia in cirrhosis