1. Clinical Approach to Neonatal Jaundice
Dr. Siddeeg Addow
Pediatric Resident
Khartoum, Sudan

2. CONTENTS: INTRODUCTION PATHOPHYSIOLOGY DIFFERENTIAL DIAGNOSIS HISTORY
EXAMINATION
INVESTIGATION

3. INTRODUCTION Bilirubin is the end product of heme degradation
Most of the daily production comes from the breakdown of RBCs in the RES
Heme biliverdin bilirubin
Bilirubin is released & bound to serum albumin
Bilirubin is uptake & conjugated with glucuronic acid
Finally conjugated bilirubin is excreted in bile

4. PATHOPHYSIOLOGY Tightly compounded to s. albumin Non toxic
UNCONJUGATED B.
CONJUGATED B.
Tightly compounded to s. albumin
Normally very small amount is present as albumin free
Insoluble in water can not be excreted in urine
Toxic
Non toxic
Water soluble
Loosely bound to albumin. Delta fraction

5. Both conjugated & unconjugated bilirubin may accumulate systemically & deposit in tissues
Normally s. bilirubin level vary b/w 0.3 & 1.2mg/dl.
The rate of systemic bilirubin production is = to the rate of hepatic uptake, conjugation & biliray excretion .
Jaundice becomes evident when the s.bilirubin levels rise above 2.0 to 2.5mg/dl

6. Levels as high as 30 to 40mg/dl can occur with sever disease
Jaundice occurs when the = b/w bilirubin production &clearance is disturbed by one or more of the following mechanisms:
Excessive production of bilirubin
Reduced hepatic uptake
Impaired conjugation
Decreased hepatocellular excretion
Impaired bile flow

7. PRDOMINATLY DIRECT HYPERBILIRUBINEMIA
CAUSES OF JAUNDICE
PRDOMINATLY DIRECT HYPERBILIRUBINEMIA
PRDOMINATLY INDIRECT HYPERBILIRUBINEMIA

8. Excessive production of bilirubin
PRDOMINATLY INDIRECT HYPERBILIRUBINEMIA
Excessive production of bilirubin
hemolytic anemia's
resorption of blood from internal hemor.
ineffective erythropoiesis

9. Reduced hepatic uptake:
drugs
some cases of Gilbert syndrome

10. Impaired bilirubin conjugation:
physiologic jaundice
breast milk jaundice
genetic deficiency of glcuronosyl transferase
decreased expression of glcuronosyl transferase
diffuse hepatocellular diseases

11. Decrease excretion of conjugated bilirubin:
PREDOMINATLY DIRECT HYPERBILIRUBINEMIA
Decrease excretion of conjugated bilirubin:
deficiency in canalicular membrane transport
drug induced canalicular membrane dysfunction
hepatocelluler damage or toxicity

12. Decreased intrahepatic bile flow :
inflammatory destruction of intrahepatic bile ducts

13. Extra hepatic biliary obstruction:
gall stone obstruction of biliary tree
extra hepatic biliary atresia
biliary stricture & choledochal cyst
primary sclerosing cholangitis
liver fluke infestation
carcinoma

14. HISTORY onset / duration pain nausea & vomiting loss of weight itching
color of stool
color of urine
past history
ttt &family history

15. EXAMINATION color of skin severity of jaundice anemia liver spleen
gall bladder
ascites

16. INVESIGATION CBC LFT Prothrombin time Alfa feto proteins UG SG U/S
ERCP & PTC
Liver biopsy

17. The End