1. Clinical round By Dr. Ehab M. Oraby
Jaundice
Clinical round By
Dr. Ehab M. Oraby

2. Definition Yellowish discoloration of:
Tissues  ex. Sclera and palate except brain.
Body fluids urine and stool except CSF, tears and saliva.
Definition
Dr. Ehab M. Oraby

3. Pathophysiology: Destruction of RBCs  release of HB  Haeme + Globin
Haeme  iron + bilirubin (in unconjugated form = water insoluble).
Conjugation occurs in liver (bilirubin becomes water soluble).
Pathophysiology:
Dr. Ehab M. Oraby

4. Secretion of conjugated form of bilirubin to biliary tract then to GIT  stool coloration.
Some of conjugated bilirubin absorbed from GIT to circulation  renal excretion.
Pathophysiology:
Dr. Ehab M. Oraby

5. Pathophysiology: Hemolytic Anemia: Young age. Congenital or Acquired.
Attacks of “crisis” ++ Hemolysis  ++ unconjugated bilirubin, ++ conjugation, ++ conjugated bilirubin  dark stool & normal urine.
Pathophysiology:
Dr. Ehab M. Oraby

6. Pathophysiology: Hemolytic Jaundice:
Anemia (chronic with periodic exacerbations).
During attacks  diffuse abdominal pain + bony pains + fever with rigors.
Splenomegaly.
Gall stones “pigment stones”.
Leg ulcers.
Pathophysiology:
Dr. Ehab M. Oraby

7. Pathophysiology: Hepatocellular Jaundice: Any age.
Mostly viral hepatitis  cirrhosis. Others: drug induced hepatitis.
Pathophysiology:
Dr. Ehab M. Oraby

8. Pathophysiology: Hepatocellular Jaundice:
Liver fail to conjugate bilirubin + fail to properly secrete conjugated fraction to biliary tree  ++ blood level of conjugated bilirubin and bile salts.
Conjugated bilirubin  jaundice + excreted in urine  dark urine.
Bile salts in blood  pruritus.
Stool is normal.
Pathophysiology:
Dr. Ehab M. Oraby

9. Pathophysiology: Hepatocellular Jaundice:
Other stigmata of LCF: gynecomastia, spider naevi, palmar erythema, ascites and lower limb edema
Pathophysiology:
Dr. Ehab M. Oraby

10. Pathophysiology: Obstructive Jaundice:
Failure of bile drainage  ++ blood level of conjugated bilirubin and bile salts  jaundice, dark urine, pale clay stool and pruritus.
Obstruction is either calcular or malignant.
Pathophysiology:
Dr. Ehab M. Oraby

11. Pathophysiology: Calcular obstruction: Females, Middle age.
By gall stone impacted in ampulla of vater.
Pathophysiology:
Dr. Ehab M. Oraby

12. Pathophysiology: Calcular obstruction: Intermittent
jaundice + pain “biliary” + fever.
Pathophysiology:
Dr. Ehab M. Oraby

13. Pathophysiology: Calcular obstruction: Gall Bladder is non-palpable
except in cases with:
double impaction or
strategic impaction.
Pathophysiology:
Dr. Ehab M. Oraby

14. Pathophysiology: Re Calcular obstruction: Intermittent
Females, Middle age.
By gall stone impacted in ampulla of vater.
Intermittent
jaundice + pain “biliary” + fever.
Gall Bladder is non-palpable
except in cases with double impaction or strategic impaction.
Pathophysiology:
Dr. Ehab M. Oraby

15. Pathophysiology: Malignant Obstruction: Males, old age. By:
Pancreatic head tumors
Malignant LN in porta hepatis
Bile duct cancer”cholangiocarcinoma”.
Pathophysiology:
Dr. Ehab M. Oraby

16. Pathophysiology: Malignant Obstruction: Painless except late.
Epigastric pain referred to back  patient position is leaning forward.
Pathophysiology:
Dr. Ehab M. Oraby

17. Pathophysiology: Malignant Obstruction:
Jaundice is progressive except:
in cases with peri-ampullary carcinoma.
Pathophysiology:
Dr. Ehab M. Oraby

18. Pathophysiology: Malignant Obstruction:
Gall Bladder is palpable “courvoiser law” except in cases with:
double pathology “cancer + gall stone” or
malignant LN ???coming from cancer Gall Bladder.
Pathophysiology:
Dr. Ehab M. Oraby

19. Pathophysiology: ReMalignant Obstruction:
Males, old age.
By:
Pancreatic head tumors
Malignant LN in porta hepatis
Bile duct cancer”cholangiocarcinoma”.
Painless except late. Epigastric pain referred to back  patient position is leaning forward.
Jaundice is progressive except in cases with peri-ampullary carcinoma.
Gall Bladder is palpable “courvoiser law” except in cases with double pathology “cancer + gall stone” or malignant LN ??? coming from cancer Gall Bladder.
Pathophysiology:
Dr. Ehab M. Oraby

20. Dr. Ehab M. Oraby

21. Examination General examination Look Fascies Complexion
Body built and position
Vital signs
Regional survey
Examination
Dr. Ehab M. Oraby

22. Examination Local abdominal examination: Inspection: General look:
Movement with respiration
Contour
Scars
Dilated veins
Pigmentation
Specific look:
Subcostal angle
Linea alba
Umbilicus
Hair distribution
Hernial orifices
Examination
Dr. Ehab M. Oraby

23. Examination Palpation: Superficial palpation Deep palpation: Liver
Gall Bladder
Spleen
Lymph Nodes
swelling
Examination
Dr. Ehab M. Oraby

24. Examination Percussion: Auscultation: Liver Gall Bladder Spleen
Ascites
Swelling
Auscultation:
Venous hum with portal hypertension
Examination
Dr. Ehab M. Oraby

25. Anatomical
Pathophysilogical
Functional
Diagnosis
Dr. Ehab M. Oraby