Jaundice

• ↑Alk Phos moreso than AST/ALT implies “cholestasis” (intrahepatic vs obstruction)
– ↑Alk Phos also seen in sarcoid, TB, bone – In this case, GGT is specific for biliary origin
Jaundice
Normal Physiology
• Bilirubin is from breakdown of hemoglobin • Unconjugated bilirubin transported to liver
– Bound to albumin because insoluble in water
• chronic hepatitis, cirrhosis, Wilson’s disease
Jaundice
DDx: Conjugated Bilirubinemia
• Intrahepatic cholestasis/impaired excretion
– Hepatitis (viral, alcoholic, and non-alcoholic)
– Could indicate malignant obstruction
Jaundice
Screening Labs
• NL LFT r/o hepatic injury or biliary tract dz
– Consider inherited disorders or hemolysis
• Ascaris lumbricoides, liver flukes
• Just remember top 5 (not parasites)
Jaundice
Initial Evaluation: History
• Jaundice, acholic stools, tea-colored urine • Fever/chills, RUQ pain (cholangitis)
– CHF – Portosystemic shunts – Drug inhibition: rifampin, probenecid
Jaundice
DDx: Unconjugated bilirubinemia
• Impaired bilirubin conjugation
– Gilbert’s disease – Crigler-Najarr syndrome – Neonatal jaundice (this is physiologic) – Hyperthyroidism – Estrogens – Liver diseases
– ↑ production of bilirubin – ↓ hepatocyte transport or conjugation – Impaired excretion of bilirubin – Impaired delivery of bilirubin into intestine • “surgically relevant jaundice” or obstructive jaundice – “Cholestasis” refers to the latter two, impaired excretion and obstructive jaundice
Cirrhosis
Hepatitis
Cirrhosis
Hepatitis
Chronic pancreatitis PSC
Drug inhibition Amyloidosis Pregnancy
Jaundice
DDx: Unconjugated bilirubinemia
• ↑production
Jaundice
Imaging for Obstructive Jaundice
• RUQ Ultrasound
– See stones, CBD diameter
• CT scan
– Identify both type & level of obstruction
• ERCP
– Direct visualization of biliary tree/panc ducts – Procedure of choice for choledocholithiasis – Diagnostic –AND- therapeutic (unlike MRCP)
• Predominant ↑AST/ALT implies intrinsic hepatocellular disease
– AST/ALT ratio > 2 in alcoholic hepatitis
• ↓albumin or ↑INR c/w advanced liver dz
Jaundice
– Should r/o ascending cholangitis, ABC/resusc
• For cholangitis: IVF, IV Antibiotics, Decompression
– Stones (remove stones vs stent vs drainage)
Jaundice
Initial Evaluation: Physical Exam
• Signs of end stage liver disease (cirrhosis)
– Ascites, splenomegaly, spider angiomata, and gynecomastia
• Jaundice evident first underneath the tongue, also evident in sclerae or skin • Courvoisier’s sign = painless, but palpable or distended gallbladder on exam
Jaundice
DDx: Obstructive Jaundice
• This is the slide to remember for surgeons • Obstructive Jaundice– extrahepatic cholestasis
– Choledocholithiasis (CBD or CHD stone) – Cancer (peri-ampullary or cholangioCA) – Strictures after invasive procedures – Acute and chronic pancreatitis – Primary sclerosing cholangitis (PSC) – Parasitic infections
– Extravascular hemolysis – Extravasation of blood into tissues – Intravascular hemolysis – Errors in production of red blood cells
• Impaired hepatic bilirubin uptake(trnsport)
• PTC useul of obstruction is prox to CHD • Endoscopic Ultrasound or EUS
Jaundice
Treatment
• If Medical, then treat the etiology • If Obstructive Jaundice:
– Could lead to life-threatening septic shock
• Reasons to have hepatitis or cirrhosis?
– Alcohol, Viral, risk factors for viral hepatitis
• • • • •
Exposure to toxins or offending drugs Inherited disorders or hemolytic conditions Recent blood transfusions or blood loss? Is patient septic or on TPN? Recent gallbladder surgery? (CBD injury)
• Any cause of hepatocellular iy cirrhosis or end-stage liver dz – Sepsis and hypoperfusion states – TPN – Pregnancy – Infiltrative dz: TB, amyloid, sarcoid, lymphoma – Drugs/toxins i.e. chlorpromazine, arsenic – Post-op patient or post-organ transplantation – Hepatic crisis in sickle cell disease
– 10-20% reabsorbed into portal circulation and re-excreted into bile or into urine by kidneys
Jaundice
Pathophysiology
• Jaundice = bilirubin staining of tissue @ lvl greater than ~2 • Mechanisms:
• Transported into hepatocyte & conjugated
– With glucuronic acid → now water soluble
• Secreted into bile • In ileum & colon, converted to urobilinogen