Jaundice

See also Obstructive Jaundice

Normal Enterohepatic Circulation

• Haem broken down into bilirubin
• Bilirubin conjugated to glucuronic acid and excreted in bile
• In gut converted to urobilinogen and urobilin
• Some urobilinogen reabsorbed and re-excreted in bile
• Some spillover of urobilinogen into urine

Signs of obstructive Jaundice

• Jaundice should be detectable in good light when bilirubin raised >30 micromol/l
• Jaundice obvious > 60 micromol/L
• 'putty' coloured stools (reduced bilirubin, reduced fat absorption)
• itching

History

• Episodes of pain typical of gallstone disease
• previous episodes of obstructive jaundice that resolved spontaneously
• biliary tract surgery
• attacks of acute pancreatitis
• anorexia
• weight loss
• non-specific upper GI disturbance
• inflammatory bowel disease
• exposure to blood, IV drugs, risky sexual behaviour

Examination

• good light
• jaundice visible in conjunctivae first then in skin of abdominal wall
• generalised itching may be evident in terms of scratch marks
• ascites
• enlarged liver spleen
• palpable gall bladder

Investigation

• Exclude HepB/C
• LFTs to confirm obstructive nature
• raised plasma bilirubin (predominantly conjugated)
• raised alkalin phosphatase
• transaminases only mildly elevated
• Clotting screen worthwhile as Vit K absorption decreased
• USS
• CT if neccesary
• ERCP
  • allows stent placement, sphincterotomy, etc.

Causes

Pre-hepatic

Haemolytic disorders

• spherocytosis
• pernicious anaemia
• incompatible blood transfusion

Hepatic

• Hepatitis

  • Hepatitis A, B, C, D, E

  • Cytomegalovirus (CMV) - rare except in immunocompromised

  • Epstein-Barr virus (EBV) - rare except in immunocompromised

  • Varicella-Zoster virus (VZV) - rare

  • Herpes Simplex virus (HSV)

  • Adenovirus - immunocompromised only

• Cirrhosis
• Cholestasis from drugs
  • chlorpromazine
  • 1 in 30,000 patients may have jaundice in response to halothane
• Liver poisons
• Liver tumours

Post-hepatic

• Obstruction within the lumen
• In the wall
  • congenital atresia of common bile duct
  • traumatic stricture
  • tumour of bile duct
  • Extra-hepatic cholangiocarcinoma
  • chronic cholangitis
• External compression
  • tumour of head of pancreas
  • Pancreatic Carcinoma
  • tumour of Ampulla of Vater
  • Acute Pancreatitis
• Liver metastases
  • Late
  • mixed pattern of obstructive and hepatic

Risks of surgery

• Infection
  • ascending cholangitis
  • peritoneal contamination
• Malabsorption of fat
  • leading to Vit K deficiency and clotting problems
• Hepatic impairment
  • reduced drug metabolism
  • defective synthesis of clotting factors
• Endotoxaemia
  • → impaired renal function (Hepatorenal Sydrome)
• Thromboembolism

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