jaund
TRANSCRIPT
Jaundice
Dr George Alexander
Consultant Gastroenterologist and Hepatologist
Columbia Asia Hospital
Types
• Pre-Hepatic - Hemolysis
• Hepatic - Hepatitis
• Post-Hepatic - Obstructive
“Medical Jaundice”
“Surgical Jaundice”
How to Differentiate – Clinically
1) Pre-Hepatic - Not much abdominal symptoms, no yellow urine
2) Hepatic - Deeper Jaundice, abdominal symptoms, prodrome, more systemic symptoms
3) Post-Hepatic - Abdominal pain, abdominal signs ( palpable GB, mass)
How to Differentiate – Investigations
1) Pre-Hepatic – Indirect hyperbilirubinemia, anemia, normal enzymes
2) Hepatic – High direct bilirubin, Markedly raised enzymes (SGOT, SGPT)
3) Post-Hepatic – High direct bilirubin, Raised Alkaline phosphatase, GGT
How to Differentiate – Investigations
Ultrasound
Liver size, echotexture, margin, biliary dilatation, PV
Obstruction vs. Liver Disease
Biliary Obstruction Liver Disease
History Pain, Fever, Prior biliary surgery, older age
Anorexia,malaise, prodrome, drugs or hepatotoxin, transfusion, family h/o
Physical Examn Fever, abd tenderness,
abd mass, abd scar
Stigmata of PHT, spider angioma
Lab studies Predominant ALP relative to AST/ALT. PT normalizes with vit K, amylase
AST/ALT relative to ALP PT not corrected with Vit K, Serology
Exceptions
Exceptions• Cholestatic Hepatitis
Exceptions• Cholestatic Hepatitis
• Acute Obstruction
Exceptions• Cholestatic Hepatitis
• Acute Obstruction
• Normal CBD with obstruction
Liver Function Tests
• Bilirubin – Direct, Indirect• SGPT• SGOT• Alkaline Phosphatase• GGT• Total Protein• Albumin• Globulin• Prothrombin Time
Aminotransferases
Leakage from damage tissues
Mild to moderate elevation: many types of liver diseaseMarked elevations : hepatitis (Viral, toxic, autoimmune, ischemic)AST/ALT > 2 suggests ALD or Cirrhosis
ALT more specific than AST for hepatic injuryAST : skeletal muscle, RBC, kidney, myocardium
Basis of Abnormality
Extrahepatic Origin
Associated Liver Disease
Alkaline Phosphatase
Overproduction and leakage into serum
Moderate elevation: many types of liver diseaseMarked elevations : Cholestases (extra and intra hepatic, infiltration)rarely alcoholic hepatitis
Bone growth or disease, placenta, intestine, tumors
Basis of Abnormality
Extrahepatic Origin
Associated Liver Disease
GGTP
Overproduction and leakage into serum
Same as APInduced by ethanol and drugs
Kidney , spleen, pancreas, lung, brain
Basis of Abnormality
Extrahepatic Origin
Associated Liver Disease
Prothrombin Time
Decreased synthetic capacity
Acute or chronic liver failure (PT unresponsive to Vit K) Biliary obstruction (PT responsive to Vit K)
Vit K deficiency : Malabsorption, malnutrition, antibiotics Consumptive coagulopathy
Basis of Abnormality
Extrahepatic Origin
Associated Liver Disease
Albumin
Decreased synthesis
Chronic Liver Disease
Reduced in nephrotic syndrome, protein losing enteropathy, vascular leak , malnutrition, malignancy, infections, inflammation
Basis of Abnormality
Extrahepatic Origin
Associated Liver Disease
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N
Patterns in Liver Disease
Hepatocyte Necrosis Biliary Obstr. Infiltr.
Etiology Toxin,isch Viral hep
Alcohol Complete Partial Infiltration
E.g.. ACT, isch HAV, HBV
Alc Hep Ca Pancr Hilar, PSC
Primary, Mets, TB
ALT,AST 50-100 x 5-50 x 2-5 x 1-5 x 1-5 x 1-3 x
ALP 1-3 x 1-3 x 1-10 x 2-20 x 2-10 x 1-20 x
Bilirubin 1-5 x 1-30 x 1-30 x 1-30 x 1-5 x 1-5 x
PT Prolonged, unresponsive to Vit K Prolonged, responsive Normal
Albumin Decreased in subacute, chronic Usually normal Usually N