Jaundice,Definition Accumulation of yellow pigment in the skin and other tissues (Bilirubin),Bilirubin MetabolismBilirubin formationTransport of bilirubin in plasmaHepatic bilirubin transport Hepatic uptakeConjugation Biliary excretionEnterohepatic circulation,Bilirubin formation,120ds,CB,Transfer acrossMicrovillar membrane,3.Biliary Excretion of Bilirubin,Bile canaliculus,Hepatic Bilirubin Transport,(lipid soluble),(water soluble),Entero-hepatic circulation,CB,B and I,Urobilinogens (coloress),be degradedBacterial Enzymes,feces (feceal urobilinogens),Reabsorbed,plasma,circulation,kidneys,50-200 mg/d,mostly,urine urobilinogen,4 mg/d,T,trace,20%,The serum of normal adults contains 1 mg of bilirubin per 100 ml.In healthy adults,The direct fraction is usually 0.2 mg/100 mlThe indirect fraction is usually 0.8 mg/100 ml,Pathophysiologic classification of Jaundice,Hemolytic JaundiceHepatic JaundiceCholestatic JaundiceCongenital non-hemolytic jaundice,Hemolytic Jaundice,PathogenesisOverproductionHemolysis (intra and extra vascular)inherited or genetic disordersacquired immune hemolytic anemia (Autoimmune hemolytic anemia)nonimmune hemolytic anemia (paroxysmal nocturnal Hemoglobinuria)Ineffective erythropoiesisOverproduction may overload the liver with UB,Hemolytic JaundiceSymptoms light yellow skin color, dark urine, dark stool,no pruitus,anemia, fever, splenomegalyLabUCB and urobilirubinfecal and urine urobilinogenhemolytic anemia ALT/AST(-),ALP/GGThemoglobinuria (in acute intravascular hemolysis)Reticulocyte counts,Cholestatic Jaundice,Pathogenesisit is due to intra- and extra hepatic obstruction of bile ductsintrahepatic Jaundice: Hepatitis, PBC, DrugsExtra Hepatic Biliary Obstruction: Stones, Inflammation, Tumors, (Ampulla of Vater),Cholestatic Jaundicesymptomsdark yellow to dark green (skin color)Pruritusdark urine and lighter stoolabdominal pain,feverChill+fever+gall bladder enlargement stone+cholangitis,Cholestatic Jaundice Lab FindingsSerum Bilirubin(CB)Feces urobilinogen(incomplete obstruction)Feces urobilinogen absence (complete obstruction)urobilirubin,urobilinogen ALT/AST ALP ,GGT ,Hepatocellular Jaundice,Due to a disease affective hepatic tissue either congenital or acquired diffuse hepatocellular injury,Hepatocellular Jaundice Symptomspale yellow to deep yellow(skin),slight pruritus,dark urine and stoolweakness, loss appetite, hepatomegaly, palmar erythema, spider,fatigue,fever,diarrhea,edema,bleeding,Hepatocellular Jaundiceliver function tests are abnormalboth CB and UCBurobilirubin urobilinogenALT/AST,ALP,GGT,Congenital non-hemolytic Jaundice,herediary disorders,rareinability of the liver to perform bilirubin uptake,conjugation and excretion.include:1.Gilberts syndrome2.Crigler-Najiar syndrome3.Rotors syndrome4.Dubin-Johnson syndrome,Jaundice- Diagnostic Procedures,HistoryP.E.Familiar occurrence of JaundiceLab findingsImage techniquesUltrasonographyCTMRIERCP (Endoscopic Retrograde cholangiopancreatography )PTCX-ray (GI, Angiography),Ultrasonography：evaluating organ lesions such as liver,gallbladder,pancreas,spleen.CT:identify the jaundice derived from different leisionsMRI:display the diameter of the bile duct and pancreatic duct.ERCP provide direct observation of lesions in the ampulla and papilla,detect pancreatic lesions.PTC display the whole biliary system,distinguish between extra- and intrahepatic obstruction of the bile duct.,Jaundice- Differential diagnosis,1. Once Jaundice is recognized, it is important to determine whether hyperbilirubinemia is predominantly CB or UCB?2. Differentiation of hemolytic from other type of jaundice is usually not difficult.3. The laboratory findings are in constant in partial biliary obstruction and differentiation from intrahepatic cholestesis is particularly difficult.,Jaundice- Differential diagnosisDifferential DiagnosisUCB or CB Exclud