DR NILESH KATE

MBBS,MD ASSOCIATE PROF

DEPT. OF PHYSIOLOGY

JAUNDICE

OBJECTIVES. Definition Mechanism of production Types Characteristic features Physiological Jaundice Prevention Treatment .

Monday, May 1, 2023

DEFINITION JAUNDICE is defined

as Yellowish discoloration of skin, sclera & mucous membrane

Monday, May 1, 2023

CAUSE

Increase bilirubin concentration

( Hyperbilirubinemia) in the body fluids.

Normal range of serum bilirubin – 2-3 mg/100ml.

Jaundice when plasma bilirubin > 2-3 gm/dl.

Monday, May 1, 2023

EXCEPTION

All internal tissue & body fluids are yellow coloured

except BRAIN

d/t – BLOOD BRAIN BARRIER which not allow

bilirubin to pass except in neonatal period.

Monday, May 1, 2023

KERNICTERUS Deposition of excess

bilirubin to brain mainly Basal Ganglia – Kernicterus.

C/f – 3 phases Decreased alertness,

Hypotonia, poor feeding, Hypertonia, Opisthotonus Hypotonia.

Monday, May 1, 2023

BILIRUBIN & JAUNDICEBILIRUBIN FORMATION.

Monday, May 1, 2023

Tetra pyrrole straight chain with Globin & Iron

BILIRUBIN & JAUNDICEUPTAKE OF BILIRUBIN.

After degradation of Hb bilirubin is released into circulation. Its free of Un-conjugated Bilirubin.

Its lipid soluble in plasma & bound to albumin

This binding prevents its excretion by the kidneys.

Monday, May 1, 2023

CONJUGATION OF BILIRUBIN This un-conjugated taken

up by liver, albumin removed & enters hepatic cells

Conjugate with UDP-Glucoronic acid to form conjugated bilirubin

Enzyme – UDP-Glucoronyl transferase.

Monday, May 1, 2023

EXCRETION OF BILIRUBIN Conjugated Bilirubin

from liver is excreted into Bile Canaliculi against conc gradient.

Enters Intestine

Monday, May 1, 2023

FORMATION & EXCRETION OF UROBILINOGEN.

In intestine Conjugated bilirubin is degraded by intestinal bacteria

β Glucoronidase convert Bilirubin to Urobilinogen & Stercobilinogen.

20% of Urobilinogen reabsorbed into portal system to liver & escape into general circulation & re-excreted into bile

From General Circulation some filtered by kidney & excreted in Urine.

Monday, May 1, 2023

BILIRUBIN CIRCULATION IN THE BODY

Monday, May 1, 2023

MECHANISM OF PRODUCTION Excessive breakdown

( Hemolysis) of RBC so called Hemolytic Jaundice or Prehepatic Jaundice.

Damage to liver cells – Hepatic or Hepatocellular Jaundice.

Obstruction to bile duct – Post hepatic or Cholestatic Jaundice.

Monday, May 1, 2023

TYPES Hemolytic Jaundice

( Pre-Hepatic) Hepatocellular

Jaundice (Hepatic Jaundice)

Cholestatic or Obstructive Jaundice.(Post-Hepatic)

Monday, May 1, 2023

HEMOLYTIC JAUNDICE ( PRE-HEPATIC)

Mechanism of production Types of serum bilirubin

accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests

Monday, May 1, 2023

MECHANISM OF PRODUCTION Excessive Breakdown

of RBC – Produces Un-

conjugated bilirubin more than healthy liver can conjugate & excrete.

Monday, May 1, 2023

TYPES OF SERUM BILIRUBIN ACCUMULATED.

Unconjugated Hyperbilirubinaemia.

Monday, May 1, 2023

VAN DEN BERGH TEST Reagent used – Diazo

reagent ( Mixture of Sulphanilic acid, Hydrochloric acid & sodium Nitrite)

Test – 2 types Direct Indirect.

Monday, May 1, 2023

VAN DEN BERGH TEST Direct – when Diazo reagent added to serum

containing Conjugated Bilirubin Reddish Brown colour developed in 30 sec.

Indirect - when Diazo reagent added to serum containing Un-Conjugated Bilirubin No colour developed but when some alcohol added which dissolves Unconjugated Bilirubin – reddish Brown colour is obtained.

Monday, May 1, 2023

VAN DEN BERGH TEST

Indirect Positive

Reaction – Due to Un-

Conjugated Bilirubin.

Monday, May 1, 2023

URINE BILIRUBIN Unconjugated

Bilirubin is insoluble in water & transported n plasma with albumin.

Since albumin is not Filtered it is not appear in Urine.

Monday, May 1, 2023

URINE UROBILINOGEN.

Liver excrete lots of conjugated bilirubin in

intestine in bile & more Urobilinogen is formed

So Urine Urobilinogen is increased.

Monday, May 1, 2023

FAECAL STERCOBILINOGEN.

Normal 25-250 mg/day.

Same as more Urobilinogen & stercobilinogen

is formed

Faeces is Dark Brown in colour.

Monday, May 1, 2023

FAECAL FAT LEVEL.

Normal

5-6% of total intake /day

Monday, May 1, 2023

SPECIFIC BLOOD TESTS

Peripheral blood film – Haemolysis, Anaemia,

Reticylocytosis.

Normal Plasma Albumin: Globulin ratio.

Serum alkaline phosphatase Normal

Liver function tests – Normal ( As liver is normal)

Monday, May 1, 2023

HEPATOCELLULAR JAUNDICE (HEPATIC JAUNDICE)

Mechanism of production Types of serum bilirubin

accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests

Monday, May 1, 2023

MECHANISM OF PRODUCTION

Inability of liver to conjugate & transport

bilirubin into bile duct due to Liver damage.

Monday, May 1, 2023

TYPES OF SERUM BILIRUBIN ACCUMULATED.

Both conjugated & Unconjugated bilirubin

increased.

Monday, May 1, 2023

VAN DEN BERGH TEST

Biphasic Reaction as

both Conjugated & Un-

conjugated bilirubin

present.

Monday, May 1, 2023

URINE BILIRUBIN Present As conjugated

bilirubin is water soluble is dissolved, filtered & appear in urine

Also called Choluric Jaundice.

Monday, May 1, 2023

URINE UROBILINOGEN.

Decreases

As damaged liver cells are producing & excreting

less of conjugated Bilirubin & thus less

Urobilinogen.

Monday, May 1, 2023

FAECAL STERCOBILINOGEN.

Less

As less formation of Stercobilinogen

So Faeces are Pale Coloured.

Monday, May 1, 2023

FAECAL FAT LEVEL.

Increased up to 40-50%.

As less bile in intestine – less emulsification &

absorption of fat

So bulky, pale, greasy & foul smelling faeces-

steatorrhoea.

Monday, May 1, 2023

SPECIFIC BLOOD TESTS

Peripheral blood film – Normal

Albumin decreased, so albumin: globulin ratio Decreased

Serum alkaline phosphatase – Increased.

Liver function test – impaired.

Monday, May 1, 2023

CHOLESTATIC OR OBSTRUCTIVE JAUNDICE.(POST-HEPATIC)

Mechanism of production Types of serum bilirubin

accumulated. Van den Bergh test Urine bilirubin Urine urobilinogen. Faecal stercobilinogen. Faecal fat level. Specific blood tests

Monday, May 1, 2023

MECHANISM OF PRODUCTION Obstruction to the

bile flow from Hepatocytes to duodenum.

Monday, May 1, 2023

TYPES OF SERUM BILIRUBIN ACCUMULATED.

Conjugated Hyperbilirubinaemia due to

impaired flow of bile.

Monday, May 1, 2023

VAN DEN BERGH TEST

Direct Positive

reaction.

As only conjugated

bilirubin present.

Monday, May 1, 2023

URINE BILIRUBIN

Present.

As conjugated

bilirubin filtered in

urine.

Monday, May 1, 2023

URINE UROBILINOGEN.

Markedly decreased or absent.

As due to obstruction conjugated bilirubin is not

released in intestine

No Urobilinogen is formed.

Monday, May 1, 2023

FAECAL STERCOBILINOGEN.

Absent – when obstruction is complete.

Stools are clay coloured.

Monday, May 1, 2023

FAECAL FAT LEVEL. Increased.

Monday, May 1, 2023

SPECIFIC BLOOD TESTS

Peripheral blood film – normal.

Plasma albumin, globulin & ratio – Normal

Serum Alkaline phosphatase – markedly increased.

Liver function tests - normal

Monday, May 1, 2023

Monday, May 1, 2023

PHYSIOLOGICAL JAUNDICE NEONATAL JAUNDICE. Mechanism of

production Appears 2-5 days after

birth & disappears in 2 weeks.

Excessive destruction of RBC & hepatic Immaturity in first 7-10 days.

Monday, May 1, 2023

SIGNS & SYMPTOMS

Monday, May 1, 2023

Monday, May 1, 2023

PREVENTION

By giving Hepatic Microsomal enzyme inducers

(Phenobarbital) to pregnant mother or

newborn-

Increases activity of Glucoronyl Transferase.

Monday, May 1, 2023

TREATMENT . PHOTOTHERAPY Exposure of skin to

white light – PHOTO-ISOMERIZATION of Bilirubin to water soluble Lumirubin which is excreted in Bile without conjugation

Monday, May 1, 2023

TREATMENT OF PATHOLOGICAL JAUNDICE IN ADULT

Monday, May 1, 2023

Thank You