diease

Jaundice


OVERVIEW OF Jaundice :

Bilirubin is a tetrapyrrole produced by the normal breakdown of heme. Most bilirubin is produced during the breakdown of hemoglobin and other hemoproteins. Accumulation of bilirubin or its conjugates in body tissues produces jaundice (ie, icterus), which is characterized by high plasma bilirubin levels and the deposition of yellow bilirubin pigments in the skin, sclerae, mucous membranes, and other less visible tissues.

 

Because bilirubin is highly insoluble in water, it must be converted into a soluble conjugate before elimination from the body. In the liver, uridine diphosphate (UDP)-glucuronyl transferase converts bilirubin to monoglucuronides and diglucuronides, referred to as conjugated bilirubin, which is then secreted into the bile by an ATP-dependent transporter. This process is highly efficient under normal conditions, so plasma unconjugated bilirubin concentrations remain low.

 

A large number of disease states lead to bilirubin accumulation in plasma. Diseases that increase the rate of bilirubin formation, such as hemolysis, or diseases that reduce the rate of bilirubin conjugation, such as Gilbert syndrome, produce unconjugated hyperbilirubinemia.

 

Diseases that reduce the rate of secretion of conjugated bilirubin into the bile or the flow of bile into the intestine produce a mixed or predominantly conjugated hyperbilirubinemia due to the reflux of conjugates back into the plasma. Elevated conjugated bilirubin levels usually indicate hepatobiliary disease.


STRUCTURE of Jaundice :

The liver is located in the upper right-hand portion of the abdominal cavity, below the diaphragm, and on top of the stomach, right kidney, and intestines.

Shaped like a cone, the liver is a dark reddish-brown organ that weighs about 3 pounds.

There are 2 distinct sources that supply blood to the liver, including the following:

  • Oxygenated blood flows in from the hepatic artery
  • Nutrient-rich blood flows in from the hepatic portal vein

The liver holds about one pint that is 13% of the body's blood supply at any given moment. The liver consists of 2 main lobes. Both are made up of 8 segments that consist of 1,000 lobules (small lobes). These lobules are connected to small ducts (tubes) that connect with larger ducts to form the common hepatic duct. The common hepatic duct transports the bile made by the liver cells to the gallbladder and duodenum (the first part of the small intestine) via the common bile duct.

 


CAUSES :

Jaundice can be caused by a problem in any of the three phases in bilirubin production.

 

Before the production of bilirubin, you may have what's called unconjugated jaundice due to increased levels of bilirubin caused by:

 

Reabsorption of a large hematoma (a collection of clotted or partially clotted blood under the skin).

Hemolytic anemias (blood cells are destroyed and removed from the bloodstream before their normal lifespan is over).

During production of bilirubin, jaundice can be caused by:

 

Viruses, including Hepatitis A, chronic Hepatitis B and C, and Epstein-Barr virus infection (infectious mononucleosis).

Alcohol.

Autoimmune disorders.

Rare genetic metabolic defects.

Medicines, including acetaminophen toxicity, penicillins, oral contraceptives, chlorpromazine and estrogenic or anabolic steroids.

After bilirubin is produced, jaundice may be caused by obstruction (blockage) of the bile ducts from:

Gallstones.

Inflammation (swelling) of the gallbladder.

Gallbladder cancer.

Pancreatic tumor.

Types:

  • Pre-hepatic (before bile is made in the liver):

Jaundice in these cases is caused by rapid increase in the breakdown and destruction of the red blood cells (hemolysis) or overworking of the liver's ability to adequately remove the increased levels of bilirubin from the blood.

             Examples of conditions with increased breakdown of red blood cells include:

malaria,

sickle cell crisis,

   spherocytosis,

thalassemia,

glucose-6-phosphate dehydrogenase deficiency (G6PD),

drugs or other toxins, and

autoimmune disorders.

  • Hepatic (the problem arises within the liver):

Jaundice in these cases is caused by the liver's inability to properly metabolize and excrete bilirubin. Examples include:

hepatitis (commonly viral or alcohol related),

cirrhosis,

drugs or other toxins,

Crigler-Najjar syndrome,

Gilbert's syndrome, and

cancer.

  • Post-hepatic (after bile has been made in the liver) :

It is also called as the obstructive jaundice where the secretion and storage of the bile is impaired.

 

Causes of obstructive jaundice include:

 

gallstones in the bile ducts,

cancer (pancreatic and gallbladder/bile duct carcinoma),

strictures of the bile ducts,

cholangitis,

congenital malformations,

pancreatitis,

parasites,

pregnancy, and

newborn jaundice.

Jaundice in newborn babies can be caused by several different conditions, although it is often a normal physiological consequence of the newborn's immature liver. Even though it is usually harmless under these circumstances, newborns with excessively elevated levels of bilirubin from other medical conditions (pathologic jaundice) may suffer devastating brain damage (kernicterus) if the underlying problem is not addressed.  Newborn jaundice is the most common condition requiring medical evaluation in newborns.

The following are some common causes of newborn jaundice:

Physiological jaundice

This form of jaundice is usually evident on the second or third day of life. It is the most common cause of newborn jaundice and is usually a transient and harmless condition. Jaundice is caused by the inability of the newborn's immature liver to process bilirubin from the accelerated breakdown of red blood cells that occurs at this age. As the newborn's liver matures, the jaundice eventually disappears.

 

Maternal-fetal blood group incompatibility (Rh, ABO)

This form of jaundice occurs when there is incompatibility between the blood types of the mother and the fetus. This leads to increased bilirubin levels from the breakdown of the fetus' red blood cells (hemolysis).

 

Breast milk jaundice

This form of jaundice occurs in breastfed newborns and usually appears at the end of the first week of life. Certain chemicals in breast milk are thought to be responsible. It is usually a harmless condition that resolves spontaneously. Mothers typically do not have to discontinue breastfeeding.

 

Breastfeeding jaundice

This form of jaundice occurs when the breastfed newborn does not receive adequate breast milk intake. This may occur because of delayed or insufficient milk production by the mother or because of poor feeding by the newborn. This inadequate intake results in dehydration and fewer bowel movements for the newborn, with subsequently decreased bilirubin excretion from the body.

 

Cephalohematoma (a collection of blood under the scalp)

Sometimes during the birthing process, the newborn may sustain a bruise or injury to the head, resulting in a blood collection/blood clot under the scalp. As this blood is naturally broken down, suddenly elevated levels of bilirubin may overwhelm the processing capability of the newborn's immature liver, resulting in jaundice.

 


PATHOPHYSIOLOGY :

Conjugated hyperbilirubinemia results from reduced secretion of conjugated bilirubin into the bile, such as occurs in patients with hepatitis, or from impaired flow of bile into the intestine, as in patients with biliary obstruction. Bile formation is sensitive to various hepatic insults, including high levels of inflammatory cytokines, as may occur in patients with septic shock.

 

High levels of conjugated bilirubin may secondarily elevate the level of unconjugated bilirubin. Although the mechanism of this effect is not fully defined, one likely cause is reduced hepatic clearance of unconjugated bilirubin that results from competition with conjugated bilirubin for uptake or excretion.

 


 


COMMON CLINICAL SIGNS AND SYMPTOMS :

Fever.

Chills.

Abdominal pain.

Flu-like symptoms.

Change in skin color.

Dark-colored urine and/or clay-colored stool

 


DIAGNOSTIC :

  • Blood test:

In blood test for liver the alpha fetoprotein levels may shoot up and this is considered as the tumour marker.

  • Angiogram:

During this test, a dye is injected into an artery to show liver tissue and any tumors.

  • Laproscopy:

The doctor uses a thin tube with a light (laparoscope) to observe the liver and other organs inside the stomach area.

  • Biopsy:

The removal of tissue for study under a microscope. It may be done using a laparoscope. A biopsy is the most reliable way to determine cancer.

  • CT scan: is shows the 3D images of the liver
  • MRI(magnetic resonance imaging):

It uses magnetic and radiofrequency waves to view the soft tissues. It alos used to reveal the metastasis of the cancer cells.

  • PET scan(positron emission tomography):

It also reveals the metastasis that the cancer cells has spread to the distant organ or not.

  • Bruising of the skin.
  • Spider angiomas (abnormal collection of blood vessels near the surface of the skin).
  • Palmar erythema (red coloration of the palms and fingertips).
  • Urinalysis (urine testing) that's positive for bilirubin shows that the patient has conjugated jaundice. The findings of urinalysis should be confirmed by serum testing. The serum testing will include a complete blood count (CBC) and bilirubin levels.
  • Your doctor will also do an exam to determine the size and tenderness of your liver. He or she may use imaging (ultrasonography and computer tomographic (CT) scanning) and liver biopsy (taking a sample of the liver) to further confirm diagnosis


TREATMENT AND PROGNOSIS :

  1. Enhanced nutrition. To prevent weight loss, your doctor may recommend more-frequent feeding or supplementation to ensure that your baby receives adequate nutrition.
  2. Light therapy (phototherapy). Your baby may be placed under a special lamp that emits light in the blue-green spectrum. The light changes the shape and structure of bilirubin molecules in such a way that they can be excreted in both the urine and stool. During treatment, your baby will wear only a diaper and protective eye patches. Light therapy may be supplemented with the use of a light-emitting pad or mattress.
  3. Intravenous immunoglobulin (IVIg). Jaundice may be related to blood type differences between mother and baby. This condition results in the baby carrying antibodies from the mother that contribute to the rapid breakdown of the baby's red blood cells. Intravenous transfusion of an immunoglobulin — a blood protein that can reduce levels of antibodies — may decrease jaundice and lessen the need for an exchange transfusion, although results are not conclusive.
  4. Exchange transfusion:

When nothing works then the blood transfusion is the last option for treatment.

 


PREVENTION :

Avoid intake of alcohol

Maintain healthy lifestlyle.

Avoids hepatitis infection

Avoid consuming large amounts of alcohol

avoid overweight