Jaundice - Once and for all

Logic

Pre-hepatic

• Increased quantity of bilirubin
• Decreased transport to the liver

Intra-hepatic

• Defective uptake
• Defective conjugation
• Defective excretion of bilirubin by liver cells

Post-hepatic

• Defective transport of conjugated bilirubin by the biliary duct system

 

 

Causes

 

Pre-hepatic

• Haemolysis
• Hereditary spherocytosis
• Haemolytic anaemia
• Pernicious anaemia
• Incompatible blood transfusion

 

Intra-hepatic

• Hepatitis and intra-hepatic cholestasis
• Hepatitis
• Cirrhosis
• Drugs
• Toxins
• Genetic condition (Gilbert's etc.)
• Liver tumour (primary or secondary)

 

Post-hepatic

• Obstructive
• Obstruction in the lumen (gallstone)
• Obstruction in the wall (atresia, stricture, chronic cholangitis, tumour of bile duct)
• External compression (pancreatitis, tumour, pancreatic cysts)

 

 

Deranged LFTs
 
Pre-hepatic
• Bilirubin increased (1)
• Everything else normal
 
 
Hepatitis
• Bilirubin increased (2)
• Alk phosphatase normal/increased
• ALT/AST increased (2)
• Gamma GT increased (2)
• PT (INR) normal

 

Cirrhosis
• Bilirubin increased (1)
• Alk phosphatase normal/increased
• ALT/AST normal/increased
• Gamma GT normal/increased
• PT (INR) increased

 

Obstruction
• Bilirubin increased (2)
• Alkaline phosphatase increased (2)
• ALT/AST normal/increased
• Gamma GT increased (2)
• PT (INR) normal

 

 

Clinical manifestation

 

Pre-hepatic

• Jaundice
• Mild
• Unconjugated bilirubin
• Bilirubin rarely >100 mmol/litre
• Urine
• Normal colour
• Stool
• Normal colour
 

 

Intra-hepatic

• Jaundice
• Variable
• Bile may be conjugated or unconjugated
• Urine
• Dark
 
• Stool
• Normal colour

 

Post-hepatic

• Jaundice
• Variable
• Conjugated bilirubin
• Bilirubin may be >1000 mmol/litre
• Urine
• Dark
• Stool
• Pale