Download MBBS Pediatric PPT 6 Jaundice In Children Lecture Notes

--- Content provided by FirstRanker.com ---

LEARNING OBJECTIVES

What is jaundice
Basic patho -physiology of bilirubin

--- Content provided by‌ FirstRanker.com ---

metabolism
Causes of jaundice
Approach to a child with jaundice
Ascites
INTRODUCTION

--- Content provided by‌ FirstRanker.com ---

Symptom of disease rather than a disease
In adults and older children sclera appears jaundiced when serum bilirubin is

increased

--- Content provided by⁠ FirstRanker.com ---

Gives yel owish hue to the skin, sclera, and mucous membranes
Normal serum bilirubin <1mg%
It is not a visible til s. bilirubin exceeds 2 mg/dl.
In newborn->5 mg/dl

--- Content provided by‌ FirstRanker.com ---

However it is difficult to see sclera in newborn due to difficulty in opening eye

BILIRUBIN

End product of hemoglobin metabolism that is excreted in bile.

--- Content provided by FirstRanker.com ---

It comes from

?

from catabolism of circulating RBCs

--- Content provided by FirstRanker.com ---

?

from ineffective erythropoiesis (bone marrow)

--- Content provided by⁠ FirstRanker.com ---

?

from turnover of heme proteins
What causes bilirubin?

--- Content provided by‌ FirstRanker.com ---

1. Overproduction by reticuloendothelial system
2. Failure of hepatocyte uptake
3. Failure to conjugate or excrete
4. Obstruction of biliary excretion into intestine

--- Content provided by⁠ FirstRanker.com ---

Normal Range of Bilirubin

It is normal to have some bilirubin in your blood. Normal levels are:

?Direct (also cal ed conjugated) bilirubin: 0 to 0.3 mg/dL

--- Content provided by‌ FirstRanker.com ---

?Total bilirubin: 0.3 to 1.9 mg/dL
Causes of Jaundice

Jaundice occurs when there is:

--- Content provided by‌ FirstRanker.com ---

too much bilirubin being produced for the liver to remove

from the blood (for example, patients with hemolytic anemia

--- Content provided by FirstRanker.com ---

have an abnormally rapid rate of destruction of their red blood

cells that releases large amounts of bilirubin into the blood)

a defect in the liver that prevents bilirubin from being

--- Content provided by FirstRanker.com ---

removed from the blood, converted to bilirubin/glucuronic

acid (conjugated) or secreted in bile; or

--- Content provided by​ FirstRanker.com ---

blockage of the bile ducts that decreases the flow of bile

and bilirubin from the liver into the intestines. For

example, the bile ducts can be blocked by worms, cancer,

--- Content provided by‌ FirstRanker.com ---

gallstones, or inflammation of the bile ducts. The

decreased conjugation, secretion, or flow of bile that can

--- Content provided by​ FirstRanker.com ---

result in jaundice is referred to as cholestasis: however,

cholestasis does not always result in jaundice.
Obstructive Jaundice

--- Content provided by‌ FirstRanker.com ---

Obstructive jaundice is a condition in which there is blockage of the flow of bile out of the

liver

INTRAHEPATIC

--- Content provided by​ FirstRanker.com ---

EXTRAHEPATIC

CAUSES OF OBSTRUCTIVE JAUNDICE: INTRAHEPATIC

--- Content provided by FirstRanker.com ---

Primary biliary cirrhosis
Sclerosing cholangitis (Inflammation/scarring)

Primary biliary cirrhosis

--- Content provided by‌ FirstRanker.com ---

Sclerosing cholangitis (Inflammation/scarring)
CAUSES OF OBSTRUCTIVE JAUNDICE: EXTRAHEPATIC

? Choledocholithiasis
? Worms

--- Content provided by‌ FirstRanker.com ---

? Malignancy : neoplasia, L.N.

Choledocholithiasis

Malignancy : Pancreatic (head of pancreas) carcinoma

--- Content provided by‍ FirstRanker.com ---

AN APPROACH TO A CHILD

WITH JAUNDICE

CLASSIC APPROACH

--- Content provided by‌ FirstRanker.com ---

Proper detailed history

Proper physical examination

--- Content provided by‌ FirstRanker.com ---

Appropriate investigations
IDENTIFY

Acute

--- Content provided by‍ FirstRanker.com ---

Chronic (more than 6 months)

IDENTIFY

Hemolytic

--- Content provided by⁠ FirstRanker.com ---

Hepatocel ular
Cholestatic
TYPES OF JAUNDICE

TYPE

--- Content provided by⁠ FirstRanker.com ---

PRE

HEPATIC

--- Content provided by⁠ FirstRanker.com ---

POST

HEPATIC

HEPATIC

--- Content provided by‌ FirstRanker.com ---

Urine color

normal

--- Content provided by‍ FirstRanker.com ---

dark

dark

Stool color

--- Content provided by⁠ FirstRanker.com ---

normal

normal

--- Content provided by‍ FirstRanker.com ---

acholic

Pruritis

no

--- Content provided by​ FirstRanker.com ---

No

yes

--- Content provided by‍ FirstRanker.com ---

Signs and Symptoms

of Jaundice

1. yel ow discoloration of the skin, mucous

--- Content provided by FirstRanker.com ---

membranes, sclera of the eyes

2. light-colored stools

--- Content provided by FirstRanker.com ---

3. dark-colored urine

4. itching of the skin.

5. nausea and vomiting

--- Content provided by⁠ FirstRanker.com ---

6. abdominal pain

7. fever

--- Content provided by‌ FirstRanker.com ---

8. weakness

9. loss of appetite

10. headache

--- Content provided by FirstRanker.com ---

11. confusion

12. swel ing of the legs and abdomen

--- Content provided by⁠ FirstRanker.com ---

13. Skin stigmata
Diagnosis of Jaundice

The health care provider wil perform a physical exam. This may reveal liver

--- Content provided by​ FirstRanker.com ---

swel ing.

?A bilirubin blood test wil be done.

Other tests vary, but may include:

--- Content provided by⁠ FirstRanker.com ---

?Hepatitis virus panel to look for infection of the liver

?Liver function tests to determine how wel the liver is working

--- Content provided by​ FirstRanker.com ---

?Complete blood count to check for low blood count or anemia

?Abdominal ultrasound
?Abdominal CT scan

--- Content provided by FirstRanker.com ---

?Endoscopic retrograde cholangiopancreatography (ERCP)

?Percutaneous transhepatic cholangiogram (PTCA)

?Liver biopsy

--- Content provided by‌ FirstRanker.com ---

?Cholesterol level

?Prothrombin time

--- Content provided by FirstRanker.com ---

IN CHILDREN

Hepatocel ular (SGOT/SGPT more than twice of ALP)

Cholestatic (SGOT/SGPT less than twice of ALP)

--- Content provided by FirstRanker.com ---

Table of diagnostic tests

Function test

Pre-hepatic Jaundice

--- Content provided by‌ FirstRanker.com ---

Hepatic Jaundice

Post-hepatic Jaundice

--- Content provided by⁠ FirstRanker.com ---

Total bilirubin

Normal / Increased

Increased

--- Content provided by‍ FirstRanker.com ---

Conjugated bilirubin

Normal

--- Content provided by​ FirstRanker.com ---

Increased

Increased

Unconjugated bilirubin Normal / Increased

--- Content provided by​ FirstRanker.com ---

Increased

Normal

--- Content provided by FirstRanker.com ---

Urobilinogen

Normal / Increased

Increased

--- Content provided by​ FirstRanker.com ---

Decreased / Negative

Dark (urobilinogen +

--- Content provided by‍ FirstRanker.com ---

Dark (conjugated

Urine Color

Normal

--- Content provided by‍ FirstRanker.com ---

conjugated bilirubin)

bilirubin)

--- Content provided by‌ FirstRanker.com ---

Stool Color

Normal

Normal/Pale

--- Content provided by⁠ FirstRanker.com ---

Pale

Alkaline phosphatase

--- Content provided by FirstRanker.com ---

Increased

levels

Normal

--- Content provided by FirstRanker.com ---

Alanine transferase and
Aspartate transferase

Increased

--- Content provided by​ FirstRanker.com ---

levels

Conjugated Bilirubin in Not Present

--- Content provided by FirstRanker.com ---

Present

Urine
Splenomegaly

--- Content provided by‌ FirstRanker.com ---

Present

Present

Absent

--- Content provided by​ FirstRanker.com ---

REMEMBER

The prognostic value of

--- Content provided by​ FirstRanker.com ---

Albumin
Coagulation profile
NEONATAL JAUNDICE

?Jaundice is clinical y detectable in the newborn when the serum

--- Content provided by​ FirstRanker.com ---

bilirubin levels are greater than 5 mg/dl. This occurs in

approximately 60% of term infants and 80% of preterm infants.

--- Content provided by FirstRanker.com ---

?Neonatal jaundice first becomes visible in the face and forehead.

Blanching reveals the underlying color. Jaundice then gradual y

becomes visible on the trunk and extremities.

--- Content provided by FirstRanker.com ---

Signs and Symptoms of Neonatal Jaundice

Newborns, as the bilirubin level rises, jaundice wil typically
progress from the head to the trunk, and then to the hands and

--- Content provided by‍ FirstRanker.com ---

feet. Additional signs and symptoms that may be seen in the
newborn include:

1. poor feeding
2. lethargy

--- Content provided by​ FirstRanker.com ---

3. changes in muscle tone
4. high-pitched crying
5. seizures.
ASCITES

--- Content provided by FirstRanker.com ---

DEFINITION

Accumulation of serous fluid in peritoneal cavity

oAs a part of generalized edema- anasarca

--- Content provided by‌ FirstRanker.com ---

oIsolated collection or disproportionate
CAUSES

1. Isolated or disproportionate

--- Content provided by‍ FirstRanker.com ---

Cardiac

?Hepatic

--- Content provided by‍ FirstRanker.com ---

Constrictive pericarditis

Cirrhosis

Neoplastic

--- Content provided by⁠ FirstRanker.com ---

Congenital hepatic fibrosis

Lymphoma

--- Content provided by‍ FirstRanker.com ---

Portal vein obstruction

Neuroblastoma

Budd chiari syndrome

--- Content provided by FirstRanker.com ---

Urinary

Neonatal cholestatis

--- Content provided by FirstRanker.com ---

Perforation

?Abdominal

Leakage from urinary tract

--- Content provided by‌ FirstRanker.com ---

Peritoneal Tuberculosis

Chylous ascites

--- Content provided by​ FirstRanker.com ---

Acute pancreatitis

Gynecological

Renal

--- Content provided by‍ FirstRanker.com ---

Ovarian tumor

Peritoneal dialysis

--- Content provided by FirstRanker.com ---

Ovarian rupture

Obstructive uropathy

2. Ascitis with generalized edema

--- Content provided by‌ FirstRanker.com ---

?Renal- Nephrotic syndrome, AGN, renal failure
?Cardiac- CHF, constrictive pericarditis
?Polyserositis- SLE, Dengue fever, sepsis
?Severe Malabsorption
CLINICAL FEATURE

--- Content provided by‍ FirstRanker.com ---

Abdominal distension-hal mark
Five classical signs

Bulging vein

--- Content provided by​ FirstRanker.com ---

Flank dullness and fullness
Shifting dullness
Fluid thrill
Puddle sign

--- Content provided by​ FirstRanker.com ---

Umbilical laughing/ herniation with tense ascites

D/D

?Gaseous distention

--- Content provided by‌ FirstRanker.com ---

?Fecal retention
?Masses
?Obesity
?Pregnancy
EVALUATION OF CAUSE

--- Content provided by​ FirstRanker.com ---

?Generalized/ isolated or predominant
?Predominant- hepatic or intra-abdominal
?Age- Neonate- urinary, chylous

--- Content provided by⁠ FirstRanker.com ---

Infancy- cholestatic

?Look for signs and symptoms of hepatic disease
?H/o contact for TB with pulmonary findings
?Presence of L. N.

--- Content provided by‌ FirstRanker.com ---

ASCITIC FLUID ANALYSIS

?Transudative/ exudative ( by SAAG ?serum albumin-ascetic fluid albumin gradient)
?SAAG- 1.1g/dl-transudative

--- Content provided by‍ FirstRanker.com ---

<1.1g/dl- exudative

?Transudative- CLD and when ascites is a part of generalized edema
?Ascitic fluid- cytology, gram staining, culture

--- Content provided by​ FirstRanker.com ---

characteeristic

disease

--- Content provided by‌ FirstRanker.com ---

Lymphocytic pleocytosis

tuberculosis

Polymorphic pleocytosis

--- Content provided by⁠ FirstRanker.com ---

Bacterial perotonitis

hemorrhagic

--- Content provided by‌ FirstRanker.com ---

Malignancy, pancreatitis,

tuberculosis

Milky white

--- Content provided by⁠ FirstRanker.com ---

Chylous ascitis
OTHER INVESTIGATIONS

?Ultrasonography? quantity, etiology, L.N., hepatic echotexture, size of

--- Content provided by⁠ FirstRanker.com ---

portal vein

?Portal venous Doppler studies
?CT Abdomen-intra abdominal mass, malignancy etc.

--- Content provided by‌ FirstRanker.com ---

?LFT
?UGI endoscopy- CLD and PH
?Chest X-ray
?Mantoux test

--- Content provided by‍ FirstRanker.com ---

TREATMENT

?Low salt diet
?Diuretics
?IV albumin

--- Content provided by FirstRanker.com ---

?Repeated large volume paracentesis
?Depend on cause of ascites
AT T- TB
Antibiotics- bacterial infection
Interferons- Heptitis B and C

--- Content provided by‌ FirstRanker.com ---

Steroids- autoimmune hepatitis
Surgery or propranolol- PH and Varices
Liver transplantation- decompensated liver, cirrhosis, portal hypertension
MCQ 1

--- Content provided by⁠ FirstRanker.com ---

Regarding bilirubin metabolism, whic h of

the following is true?

a) Normal elimination is through the urine and the stool

--- Content provided by​ FirstRanker.com ---

b) Serum bilirubin concentration is not influenced by medications
c) Bilirubin is primarily free in circulation
d) Heme protein is primarily broken down in circulation

MCQ 2

--- Content provided by⁠ FirstRanker.com ---

Followings are alarming signs in a patient with jaundice, except:
a) Altered sensorium
b) Raised INR
c) Raised ALT

--- Content provided by‌ FirstRanker.com ---

d) Persistent vomiting