HYPERBILIRUBINEMIA

Specimen Test Pre-hepatic or Hepatocellular jaundice Posthepatic or

hemolytic or obstructive or
retention regurgitation
jaundice jaundice

Blood Unconjugated ++ + Normal

bilirubin (van den
Bergh indirect
test)

Blood Conjugated Normal Excretion is rate-limiting. ++

bilirubin (van den It is the first impaired
Bergh direct test) activity. In early phase, it is
increased

Blood Alkaline Normal 2–3 times increased 10–12 times

phosphatase (40– increased
125 U/L)
Specimen Test Pre-hepatic or Hepatocellular jaundice Post-hepatic or
hemolytic or obstructive or
retention regurgitation
jaundice jaundice

Urine Bile salt Absent Absent Present

(Hay’s test)

Urine Conjugated Absent Present Present

bilirubin
(Fouchet’s)

Urine Urobilinogen +++ Increased in early phases; Absent

s (Ehrlich later decreased as
test) production is low. Earliest
manifestation of recovery is
presence of bilinogen in
urine

Feces Urobilins ++ Normal or decreased Clay-colored

 Type of Class of Causes
bilirubin jaundice

Unconjugated Pre-hepatic or Abnormal red cells; antibodies; drugs and

hemolytic toxins; thalassemia; hemoglobinopathies
Gilbert’s syndrome; Crigler-Najjar
syndrome

Unconjugated Hepatic or Viral hepatitis; toxic hepatitis; intrahepatic

and hepatocellular cholestasis
conjugated

Conjugated or Post-hepatic Extrahepatic cholestasis; gallstones;

obstructive tumors of bile duct; carcinoma of
pancreas
Evaluation of patient with Jaundice
 Personal data
Chief complain Yellow discoloration

History of presenting illness

How did the skin discoloration start? for ➔ Sudden Choledocholithiasis- Acute
how long ? hepatitis - sepsis,hemolysis, Budd- chiari
syndrome
➔ Gradual : Cancer in the head of the
pancreas, Chronic hepatitis, CHF
Does the discoloration change with time with fasting, stress, menstruation? gilbert
? syndrome

Is your urine dark? Dark :

➔ Hepatitis
➔ Alcoholic liver
➔ Hepatotoxicity
➔ Biliary obstruction
➔ hemolysis (by hemoglobinuria)
Are your stools pale ? Biliary obstruction (with dark urine )
 Associated symptoms
Do you have any skin Itching (pruritus ) ➔ Biliary obstruction
Do you have adominal pain? epigastric: pancreatic cancer, pancreatitis
RUQ: Choledocholithiasis
Does the pain radiate ? To right shoulder : ➔ Choledocholithiasis

Characteristic of the pain Biliary : ➔ Choledocholithiasis.

Dull : ➔ Cancer in the head of the pancreas.

Does anything increase the pain? Fatty Food ➔ Choledocholithiasis

Do you have any Fever, chills and rigor ? ➔ Hepatitis

➔ Cholecystitis.
➔ Hepatitis
Did you loss weight? ➔ Cancer in the head of the pancreas
➔ Alcoholic liver.
➔ hepatobiliary cancer
Anemia or splenomegaly ? ➔ Pre hepatic
Have you had any vomiting of blood or liver cirrhosis
passage of dark stools?
Do you have Itching ? ➔ Obstructive jaundice
 Past medical and surgical history
Have you had similar symptoms (pain)? ➔ Choledocholithiasis
Any history of existing liver disease?

Do you have sickle cell- thalassemia? ➔ Hemolysis.

Do you have a history of IBD such as ➔ Primary sclerosing cholangitis

ulcerative colitis?

Do you have any autoimmune diseases ?

Have you been recently exposed to anyone ➔ Hepatitis A or B

with hepatitis?

Did you have a recent blood transfusion? ➔ Hemolysis.

➔ Hepatitis B

Hx of needle stick injury ? ➔ Hepatitis

Hx of gallstones ? ➔ Cholestatic jaundice

Have you had any surgeries ( especially Stricture , retained stone

biliary surgery) ?
 Medication
Have you started any new medications TB medication or herbal
recently? ➔ Hepatotoxicity.
Do you take herbal medication? ➔ Hepatotoxicity.

Have you been immunized against hepatitis

B?
Family History
Does anybody in the family have similar ➔ Hepatitis
symptoms?
Have you or has anyone in your family ever ➔ Hypercoagulable states may result in
had blood clots? Budd-Chiari syndrome.

History of HBV in the mother ? ➔ vertical transmission

Family Hx of any liver diseases ? ➔ Family history of jaundice or liver disease

suggests the possibility of hereditary
hyperbilirubinemia or genetic liver disease
 Social history
Do you drink alcohol /How much? How ➔ Alcoholic liver
long?
Have you ever used intravenous drugs? ➔ Hepatitis

Have you ever had high-risk sexual ➔ Hepatitis

behavior?
Have you traveled recently? (to areas where ➔ Hepatitis
hepatitis A is endemic)

Have you had any recent contact with

patients with jaundice or liver problems?
Do you have any tattoos ? ➔ Hepatitis

(For Woman ) are you pregnant ? ➔ Pregnancy related

 Systematic Review
Investigation :
➔ CBC
➔ Liver function test
➔ Coagulation profile
➔ US→ Choledocholithiasis
➔ CT→ Cancer in the pancreas