Clinical Approach to Neonatal Jaundice
Transcript of Clinical Approach to Neonatal Jaundice
Dr. Siddeeg AddowPediatric Resident Khartoum, Sudan
Clinical Approach to Neonatal Jaundice
CONTENTS:
INTRODUCTIONPATHOPHYSIOLOGYDIFFERENTIAL DIAGNOSISHISTORYEXAMINATIONINVESTIGATION
INTRODUCTIONBilirubin is the end product of heme Bilirubin is the end product of heme degradationdegradationMost of the daily production comes Most of the daily production comes from the breakdown of RBCs in the from the breakdown of RBCs in the RESRESHeme biliverdin Heme biliverdin bilirubin bilirubin Bilirubin is released & bound to serum Bilirubin is released & bound to serum albuminalbuminBilirubin is uptake & conjugated with Bilirubin is uptake & conjugated with glucuronic acidglucuronic acidFinally conjugated bilirubin is excreted Finally conjugated bilirubin is excreted in bile in bile
PATHOPHYSIOLOGY
UNCONJUGATED B. CONJUGATED B.Tightly Tightly compounded to s. compounded to s. albumin albumin Normally very small Normally very small amount is present amount is present as albumin free as albumin free Insoluble in water Insoluble in water can not be excreted can not be excreted in urinein urineToxic Toxic
Non toxicNon toxicWater solubleWater solubleLoosely bound to Loosely bound to albumin. Delta albumin. Delta fraction fraction
Both conjugated & unconjugated Both conjugated & unconjugated bilirubin may accumulate bilirubin may accumulate systemically & deposit in tissues systemically & deposit in tissues Normally s. bilirubin level vary Normally s. bilirubin level vary b/w 0.3 & 1.2mg/dl. b/w 0.3 & 1.2mg/dl. The rate of systemic bilirubin The rate of systemic bilirubin production is = to the rate of production is = to the rate of hepatic uptake, conjugation & hepatic uptake, conjugation & biliray excretion .biliray excretion .Jaundice becomes evident when Jaundice becomes evident when the s.bilirubin levels rise above the s.bilirubin levels rise above 2.0 to 2.5mg/dl 2.0 to 2.5mg/dl
Levels as high as 30 to 40mg/dl Levels as high as 30 to 40mg/dl can occur with sever diseasecan occur with sever diseaseJaundice occurs when the = b/w Jaundice occurs when the = b/w bilirubin production &clearance bilirubin production &clearance is disturbed by one or more of is disturbed by one or more of the following mechanisms:the following mechanisms:
1.1.Excessive production of bilirubinExcessive production of bilirubin2.2.Reduced hepatic uptakeReduced hepatic uptake3.3.Impaired conjugationImpaired conjugation4.4.Decreased hepatocellular Decreased hepatocellular
excretionexcretion5.5.Impaired bile flowImpaired bile flow
CAUSES OF JAUNDICE
Excessive production of Excessive production of bilirubinbilirubin
hemolytic anemia'sresorption of blood from internal hemor.ineffective erythropoiesis
Reduced hepatic uptake:
drugs some cases of Gilbert syndrome
Impaired bilirubin Impaired bilirubin conjugation:conjugation:
physiologic jaundicebreast milk jaundicegenetic deficiency of glcuronosyl transferasedecreased expression of glcuronosyl transferasediffuse hepatocellular diseases
Decrease excretion of conjugated bilirubin:
deficiency in canalicular membrane transportdrug induced canalicular membrane dysfunctionhepatocelluler damage or toxicity
Decreased intrahepatic bile flow :
inflammatory destruction of intrahepatic bile ducts
Extra hepatic biliary Extra hepatic biliary obstruction:obstruction:
gall stone obstruction of biliary treeextra hepatic biliary atresiabiliary stricture & choledochal cystprimary sclerosing cholangitisliver fluke infestationcarcinoma
HISTORYonset / durationpainnausea & vomitingloss of weight itchingcolor of stoolcolor of urinepast historyttt &family history
EXAMINATIONcolor of skinseverity of jaundiceanemialiverspleengall bladderascites
INVESIGATIONCBCLFTProthrombin timeAlfa feto proteinsUGSGU/SERCP & PTCLiver biopsy
The EndThe End