Jaundice Types | Obstructive | Hepatocellular and Hemolytic Jaundice

Jaundice Types | Obstructive | Hepatocellular and Hemolytic Jaundice .

What Causes Jaundice

Jaundice is a symptom complex characterized by increase of bile pigments in body fluids and tissues. Jaundice is perceptible only when the level of bilirubin and only its conjugates exceed 1.5mg/100ml in plasma. In its mildest form it is recognized by yellow discoloration of sclera. With deeper jaundice the skin and mucous membrane are also stained.

Normal bile pigment metabolism1.  Breakdown phase

• Hemoglobin breakdown takes place in reticulo-endothelial system forming bile pigment bilirubin which is transported to blood stream attached to albumin.

2.  Conjugation phase

• Un-conjugated bilirubin is lipid soluble and cannot be excreted by kidney.
  
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  Therefore, for elimination it is sent to liver and chemically altered there (i.e. conjugated).

3.  Alimentary excretion phase

• Bilirubin is excreted through bile into intestines where it is converted into stercobilinogen by bacterial action.
• A large part is re-absorbed from intestines to portal blood and taken back to liver and re-excreted into bile (entero-hepatic circulation).
• Stercobilinogen which is not absorbed gives the feces its brown color.

4.  Renal excretion phase

• A small part of stercobilinogen (4mg daily) passes, into general blood stream and is carried to kidney for excretion in urine as urobilinogen.

Mechanism of jaundice productionIncrease of bilirubin in blood may arise in 4 different ways

Increased bilirubin load on liver cells e.

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g. hemolytic states.

Defective uptake by liver cells e.g. in hepatitis.

Defective conjugation e.g. in hepatitis, cirrhosis of liver.

Defective excretion into biliary canal e.g. in hepatitis, Dubin Johnson syndrome, carcinoma of gallbladder, gallstones and biliary stricture.

Clinically jaundice is classified into 3 types

Hemolytic jaundice

Hepato-cellular jaundice

Obstructive jaundice

Hemolytic Jaundice

• Causes of hemolytic jaundice

Sickle cell disease.

Congenital spherocytosis.

G6PD deficiency.

Infection both viral and bacterial.

Antibodies in serum e.g. rhesus or transfusion of blood, incompatibility and autoimmune hemolytic disease.

Trauma to red cells- cardiac hemolysis (in patients with prosthetic valve).

Associated with enlarged spleen (Hodgkin’s disease).

Hepato-cellular Jaundice

• Causes of Acute hepato-cellular jaundice

Viral hepatitis

Hepatic immaturity

Drug hepatitis

Alcoholic hepatitis

Leptospirosis

Yellow fever

• Causes of Chronic hepato-cellular jaundice

Cirrhosis of liver

Congenital hyper-bilirubin

Obstructive Jaundice

A.  Without mechanical obstruction

Acute – drugs e.g. chlorpromazine and viral hepatitis with cholestasis.

Chronic – primary biliary cirrhosis.

B.  With mechanical obstruction

• Intra-hepatic

Intra-hepatic cancers.

Congenital obliteration of bile ducts.

• Extra-hepatic (surgical jaundice)

Gallstones, foreign body, parasites (ascaris and hydatids).

Congenital atresia, stricture.

Carcinoma head of pancreas, chronic pancreatitis.