JAUNDICE

By Bish

Objectives

• Define hyperbilirubinemia (Jaundice).

• Differentiate between physiological and pathological jaundice.

• State causes of hyperbilirubinemia.• Describe the most dangerous

complication of hyperbilirubinemia.• Discuss the management of

hyperbilirubinemia

Definition: Hyperbilirubinemia Hyperbilirubinemia:

excessive level bilirubin in the blood characterized by jaundice, a yellowish

discoloration of the skin, sclerae, mucous membranes and nails Typically seen at bili levels of: 85-120

Unconjugated bilirubin = Indirect bilirubin.

Conjugated bilirubin = Direct bilirubin.

Why am I learning this?

Is it important?

Why?

Jaundice is quite common

Full term infants: at least 60%

Preterm infants: over 80%

Most Importantly…

Most Importantly…

Kernicterus: unconjugated bilirubin deposits in the brain yellow staining + degenerative lesions

Phase 1: decreased alertness

Hypotonia

Poor feeding

Phase 2: Hypertonia,

Retrocollis, opisthotonus

Phase 3: Hypotonia

Source Of Bilirubin• 85% from old RBC , the

rest from non haem proteins• Hb is degraded to Haem and Globin• Iron is extracted from

Haem Rest is converted to

bilirubin• Bilirubin travels to liver

bound to albumin

Journey through the liver

Bilirubin taken up Conjugated to form water soluble

conjugate Conjugate secreted into bile

In The Gut

Bilirubin diglucuronide may be Deconjugated or Metabolised by bacteria to urobilinogen

partially reabsorbed (remainder makes the stool brown)

So where can things go wrong?

Pathophysiology Of Jaundice Hyperbilirubinemia is due to:Excess bilirubin production

Haemolytic Impaired uptake by hepatocyte

Hep/cellular.Failure of Conjugation

Hep/cellular. Impaired secretion of conj.bil.

Hep/cellular. Impaired bile flow.

Obst.Jaundice

Classifications

Physiological Jaundice

Pathological Jaundice

Classifications

1. General state of baby is well

2. Appears 2-3days 3. Disappears <2 week (term

infants) <4 weeks (preterm infants)

Pathophysiology increased hematocrit and decreased RBC lifespan immature glucuronyl transferase enzyme system

(slow conjugation of bilirubin) increased enterohepatic circulation

Physiological jaundice :

1. Appears earlier (first 24 hours of life)

2. Fades >2 weeks (term infants)

>4 weeks (preterm infants)

Pathological Jaundice

Back to our table..let’s break things down into basics..

Hint…

Good Job!

Now that you’re a pro..

You’re called by a nurse for a new admission regarding a baby with elevated bili..what do you want to know

Approach to jaundiced baby

Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery

Assess clinical condition (well or ill) Decide whether jaundice is physiological

or pathological Look for evidence of kernicterus* in

deeply jaundiced NB

*review..what do you look for?

Approach to jaundiced baby

Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery

Assess clinical condition (well or ill) Decide whether jaundice is physiological

or pathological Look for evidence of kernicterus* in

deeply jaundiced NB

*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions

Why does the age (hours) of baby matter?

Causes of jaundice

Appearing within 24 hours of age Hemolytic disease of NB : Rh, ABO Infections: TORCH, malaria, bacterial

Appearing between 24-72 hours of life Physiological G6PD deficiency Dehydration (breast feeding jaundice) Sepsis Polycythemia Concealed hemorrhage Intraventricular hemorrhage Increased entero-hepatic circulation

Appearing beyond 1 week Breast milk jaundice Prolonged physiologic jaundice in preterm Hypothyroidism Neonatal hepatitis Conjugation dysfunction

   - e.g. Gilbert syndrome, Crigler-Najjar syndrome Inborn errors of metabolism

   - e.g. galactosemia Biliary tract obstruction  

   - e.g. biliary atresia

What workup/labs do you order

Workup

Initial laboratory tests Total & direct bilirubin Blood group and Rh for mother and baby CBC/d, retic count and peripheral smear Coomb test TSH, G6PD screen Conjugated hyperbilirubinemia:

AST, ALT, PT, PTT, serum albumin, ammonia, TSH, TORCH screen, septic work-up

Treatment?

Treatment

During pregnancy (if severe) Intrauterine blood transfusion Early delivery

After pregnancy Increase feeds (especially in breast

feeding jaundice) Phototherapy Exchange transfusion (if severe)

Bilirubin chart

Side effects of phototherapy Increased insensible water loss Loose stools Skin rash Bronze baby syndrome Hyperthermia Upsets maternal baby interaction

Thank You