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