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Jaundice<br />By Bish<br />
Objectives<br /><ul><li>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</li></li></ul><li>Definition: Hyperbilirubinemia<br />Hyperbilirubinemia: <br...
Why am I learning this?<br />Is it important?<br />
Why?<br />Jaundice is quite common<br /> Full term infants: at least 60% <br /> Preterm infants: over 80% <br />
Most Importantly…<br />
Most Importantly…<br />Kernicterus: unconjugated bilirubin deposits in the brain  yellow staining + degenerative lesions<...
Source Of Bilirubin<br /><ul><li>85% from old RBC , the rest </li></ul> from  non haem proteins<br /><ul><li> Hb is degrad...
Journey through the liver<br /> Bilirubin taken up<br /> Conjugated to form water soluble conjugate<br /> Conjugate secret...
In The Gut<br />Bilirubin diglucuronide may be  <br />Deconjugated or<br /> Metabolised by bacteria to urobilinogenpartia...
So where can things go wrong?<br />
Pathophysiology Of Jaundice<br />Hyperbilirubinemia is due to:<br /><ul><li>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</li></li></ul><li>Classifications<br />
Classifications<br />  Physiological Jaundice <br />  Pathological Jaundice<br />
Physiological jaundice :<br />1. General state of baby is well<br />	 2. Appears 2-3days    	<br /> 3. Disappears  <2 week...
 Pathological Jaundice <br />		1. Appears earlier (first 24 hours of life)<br />		2. Fades  >2 weeks     (term infants)   ...
Back to our table..let’s break things down into basics..<br />
Hint…<br />
Good Job!<br />
Now that you’re a pro..<br />You’re called by a nurse for a new admission regarding a baby with elevated bili..what do you...
Approach to jaundiced baby<br />Get  age of baby (hours), gestational age, pregnancy hx, septic risk factors, complication...
Approach to jaundiced baby<br />Get  age of baby (hours), gestational age, pregnancy hx, septic risk factors, complication...
Why does the age (hours) of baby matter?<br />
Causes of jaundice<br />Appearing within 24 hours of age<br />Hemolytic disease of NB : Rh, ABO<br />Infections: TORCH, ma...
What workup/labs do you order<br />
Workup<br />Initial laboratory tests <br />Total & direct bilirubin <br />Blood group and Rh for mother and baby <br />CBC...
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Jaundice presentation

  1. 1. Jaundice<br />By Bish<br />
  2. 2. Objectives<br /><ul><li>Define hyperbilirubinemia (Jaundice).
  3. 3. Differentiate between physiological and pathological jaundice.
  4. 4. State causes of hyperbilirubinemia.
  5. 5. Describe the most dangerous complication of hyperbilirubinemia.
  6. 6. Discuss the management of hyperbilirubinemia</li></li></ul><li>Definition: Hyperbilirubinemia<br />Hyperbilirubinemia: <br />excessive level bilirubin in the blood <br />characterized by jaundice, a yellowish discoloration of the skin, sclerae, mucous membranes and nails<br />Typically seen at bili levels of: 85-120<br />Unconjugated bilirubin = Indirect bilirubin.<br />Conjugated bilirubin = Direct bilirubin.<br />
  7. 7. Why am I learning this?<br />Is it important?<br />
  8. 8. Why?<br />Jaundice is quite common<br /> Full term infants: at least 60% <br /> Preterm infants: over 80% <br />
  9. 9. Most Importantly…<br />
  10. 10. Most Importantly…<br />Kernicterus: unconjugated bilirubin deposits in the brain  yellow staining + degenerative lesions<br />Phase 1: decreased alertness<br />Hypotonia<br /> Poor feeding<br /> Phase 2: Hypertonia, <br />Retrocollis, opisthotonus<br /> Phase 3: Hypotonia<br />
  11. 11. Source Of Bilirubin<br /><ul><li>85% from old RBC , the rest </li></ul> from non haem proteins<br /><ul><li> Hb is degraded to Haem</li></ul> and Globin<br /><ul><li> Iron is extracted from Haem</li></ul> Rest is converted to bilirubin<br /><ul><li> Bilirubin travels to liver bound</li></ul> to albumin<br />
  12. 12. Journey through the liver<br /> Bilirubin taken up<br /> Conjugated to form water soluble conjugate<br /> Conjugate secreted into bile<br />
  13. 13.
  14. 14. In The Gut<br />Bilirubin diglucuronide may be <br />Deconjugated or<br /> Metabolised by bacteria to urobilinogenpartially reabsorbed (remainder makes the stool brown)<br />
  15. 15. So where can things go wrong?<br />
  16. 16. Pathophysiology Of Jaundice<br />Hyperbilirubinemia is due to:<br /><ul><li>Excess bilirubin production Haemolytic
  17. 17. Impaired uptake by hepatocyte Hep/cellular.
  18. 18. Failure of Conjugation Hep/cellular.
  19. 19. Impaired secretion of conj.bil. Hep/cellular.
  20. 20. Impaired bile flow. Obst.Jaundice</li></li></ul><li>Classifications<br />
  21. 21. Classifications<br /> Physiological Jaundice <br /> Pathological Jaundice<br />
  22. 22. Physiological jaundice :<br />1. General state of baby is well<br /> 2. Appears 2-3days <br /> 3. Disappears <2 week (term infants) <br /> <4 weeks (preterm infants)<br />Pathophysiology<br />increased hematocrit and decreased RBC lifespan <br />immature glucuronyltransferase enzyme system (slow conjugation of bilirubin) <br />increased enterohepatic circulation<br />
  23. 23. Pathological Jaundice <br /> 1. Appears earlier (first 24 hours of life)<br /> 2. Fades >2 weeks (term infants) <br />>4 weeks (preterm infants)<br />
  24. 24. Back to our table..let’s break things down into basics..<br />
  25. 25. Hint…<br />
  26. 26. Good Job!<br />
  27. 27. Now that you’re a pro..<br />You’re called by a nurse for a new admission regarding a baby with elevated bili..what do you want to know<br />
  28. 28. Approach to jaundiced baby<br />Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery<br />Assess clinical condition (well or ill)<br />Decide whether jaundice is physiological or pathological<br />Look for evidence of kernicterus* in deeply jaundiced NB<br />*review..what do you look for?<br />
  29. 29. Approach to jaundiced baby<br />Get age of baby (hours), gestational age, pregnancy hx, septic risk factors, complications with delivery<br />Assess clinical condition (well or ill)<br />Decide whether jaundice is physiological or pathological<br />Look for evidence of kernicterus* in deeply jaundiced NB<br />*Lethargy and poor feeding, poor or absent Moro's, opisthotonus or convulsions<br />
  30. 30. Why does the age (hours) of baby matter?<br />
  31. 31. Causes of jaundice<br />Appearing within 24 hours of age<br />Hemolytic disease of NB : Rh, ABO<br />Infections: TORCH, malaria, bacterial<br />Appearing between 24-72 hours of life<br />Physiological<br />G6PD deficiency<br />Dehydration (breast feeding jaundice)<br />Sepsis<br />Polycythemia<br />Concealed hemorrhage<br />Intraventricular hemorrhage<br />Increased entero-hepatic circulation<br />Appearing beyond 1 week<br />Breast milk jaundice<br />Prolonged physiologic jaundice in preterm<br />Hypothyroidism<br />Neonatal hepatitis <br />Conjugation dysfunction   - e.g. Gilbert syndrome, Crigler-Najjarsyndrome<br />Inborn errors of metabolism   - e.g. galactosemia<br />Biliarytract obstruction      - e.g. biliaryatresia<br />
  32. 32. What workup/labs do you order<br />
  33. 33. Workup<br />Initial laboratory tests <br />Total & direct bilirubin <br />Blood group and Rh for mother and baby <br />CBC/d, reticcount and peripheral smear <br />Coombtest<br />TSH, G6PD screen <br />Conjugated hyperbilirubinemia: <br />AST, ALT, PT, PTT, serum albumin, ammonia, TSH, TORCH screen, septic work-up<br />
  34. 34. Treatment?<br />
  35. 35. Treatment<br />During pregnancy (if severe)<br /> Intrauterine blood transfusion<br />Early delivery<br />After pregnancy <br />Increase feeds (especially in breast feeding jaundice)<br />Phototherapy<br />Exchange transfusion (if severe)<br />
  36. 36. Bilirubin chart<br />
  37. 37. Side effects of phototherapy<br />Increased insensible water loss<br />Loose stools<br />Skin rash<br />Bronze baby syndrome<br />Hyperthermia<br />Upsets maternal baby interaction <br />
  38. 38.
  39. 39. Thank You<br />
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