JAUNDICE

Hemoglobin
(70 to 80%) Erythroid cells
Heme
(250 to 400 mg/day)
Heme oxygenase
Biliverdin reductase
Heme proteins
myoglobin, cytochromes
(20 to 25%)
Biliverdin
Bilirubin
ferritin apoferritin
NADPH + H+
NADP+
3 [O]
Fe3+ + CO
Indirect
unconjugated
pre-hepatic
albumin

albumin-Bilirubin
ligandin
ligandin-Bilirubin
ER
Bilirubin diglucuronide
albumin
hepatocyte
UDP-Glucuronyl
transferase
bile (gall bladder)
direct
conjugated
post-hepatic
2 UDP-glucuronate
2 UDP

Bilirubin diglucuronide
Intrahepatic
urobilinogen
cycle
2 glucuronate Bacterial enzyme
Bilirubin
Bacterial enzyme
Intestines kidneys
Urobilinogen
Bacterial enzymes
Stercobilinogen
liver
Urobilin
kidneys
urine
Stercobilin Feces

 Normal plasma bilirubin: 0.2–0.8 mg/dl.
 Unconjugated bilirubin: 0.2–0.6 mg/dl.
 Conjugated bilirubin: 0–0.2 mg/dl.
 If the plasma bilirubin level exceeds 1mg/dl,
the condition is called hyperbilirubinemia.
 Levels between 1 & 2 mg/dl are indicative of
latent jaundice.

 When the bilirubin level exceeds 2 mg/dl, it
diffuses into tissues producing yellowish
discoloration of sclera, conjunctiva, skin &
mucous membrane resulting in jaundice.
 Icterus is the Greek term for jaundice.

 It is a specific test for for identificaion of
increased serum bilirubin levels.
 Normal serum gives a negative van den
Bergh reaction.
 Mechanism of the reaction:
 Van den Bergh reagent is a mixture of equal
volumes of sulfanilic acid (in dilute HCI)&
sodium nitrite.

 Principle:
 Diazotised sulfanilic acid reacts with bilirubin
to form a purple coloured azobilirubin.
 Direct and indirect reactions:
 Bilirubin as such is insoluble in water while
the conjugated bilirubin is soluble.

 Van den Bergh reagent reacts with
conjugated bilirubin & gives a purple colour
immediately (normally within 30 seconds.
 This is direct positive van den Bergh reaction.
 Addition of methanol (or alcohol) dissolves
the unconjugated bilirubin & gives the van
den Bergh reaction (normally within 30
minutes) positive.
 This is indirect positive.

 lf the serum contains both unconjugated and
conjugated bilirubin in high concentration,
the purple colour is produced immediately
(direct positive) which is further intensified
by the addition of alcohol (indirect positive).
 This type of reaction is known as biphasic.

 Useful in understanding the nature of
jaundice.
 This is due to jaundice is characterized by
increased serum concentration of
unconjugated bilirubin (hemolytic),
conjugated bilirubin (obstructive) or both of
them (hepatic).

 Indirect positive - Hemolytic jaundice
 Direct positive - Obstructive jaundice
 Biphasic - Hepatic jaundice
 Bilirubin in urine:
 The conjugated bilirubin, being water
soluble, is excreted in urine.
 Unconjugated bilirubin is not excreted.
 Bilirubin in urine can be detected by
Fouchet's test or Gmelin's test.

 Depending on the nature of the bilirubin
elevated,
 Conjugated or Unconjugated
hyperbilirubinemia.
 Based on the cause:
 Classified into congenital & acquired.

 They result from abnormal uptake,
conjugation or excretion of bilirubin due to
inherited defects.
 Crigler-Najjar Syndrome:
 Enzyme deficiency: UDP glucuronyl
transferase.
 There is a defect in the conjugation.

 Type 1(Congenital non-hemolytic jaundice),
 There is severe deficiency of UDP glucuronyl
transferase.
 The disease is often fatal & the children die
before the age of 2.
 Jaundice usually appears within the first 24
hours of life.
 Unconjugated bilirubin level increases to
more than 20 mg/dl, & results in kernicterus.

 Type 2 disease: It is a milder form.
 Only the second stage of conjugation is
deficient.
 When barbiturates are given, some response
is seen & jaundice improves.
 Bilirubin level in blood exceeds 20 mg/dl in
Crigler-Najjar syndrome Type 1
 Does not exceed 20 mg/ dl in Crigler-Najjar
syndrome Type 2.

 It is inherited as an autosomal dominant trait.
 The defect in uptake of bilirubin by the liver.
 Also due to reduced glucuronyl transferase
activity
 Bilirubin level is usually around 3 mg/dl &
patient is asymptomatic.
 Presence of mild jaundice.

 It is an autosomal recessive trait.
 Defective excretion of conjugated bilirubin
 Conjugated bilirubin is increased in blood.
 The disease results from the defective ATP
dependent organic anion transport in bile
canaliculi.
 The bilirubin is deposited in the liver & the liver
appears black.
 This is called as Black liver jaundice.

 It is an autosomal recessive condition.
 Bilirubin excretion is defective.
 There is no staining of the liver.

 Jaundice (also known as icterus) may be
considered as a symptom rather than a
disease.
 It is frequently caused due to multiple factors.
 Jaundice is 3 major types-
 Hemolytic Jaundice
 Hepatic Jaundice
 Obstructive Jaundice

 This condition is associated with increased
hemolysis of erythrocytes (e.g. incompatible
blood transfusion, malaria, sickle-cell
anemia).
 This results in the overproduction of bilirubin
beyond the ability of the liver to conjugate &
excrete.

 In hemolytic jaundice, more bilirubin is excreted into
the bile leading to the increased formation of
urobilinogen & stercobilinogen.
 Hemolytic jaundice is characterized by
 Elevation in the serum unconjugated bilirubin.
 Increased excretion of urobilinogen in urine.
 Dark brown colour of feces due to high content of
stercobilinogen.
 Deposited in brain, leading to mental retardation,
fits, toxic encephalitis & spasticity.

 If the child develops hemolytic disease, child
may be given exchange transfusion along
with phototherapy & barbiturates.
 Phototherapy with blue light (440 nm wave
length) isomerizes the insoluble bilirubin to
more soluble isomers.
 These can be excreted through urine without
conjugation.

 It is caused by dysfunction of the Iiver due to
damage to the parenchymal cells.
 This may be attributed to viral infection,
poisons & toxins (chloroform, carbon
tetrachloride, phosphorus etc.) cirrhosis of
liver, cardiac failure etc.
 Among these, viral hepatitis is most common.

 Damage to the liver adversely affects the
bilirubin uptake & its conjugation by liver cells.
 Hepatic jaundice is characterized by
 Increased levels of conjugated & unconjugated
bilirubin in the serum.
 Dark coloured urine due to the excessive
excretion of bilirubin & urobilinogen.

 lncreased activities of alanine transaminase
(SGPT) & aspartate transaminase (SGOT)
released into circulation due to damage to
hepatocytes.
 The patients pass pale, clay coloured stools
due to the absence of stercobilinogen.
 Symptoms:
 Weakness, loss of appetite, hepatomegaly &
nausea.

 This is due to an obstruction in the bile duct
that prevents the passage of bile into the
intestine.
 The obstruction may be caused by gall
stones, tumors etc.
 Due to the blockage in bile duct, the
conjugated bilirubin from the liver enters the
circulation.

 Obstructive jaundice is characterized by
 Increased concentration of conjugated
bilirubin in serum.
 Serum alkaline phosphatase is elevated as it
is released from the cells of the damaged bile
duct.
 Dark coloured urine due to increased
excretion of bilirubin & clay coloured feces
due to absence of stercobilinogen.

 Feces contain excess fat indicating
impairment in fat digestion and absorption
in the absence of bile (specifically bile salts).
 The patients experience nausea and
gastrointestinal pain.

Hemolytic Hepatic Obstructive
Blood, free bilirubin Increased Increased Normal
Blood,conj. bilirubin Normal Increased Increased
Blood, ALP Normal Increased Very high
Urine, bile salts Nil Nil Present
Urine, conj.bilirubin Nil Nil Present
Urine, bilinogens Increased Nil Nil
Fecal urobilinogen Increased Decreased Absent

 It is caused by increased hemolysis coupled
with immature hepatic system for the uptake,
conjugation & secretion of bilirubin.
 The activity of the enzyme UDP-glucuronyl
transferase is low in the newborn.
 There is a limitation in the availability of the
substrate UDP-glucuronic acid for conjugation.

 The serum uncojugated bilirubin is highly
elevated (may go beyond 25 mg/dl).
 Which can cross the blood brain barrier.
 This results in hyperbilirubinemic toxic
encephalopathy or kernicterus that causes
mental retardation.

 The drug phenobarbital is used in the
treatment of neonatal jaundice, as it can
induce bilirubin metabolising enzymes in liver.
 In some neonates, blood transfusion may be
necessary to prevent brain damage.

 Bilirubin can absorb blue light (420-470 nm)
 Phototherapy deals with the exposure of the
jaundiced neonates to blue light.
 By a process called photoisomerization, the
toxic native unconjugated bilirubin gets
converted into a non-toxic isomer namely
lumirubin.

 Lumirubin can be easily excreted by the
kidneys in the unconjugated form (in
contrast to bilirubin which cannot be
excreted).
 Serum bilirubin is monitored every 12-24
hours, and phototherapy is continuously
carried out till the serum bilirubin becomes
normal (< 1 mg/dl)

 In some breast-fed infants, prolongation of
the jaundice has been attributed to high level
of an estrogen derivative in maternal blood,
which is excreted through the milk.
 This would inhibit the glucuronyl transferase
 Sulpha & other drugs may release bilirubin
from albumin, & may cause jaundice in
newborn.

 Text book of Biochemistry – DM Vasudevan
 Text book of Biochemistry – U Satyanarayana
 Text book of Biochemistry – MN Chatterjea

JAUNDICE

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JAUNDICE