Differencial Diagnosis of
Jaundice
Zhang shuncai
Department of Gastroenterology,
Zhongshan Hospital
Summarization
? Definition,serum total bilirubin (STB) >
34μmol/L,causing a yellow color of skin,sclera and
tissue fluid
? Latent icterus,an increase of STB but not more
than 34μmol/L,without color changes of skin and
sclera
? False jaundice,yellow skin and sclera but
without hyperbilirubinemia,due to ingestion of
some drugs and foods
Metabolism of Bilirubin
? Source of bilirubin
? Transport of bilirubin
? Absorbed by hepatocytes
? Conjugation of bilirubin
? Excretion of bilirubin
Source of Bilirubin
? Senile red blood cell (RBC) 80~85 %
RBC’s lifetime,about 120 days
? Immature RBC 10~15%
? Others 1~5%,like free heme in liver and some
proteins containing heme
Transport of Bilirubin
? Characteristic of free bilirubin,
Unconjugated with glucuronate transferase
Undissolvable
Poisonous to biotic membrane which
contains phospholid
? Transport formation,
Conjugated with albumin forming albumin-bilirubin
complex,and transport to hepatocyte
Absorption of Bilirubin
1,Intake of unconjugated bilirubin by?
2,Separation of albumin from bilirubin,
3,Bilirubin enters the hepatic cell,
4,To the microsome by Y,Z protein
Conjugation of Bilirubin
? Conjugated with glucuronate
75%,by glucuronide transferase
? Others 25%,conjugated with glucose,glycine
? Characteristic of conjugated bilirubin
Dissolvable
Nonpoisonous to biomembrane which
contains phospholipid
Elimination through urine
Excretion of Bilirubin
CB Golgi bile capillary
bile tubule bile duct intestine
Urobilinogen fecalbilinogen excretion
lower ileum,colon reabsorption
portal vein liver bilirubin biles intestine
Classification of Bilirubin (1)
? By etiology,
Hemolytic jaundice
Hepatic jaundice
Obstructive jaundice
Congenital jaundice
Classification of Bilirubin (2)
By the type of bilirubin
? Hyperbilirubinemia mainly by unconjugated
bilirubin
Over-produced bilirubin,hemolytic jaundice
Bilirubin absorption blocked,Gilbert syndrome
Bilirubin conjugation blocked,Gilbert syndrome
? Hyperbilirubinemia mainly by conjugated bilirubin
Post-hepatic obstruction,cholelithiasis,cancer of the
head of the pancreas
Intra-hepatic obstruction,hepatolithiasis
Intra-hepatic chlolestasis,hepatitis,drugs,infection
Mechanism and Character of Jaundice (1)
? Hemolytic jaundice
Either kind of hemolysis could make an
overproduction of bilirubin,once the capacity of
the bilirubin metabolism by hepatocytes is
exceeded,the serum unconjugated bilirubin
increased and the jaundice forms,such as
congenital and acquired hemolytic jaundice
Character of Hemolytic Jaundice
? A lightly lemon color of sclera
? Fever,back pain,pale skin
? Without itch
? Splenomegaly
? Compensatively active bone-marrow proliferation
? Hyperbilirubinemia mainly by unconjugated
bilirubin,<85 μ mol/L
? Urobilinogen ↑,urobilin (-)
? Hemoglobin urine,urinary siderosis
Hepatic Jaundice (1)
Etiology and mechanism,hepatocytes may be
injured in any liver diseases
? Disorder in the absorption,conjugation and
excretion,UCB↑
? Bilirubin draining disorder,CB↑
Hepatic Jaundice (2)
? A light yellow or golden color of skin and
sclera
? There may be skin itch
? CB↑ UCB↑
? urobilin (+),urobilinogen↑
? Impaired liver function
? Liver biopsy
Cholestatic Jaundice (1)
Etiology and Mechanism
1,Extra-hepatic obstuctive cholestasis,
Intra-hepatic biliary obstruction,cholelithiasis,carcinoma
of bile duct
Extra-hepatic biliary obstruction,cancer of the head of the
pancreas,carcinoma of ampulla
2,Intra-hepatic obstructive cholestasis,
Intra-hepatic muddy stone,Clonorchis sinesis disease
Bile duct obstructed→cholanjiectasis→rupture of bile
duct→bile retroflows to the blood→conjugated bilirubin
increased
Cholestatic Jaundice (2)
? Intra-hepatic cholestasis,bile production and
excretion↓ infection,drugs,
? Changes in the structure and function of the
hepatic cell membrane
? Dysfunction of microtubule and microfilament
? The permeability of bile capillary membrane and
tight junction ↑
? Disorder in the bile acid metabolism
Character of Cholestatic Jaundice
? Dark yellow skin
? Obvious skin itch
? Hyperbilirubinemia mainly by conjugated
bilirubin
? Urobilin (+)
? Urobilinogen ↓or (-)
? Fecal, light gray or potter’s clay color
? Cholesterol,γ -GT and ALP↑↑↑
Congenital Nonhemolytic Jaundice (1)
? Gilbert syndrome disorder in absorption and
conjugation of bilirubin (innate inadequate of glucuronide
transferase)
Character,
Hyperbilirubinemia mainly by unconjugated bilirubin
STB < 80 μmol/L
No hemolysis
Normal liver function
Normal cholecystography
Congenital Nonhemolytic Jaundice (2)
? Dubin-Johnson syndrome
Disorder in excretion of conjugated bilirubin and
organic negative ion
Character
Hyperbilirubinemia mainly by conjugated bilirubin
ICG test ↓
Cholecystomy,
Black megalohepatia
Congenital Nonhemolytic Jaundice (3)
Rotor syndrome intake or excretion disorder
character,
1,Hyperbilirubinemia mainly by conjugated bilirubin
2,ICG test ↓
3,Cholecystomy,normal or?
4,Liver biopsy,normal,without megalohepetia
Crigler-Najjar syndrome lack of glucuronide
transferase, usually died of nuclear jaundice
Differntiation Diagnosis of Jaundice
? Diagnosis STB>17.1 μmol/L
? Classification
? History,signs and major laboratory
examinations
? Some special examinations may be key point
Liver Function,Urobilinogen and
Urobilin
Jau n d ic e
S erum Bil
T y p e CB UCB R atio
%
U r o -
b il ir u b in
U r o
- b il in
h em oly tic L O bv < 20 － M
H epat i c M M 20 - 60 ++ L ↑
or N
Ch ol i st at i c Obv M > 60 ++ + ± or
－
The importance of history,symptoms
and signs (1) history
? history
? ages newborns---physical jaundice,neonatal
jaundice,congenital atresia of biliary duct
senile-----carcinoma
? Contact history drugs,poisons,blood transfused
and other contagious disease
? Family history congenital jaundice,hemolytic history
? Past history biliary operation or liver disease
? Pregnant history acute fatty liver of pregnancy,severe
hepatitis,recurrent jaundice of pregnant
? Clinical course hepatitis,1 month
cholelithiasis,might recur
The importance of history,symptoms
and signs (2) symptoms
fever biliary disease---cholangitis,hyperpyrexia
abdominal pain biliary colic,upper abdominal and
back pain,
dyspepsia viral hepatitis,cancer of the head of the
pancreas,
skin itch cholestatic jaundice and hepatic jaundice,
weight obviously reduce in patients with malignant
disease,
color of urine and fecal
cholestatic jaundice,light gray or potter’s clay
color fecal
The importance of history,symptoms
and signs (3) signs
Skin hemolytic,pale
hepatic,hepatic palm,spider nevus,hepatic face
obstructic,skin itch,pigmentation,eyelids xanthoma
Hepatomegaly
acute hepatitis,megaloheptia,soft touch
hepatocarcinoma,swelling,hard touch with tubercle
cirrhosis,shrink,hard touch
blood flow disorder,megalohepetia,palpation pain
Splenomegaly cirrhosis,megalosplenia
Cholecystomegaly extra-hepatic obstruction,
Courvoisier`s sign
Others ascites,breast development in male---cirrhosis,
hematoascites---tumor
Other Laboratory Examinations
ALT ALP
γ -
GT
PT VitK ALb T-
CHE
chol Bile
acid
AFP
H
N- long No
res
N- N- N- N-
Ch
N- - long res N N- N N- N
T N- - N-
long
res N N- N N-
Differencial Diagnosis of
Jaundice
Clinical examination
Multiple biochemical
examination abnormal
single biochemical
examination abnormal
ultrasound Hemolytic test
+ -
Bile acid
high normal
Dubin-Johnson Gilbert
Cholangi-
ectasis
ERCP or
PTC
No cholangiectasis
Accord different
Other
examinations
biopsy
CT or/and
ERCP,PTC
diagnosis
Jaundice
Zhang shuncai
Department of Gastroenterology,
Zhongshan Hospital
Summarization
? Definition,serum total bilirubin (STB) >
34μmol/L,causing a yellow color of skin,sclera and
tissue fluid
? Latent icterus,an increase of STB but not more
than 34μmol/L,without color changes of skin and
sclera
? False jaundice,yellow skin and sclera but
without hyperbilirubinemia,due to ingestion of
some drugs and foods
Metabolism of Bilirubin
? Source of bilirubin
? Transport of bilirubin
? Absorbed by hepatocytes
? Conjugation of bilirubin
? Excretion of bilirubin
Source of Bilirubin
? Senile red blood cell (RBC) 80~85 %
RBC’s lifetime,about 120 days
? Immature RBC 10~15%
? Others 1~5%,like free heme in liver and some
proteins containing heme
Transport of Bilirubin
? Characteristic of free bilirubin,
Unconjugated with glucuronate transferase
Undissolvable
Poisonous to biotic membrane which
contains phospholid
? Transport formation,
Conjugated with albumin forming albumin-bilirubin
complex,and transport to hepatocyte
Absorption of Bilirubin
1,Intake of unconjugated bilirubin by?
2,Separation of albumin from bilirubin,
3,Bilirubin enters the hepatic cell,
4,To the microsome by Y,Z protein
Conjugation of Bilirubin
? Conjugated with glucuronate
75%,by glucuronide transferase
? Others 25%,conjugated with glucose,glycine
? Characteristic of conjugated bilirubin
Dissolvable
Nonpoisonous to biomembrane which
contains phospholipid
Elimination through urine
Excretion of Bilirubin
CB Golgi bile capillary
bile tubule bile duct intestine
Urobilinogen fecalbilinogen excretion
lower ileum,colon reabsorption
portal vein liver bilirubin biles intestine
Classification of Bilirubin (1)
? By etiology,
Hemolytic jaundice
Hepatic jaundice
Obstructive jaundice
Congenital jaundice
Classification of Bilirubin (2)
By the type of bilirubin
? Hyperbilirubinemia mainly by unconjugated
bilirubin
Over-produced bilirubin,hemolytic jaundice
Bilirubin absorption blocked,Gilbert syndrome
Bilirubin conjugation blocked,Gilbert syndrome
? Hyperbilirubinemia mainly by conjugated bilirubin
Post-hepatic obstruction,cholelithiasis,cancer of the
head of the pancreas
Intra-hepatic obstruction,hepatolithiasis
Intra-hepatic chlolestasis,hepatitis,drugs,infection
Mechanism and Character of Jaundice (1)
? Hemolytic jaundice
Either kind of hemolysis could make an
overproduction of bilirubin,once the capacity of
the bilirubin metabolism by hepatocytes is
exceeded,the serum unconjugated bilirubin
increased and the jaundice forms,such as
congenital and acquired hemolytic jaundice
Character of Hemolytic Jaundice
? A lightly lemon color of sclera
? Fever,back pain,pale skin
? Without itch
? Splenomegaly
? Compensatively active bone-marrow proliferation
? Hyperbilirubinemia mainly by unconjugated
bilirubin,<85 μ mol/L
? Urobilinogen ↑,urobilin (-)
? Hemoglobin urine,urinary siderosis
Hepatic Jaundice (1)
Etiology and mechanism,hepatocytes may be
injured in any liver diseases
? Disorder in the absorption,conjugation and
excretion,UCB↑
? Bilirubin draining disorder,CB↑
Hepatic Jaundice (2)
? A light yellow or golden color of skin and
sclera
? There may be skin itch
? CB↑ UCB↑
? urobilin (+),urobilinogen↑
? Impaired liver function
? Liver biopsy
Cholestatic Jaundice (1)
Etiology and Mechanism
1,Extra-hepatic obstuctive cholestasis,
Intra-hepatic biliary obstruction,cholelithiasis,carcinoma
of bile duct
Extra-hepatic biliary obstruction,cancer of the head of the
pancreas,carcinoma of ampulla
2,Intra-hepatic obstructive cholestasis,
Intra-hepatic muddy stone,Clonorchis sinesis disease
Bile duct obstructed→cholanjiectasis→rupture of bile
duct→bile retroflows to the blood→conjugated bilirubin
increased
Cholestatic Jaundice (2)
? Intra-hepatic cholestasis,bile production and
excretion↓ infection,drugs,
? Changes in the structure and function of the
hepatic cell membrane
? Dysfunction of microtubule and microfilament
? The permeability of bile capillary membrane and
tight junction ↑
? Disorder in the bile acid metabolism
Character of Cholestatic Jaundice
? Dark yellow skin
? Obvious skin itch
? Hyperbilirubinemia mainly by conjugated
bilirubin
? Urobilin (+)
? Urobilinogen ↓or (-)
? Fecal, light gray or potter’s clay color
? Cholesterol,γ -GT and ALP↑↑↑
Congenital Nonhemolytic Jaundice (1)
? Gilbert syndrome disorder in absorption and
conjugation of bilirubin (innate inadequate of glucuronide
transferase)
Character,
Hyperbilirubinemia mainly by unconjugated bilirubin
STB < 80 μmol/L
No hemolysis
Normal liver function
Normal cholecystography
Congenital Nonhemolytic Jaundice (2)
? Dubin-Johnson syndrome
Disorder in excretion of conjugated bilirubin and
organic negative ion
Character
Hyperbilirubinemia mainly by conjugated bilirubin
ICG test ↓
Cholecystomy,
Black megalohepatia
Congenital Nonhemolytic Jaundice (3)
Rotor syndrome intake or excretion disorder
character,
1,Hyperbilirubinemia mainly by conjugated bilirubin
2,ICG test ↓
3,Cholecystomy,normal or?
4,Liver biopsy,normal,without megalohepetia
Crigler-Najjar syndrome lack of glucuronide
transferase, usually died of nuclear jaundice
Differntiation Diagnosis of Jaundice
? Diagnosis STB>17.1 μmol/L
? Classification
? History,signs and major laboratory
examinations
? Some special examinations may be key point
Liver Function,Urobilinogen and
Urobilin
Jau n d ic e
S erum Bil
T y p e CB UCB R atio
%
U r o -
b il ir u b in
U r o
- b il in
h em oly tic L O bv < 20 － M
H epat i c M M 20 - 60 ++ L ↑
or N
Ch ol i st at i c Obv M > 60 ++ + ± or
－
The importance of history,symptoms
and signs (1) history
? history
? ages newborns---physical jaundice,neonatal
jaundice,congenital atresia of biliary duct
senile-----carcinoma
? Contact history drugs,poisons,blood transfused
and other contagious disease
? Family history congenital jaundice,hemolytic history
? Past history biliary operation or liver disease
? Pregnant history acute fatty liver of pregnancy,severe
hepatitis,recurrent jaundice of pregnant
? Clinical course hepatitis,1 month
cholelithiasis,might recur
The importance of history,symptoms
and signs (2) symptoms
fever biliary disease---cholangitis,hyperpyrexia
abdominal pain biliary colic,upper abdominal and
back pain,
dyspepsia viral hepatitis,cancer of the head of the
pancreas,
skin itch cholestatic jaundice and hepatic jaundice,
weight obviously reduce in patients with malignant
disease,
color of urine and fecal
cholestatic jaundice,light gray or potter’s clay
color fecal
The importance of history,symptoms
and signs (3) signs
Skin hemolytic,pale
hepatic,hepatic palm,spider nevus,hepatic face
obstructic,skin itch,pigmentation,eyelids xanthoma
Hepatomegaly
acute hepatitis,megaloheptia,soft touch
hepatocarcinoma,swelling,hard touch with tubercle
cirrhosis,shrink,hard touch
blood flow disorder,megalohepetia,palpation pain
Splenomegaly cirrhosis,megalosplenia
Cholecystomegaly extra-hepatic obstruction,
Courvoisier`s sign
Others ascites,breast development in male---cirrhosis,
hematoascites---tumor
Other Laboratory Examinations
ALT ALP
γ -
GT
PT VitK ALb T-
CHE
chol Bile
acid
AFP
H
N- long No
res
N- N- N- N-
Ch
N- - long res N N- N N- N
T N- - N-
long
res N N- N N-
Differencial Diagnosis of
Jaundice
Clinical examination
Multiple biochemical
examination abnormal
single biochemical
examination abnormal
ultrasound Hemolytic test
+ -
Bile acid
high normal
Dubin-Johnson Gilbert
Cholangi-
ectasis
ERCP or
PTC
No cholangiectasis
Accord different
Other
examinations
biopsy
CT or/and
ERCP,PTC
diagnosis
