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and everyone here be okay. And you just struck a good yes, and the job. Cool. Welcome. Uh, be back. Um, like, like around my name's Michelle. Hopefully most of you are familiar with me. Today is going to be a continuation about finals. Easy, Siris. It could be talking about your list on down. Finally. It's okay. So this is clinically orientated teaching not too much of a basic sciences of jaundice, but it's a very, very important topic in exams in clinical practice. It's very important because it's very important exam is because there's so many different causes of jaundice. It's from medical disease. It can be a surgical disease. So examples can love to ask questions around doing this because they contest a lot of medical knowledge using the presentation of jaundice. Okay, so it's very important Disease super high. You for exams, too. So we'll try. We'll hopefully have, uh, some good impact knowledge for you today on Allegra and said, So today's teaching is gonna be a little bit different. So I tried something bit more creative based all the clinical vignettes, an SPH around Simpsons characters, maybe just to sort of switch up the side of teaching it better on basically help. Remember, just help you guys remember the different cause of jaundice and a little bit more unique way as well. Eso if it'll be useful little fun, something based on the single best answers around the sort of character profiles and Simpsons haven't seen Simpsons. Don't worry, okay? You don't need to know The Simpsons to understand the single Best on says. It's just a little bit fun, Um, but hopefully be used so we'll see how it goes. But if you guys just want to let me know who your favorite Simpsons characters are, I'll be getting the child to stop it. But we will get into it. So John Doe's refers to yellowing off the skin and the sclera. Okay, this is hopefully stuff you guys know. So currently, seeing the patient having a yellow discoloration of the skin sclera mucous membranes that for doing this is all about Okay. Usually the sclera will be affected initially, even if there's a mild elevation and Billy Rubin levels, Can anyone tell me, why does the East Clara get affected initially like, Why is it the first place is you see John this. You know that soluble What? What does the sclera have? A lot of the last lesson. Bite is very good. They have a lot of these fibers, which fine Billy Rubin. And that's why, even if there's mild elevations in Billy Reuben, it's usually the sclera that appears clinically. George dispersed. Okay, then that's what we refer to buy the scleral icterus. Okay, but yes, that's important. So in terms of keep things about jaundice, So I said it's an important clinical feature to recognize, particularly in liver disease. Okay, I'll see when we think about liver failure and becomes a liver disease, jaundice is the predominant symptom we think about. But liver disease is not the only cause of jaundice. Okay, we'll talk through all the different cause of jaundice. Have you said examples love to use Georgia State test immorality of medical knowledge on having a strong understanding off the underlying Billy Rubin. Physiology is super important to understand because of Junior's, the pathology of your legs and how we think about the diagnosis for doing this as well. So we're gonna first speed. This is a little bit of, uh, there's the only based experience before we start talking about the current system, but it's important that everyone has this sort of knowledge Nail down before we start going into the clip stuff. So this is all about box and sentence. Yeah, cool the most. Most you've got this much. Most of you've got the correct answer here, which is a so stick a bill, and so pregnancy is a cystic a billion. So questions basically asking which of these following substances is responsible for the brown pigmentation off PC's the stools So and they're correct. Answer here. Stuck a bell in the guest distractibility What gives the characteristic brown pigmentation of stools. So this is gonna be this into talking quite quickly about the bilirubin physiology on. But hopefully you guys have this nail down so that we could just go straight into a lot of clinical stuff around doing this. So I mean, it's the A gram. This gonna go through bilirubin physiology, quickly nail it down, and then we'll talk through some of the best days. So we have Macrophage is typically most red blood cells going to get broken down in the spleen, okay, as well as otherwise. But predominantly in the spleen. So right dot cells part of the red blood cells. We have a product substance called him. I guess that makes up part of the red blood cell he was going to get metabolized eventually into on conjugated Billy Rubin. Okay, so this big Ruben, which is lipid soluble, Okay, it hasn't gone to a specific conjugation steps that makes it water soluble. This is specifically a lipid soluble product. There's water insoluble. Okay, It's only lipid soluble. So it's uncomplicated. Billy Ruben can only travel in the blood with the presence of a carrier protein. Okay, because it's not water soluble, so that carry is going to be albumin. So uncomplicated aren't conjugated. Bilirubin will travel in the blood using albumin as a carrier, and then it will eventually go to the liver. Well, it will react with this specific enzyme called you. You DPT do cortisol transferase you tpg t enzymes. And this is the enzyme that does the characteristic key conjugation step that makes unconjugated Billy Rubin into conjugated Billy Rubin. Okay, The key thing about conjugated bilirubin is that it is water soluble conjugated. Billy Rubin will then get excreted into the biliary system along with the bile by the liver. Eventually you will reach the intestines and then in the intestines it will undergo series of steps and eventually form your ability. Okay, so we'll be metabolized to your ability. Europe allergic can go to two different pathways. Basically, one pathway is that you'll be further metabolized and eventually excreted out as a stoke ability. Okay, so you bled. You'll get metabolized a bunch of each of stuck ability. And as we said, stuck ability is what gives the characteristic around pigmentation off pieces. Okay, so remember, circle billions of thing that gives stools characteristic brown pigment station some of the Europe allergic goes through another pathway where it gets reabsorbed through this particular circulation. Colby, Andrew, have Patrick circulation. Okay, so the your ability engine in the intestines will get we re absorbed through the portal vein back to the liver. Okay, so it's and two row patrick circulation on in the liver somewhere will go back into back into the bile and be excreted. And some of it will end up in the systemic circulation on reach the kidneys. Okay, Because this country, because this your Aplenzin is water soluble, it will be excreted out into the Europe. Okay, so you're a pledge in can get excreted out because it's water soluble and yes, so that so? That's the bilirubin cycle. Okay, so hopefully that's clear. This is basically all the physiology need to remember regarding any Rubin. But if you understand all of that understanding, jaundice will be really simple. Okay, this is very much the basis for everything else we're gonna talk about today. So can you guys tell me? So we're going to start talking about jaundice now? Can you guys tell me, how do we casted by their causes of jaundice When we think about jaundice? When you think about the different causes of donors, how would you classify them? Yeah, you know, in the shop prehepatic intrahepatic posthepatic Good. Any other words? Any other terms you could use to describe the described? Um, coli started? Yeah, because cholesterol is good for describing post up on it. You can use obstructive to describe posthepatic. Jaundice is well mixed. Yeah, I can see what you mean by mixing. There's a load of various different terminology here. Hemolytic. Very good eso for preop attic. So there's various different terminology. Is to be aware of. But the passageway people just tend to describe it is to just say Prehepatic Jonas. Okay, so these are causes of jaundice where the problem in the bilirubin cycle is around someone this part of the problem. Okay, so some some problem that's leading to increased bilirubin and eat in this part of the pathway. Okay, All potentially, the actual conjugation step is well, we have a part of several donors. Okay, so it's it's in the name is a problem with the liver. We also have post hepatic Jordan this. Okay, so this is a problem with in the biliary system, okay? And POSTHEPATIC Jones is also known as obstructive jaundice or cool. Is that doing this as well? Okay, so I'm going to run through all these different causes through a series off clinically based SPS. And hopefully you guys will understand all the pathology as well at the same time. The next question, if you have any questions throughout the session, is still free to leave it on the job. You have a couple of other final TZ team members who will be happy for a question throughout the sessions. Well, so people for you to us. Anything during the day in the top. Okay, we'll call it that. Okay, So got a better split. It would have expected, basically, between B and C. So it's very interesting. I understand the split, but correct answer here is be okay. This is basically the differentiation between B and C is basically because the questions asking What is he likely cause of this? Jones? Okay, so let's let's go through this sp from the stuff from, uh from It's basic. So you have a s be talking about Grandpa Simpson. Okay? So you can get it from his name is this is ah, elderly gentleman. As a history of two months, he has a two month history of painful numb blue fingers and toes. Okay. And this painting is worse after cold showers. Um, but the symptoms improve when he warms up. Okay, So, uh, can you do want to tell me what is that? Describing this sort of description off painful number. Your fingers worse after intercourse bit improved after the showers. What are we trying to get up? That's facility does sentences renal. So not not not like, really. Nodes cold. The cold ultimate and hemolytic anemia. Very good. Yeah, very good. So I can see where you Where you going with the Raynaud's? That? Definitely. Actually. Yeah. It's a good point. You know, it's just from that description. You could say renal does Well, um, but the description here is describing more cold or too immune. Hemolytic anemia. Eso if you could keep going. So on examination, he has scleral actress, Okay, and we'll talk about it. So if you're on this as well, clinically and he has a significantly raised lymphocyte count with smart cells and your sights on a but from so can you send me What is the overall diagnosis? They're like, What's the underlying diagnosis that Gram perception has ignoring the the painful number doing fingers? What's the underlying diagnosis? This is an elderly gentleman. Gentle. This another gentleman with lymphocytosis is smart cells on a smart cells and your site on a but film lymphoma. Leukemia. It's an elderly gentleman, which means hematologic or malignancy will be thinking about most CLL. Very good. Chronic lymphocytic leukemia. Okay, so we discussed moving, discussed this condition so extremely discussed this condition during case hematologic away even told you for final stop. But this is a presentation off chronic lymphocytic leukemia. So C l o eso Why? I see. Also again, this is an elderly gentleman lymphocytosis on the full blood count. Smart sounds are characteristic on the no no blood film. Okay, So kind of thing. We can diagnose that. We can say that the most likely diagnosis is chronic lymphocytic leukemia. See, it's yellow. And one of the complications. Bad complications off cll is autoimmune. Hemolytic anemia is okay, so that's what their description is off the painful number your fingers on. So the thing was with the hemolytic anemia, you get low, he low hemoglobin on. Also take patients are at risk of getting jaundiced as well because of a hemolytic anemia. Because, uh, blood cells leak access uncomplicated Billy Rubin to that little jaundice. So that's why the most likely diagnosis in terms of the jaundice is autoimmune hemolytic anemia on to diagnose ultimate hemolytic anemia. You do a direct and stopping test. Okay. Also commonly known at the direct Coombs test. I don't antiglobulin test. So that's a test to check for auto immune. Immune mediated hemolysis Basically. Okay, So there's that the answer option sees of bone marrow biopsy that could help out help confirm the diagnosis off Cielo. But the questions are seeing what's the life? Because of its jaundice, so that the cause of his jaundice is the cumulative anemia. Okay, again, flow. Cytometry would be useful to assess for particular fingertip markers in, um well, this yellow Okay, but again, we're talking about the going to say asthmatic fragility test. Can you guys tell me, what do you use the osmotic fragility testicle? Which condition is automatic fertility test? Useful spirit cytosis. Very good. Okay, very good. So that's a investigation you do for a registry spirit cytosis. So his vision does have spir site. But the cause of this fear sites is actually due to the hemolytic anemia. Okay, not due to I read it very seriously. Tosis on cytogenetic genetics Again, we're thinking about the cause of the jaundice, which is because of the autoimmune hemolytic anemia. Okay, eso some of us. Can you? So can you repeat widest called autoimmune Hemolytic anemia cause hemolytic anemia. So it's basically getting immune mediated damage. Teo bent blood cells to go into the full pathophysiology phase to be outside the scope But eventually it's a type of humility in India needing to increase uncomplicated pretty with them. Okay, so let's talk through, uh, way or another rescue on. Then we will talk to this particular type of doing this. Very good. I think that one's ever got this on. This is probably the easiest way. It is so much easier than the last one. I think I probably gave away the answer with the last one was What do you think about it? Yeah, So let's call it there. So they correct answer here is we increased? Uncontradicted believe in. And so Yeah, so let's talk through this. So So this is a question about Bo. Okay, so the bottom the moment since this TV show on way we got this description ways. Basically, he's had a valve replacement. Okay? He's had an uncomplicated about the basement, but he's now presented with shortness of breath on exertion. And as hemoglobin's down as well. Okay, so he's got symptomatic anemia basically, and he's also clinically joined us as well. Hey, has a talent click sound during s too. So he has a metallic click during the second out. Some so and yes, tell me what Which valve? It has likely been replaced if he has a metallic clicks on doing at the second heart sound. Yeah, very good. Allergic mouth. So we'll talk about this more during osteo Siris, but basically you, whenever you palpated someone's pulse whenever you palpate someone's crowded pulse and they haven't healed so well if they have about the placement, if he had a click before you feel across it posts and it's think is corresponding to the first stop sound s one. That means it's most likely a my survival policeman. You hear the click after you feel the chronic ball, so it it's corresponding with the second heart sound. It means it's likely in a little vial of the basement it we'll talk about it doing Oscar stuff, this patient, like he has a lt valve replacement on. He also has schistocytes on his blood film. Okay, so, again, this is very much a long hematology going on here, but just decides on a blood film basically means blood blood cells, red blood cells are getting sheared. Okay, They're getting busted up because of something. There's some kind of obstruction, something blocking something in its way that's causing the red blood cells to get she had to get busted up. And that's what the the product of that are these Chester sites. Okay, so in this case, the actual cause of the chest besides, the thing that's making the red blood cells get sheared is the metallic valve. Okay, so you're getting a mechanical damage of red blood cells, which is leading to humility hemolysis. Okay. And the key thing that the questions asking is which blood test is finding do you get with hemolysis? But hemolytic anemia is leading to jaundice. Is you get a new cream Uncomplicated. Billy Ruben again. We'll talk about why, uh So yes, yes, tell me. Could be What? What other conditions can lead to schistocytes on the blood from is a mechanic. Oh, damage is because one of the one of the other cause is off Chester sites on a blood phone. D i c TTP hate us. Very good. What you can What do you call those group of conditions too? Yeah, very good. Ma. Huh? Okay, So a micro basically microangiopathic hemolytic anemia issues at all talking about things like the icy humility Remix syndrome TTP things like help syndrome, Making all the old can cause chest the sites. Okay, so those are some of the other differential sports just decides to think about. But in this case, the most likely cause of the shift societies the mechanical damage because of the prosthetic buff. Okay, uh, in terms of the other answer option. So you get increased uncontradicted bilirubin not increased. Conjugated Billy Rubin splenomegaly so with mechanical hemolysis because of a valve replacement, you don't get much splenomegaly. Okay, Typically, you get that more if you having extra vastly mal assists. Okay. Where the blood cells are getting damaged outside of the blood and the spleen. Needing to spend a million after blue bins I have to global would typically be low in the hemolytic anemia is because they have to grow bins, find up all the free hemoglobin and typically you get a normal or a low MCV with, um uh, hemolytic anemia is generally is Well, so that's why the correct answer is increase uncontradicted. So let's talk to the community comedians now. So hemolytic anemia is they tend to cause a prediabetic jaundice. Okay, we'll talk through. Ah, the pathology will go back to that diagram again. But when we think about classified hemolytic anemia is I like to think about them as humanistic anemia. Is that caused more of intervascularly mal assists. Okay, So blood cells breaking down within the blood vessels and hemolytic anemia is where the blood vessels are getting broken down outside of the blood vessels, usually in the spleen. Okay, so that's what the way I like to group these group little anemia. So, in terms of causes off intravascular malicious, mainly the's other, some of the really important ones to be aware of. Okay, So things are g six PD microangiopathic humiliating anemia is that we talked about a mechanical damage like we talked about the SBA. Okay. And there's many other important causes, like humanistic disease of the newborn. Can you think of any infections that cause mainly intravascular malicious malaria? Bridget, malaria is very, very common cause of in severe intravascular most is, uh so So that's intravascular volume. So mainly extra fasting Moses. Oh, there's many other conditions. Sickle cell, very common condition at our seniors, things that make the spleen work harder. Okay, So things like spirits cytosis hyper span is, um autoimmune hemolytic anemia is like we talked about. Okay, this many closes off extravascular. Most is So that's a That's a nice way. I think off classifying hemolytic anemia is and it's quite clinically relevant to think about them this way as well. Uh, so in terms of the actual pathology, So this is a application off the initial physiology diagram. So if you think about intravascular and most cysts So if that blood cells are getting broken down within the blood, that's going to lead to increase unconstipated Billy Rubin. Same thing get even if the red blood cells are getting breaking down, broken down outside of the but that will still need to increase uncontradicted Billy Rubin. Okay, eventually, if you go through this whole cycle, that can eventually lead to increase your ability gyn in the Europe as well. Okay, but this isn't that clinically relevant. The main thing that's going to relevance is the uncontradicted hyperbilirubinemia. Okay, so you get high uncontradicted begin with, So So let's talk about that stroke go through some of the key blood test finding for humility drawn there. So obviously you get low hemoglobin. Usually the MCV is normal. Okay, But it can be low sometimes as well. Uh, uncomplicated Billy Ruben, Like we talked about this classically high with humility, Jaundice, ldh well, congrat up captivity because it's sign of increased cell turnover, particular sites. So these are premature red blood cells pumped out by the bone marrow to try and respond to the lack of red blood cells in the body. Have to go. Been to go down because it's getting more. It's moving up all the hemoglobin in the blood. Ah, you get increased your ablation like we talked about. If someone has severe intravascular monocytes where you start get so if someone has to be a intravascular monstrous, that can lead to chemo surgery in your ears. So I and ending up in the urine. And also it might look into heat hemoglobin itself, getting ended up ending up in the urine. Okay, as that's hemoglobin urea. If you do a urinalysis on someone with human global area that could lead to a positive blood test, blood results on a year in urinalysis. Uh, they don't tell me any other conditions that actually two positive blood on your analysis. In addition to hemoglobinuria, the left pretty syndrome goods. Uh, rhabdomyolysis. Very good. Uh, yeah. Doesn't kidney stones get so remember? The hemoglobin area is not a very common cords off blood. Positive blood on the urinalysis. Okay, this way. More common. Causes cancer. Good. Those have something important things sticking. Think about my hemoglobin. Urea. It's not technically your blood cells. It's just pure hemoglobin ending up in the urine. But that can also cause blood to be positive on urinalysis. Okay. And some patients can also end up with pigmented Goldstone. So these are different to the normal Goldstone's we think about, like, the cholesterol go stones. He's a bilirubin, Goldstone so that it's because of access. But you have been going to deliver and getting precipitated to form a gallstone. And typically that black and radio of cake. Okay, that's a big minted Costin's. Okay, so I'm talking about human. It it don't, mister. So we'll keep going on. This is a question about crusty that from Okay. Okay. So most of you and 40 a couple of you went for a and B as well. Okay, uh, so the car cancer is eat. Let's correct the majority of your right. Uh, just a note. There's no such thing as the beat. There's no such thing as fasting induced called Stasis. I just made that up. Okay. Card and his d So your best syndrome. So I stopped about your best. So? So we got crusty who is was due to have a fasting glucose test to check a B has type two diabetes. Hey, has a history off alpha thalassemia trait. It's, um Oh, quick question. Can Yes. Tell me why Does Why is cross be having a fast fasting glucose tests instead off HBA one C test to check ups. Diabetes? Why would he have a fasting glucose? That's just based on the thing I mentioned in this SPCA. Why would you have busting it goes just in instead of, ah, instead off HBA one c check. Yeah, very good. Yes, Policy Mya. Okay, so remember, you don't don't use uh hey HBA one c to check some to diagnose diabetes. It they have some type of hemoglobinopathy. Okay, it's off the house, you know, treat. It means it could affect the reading on page here and see So the likely reason why he's had a busting glucose test okay on it also imagine he's been stressed all night on Go. He's coming to the GP community. You told us. Okay. And there's nothing other. There's nothing else notable on examination, so he seems clinically, but he seems very well apart from the appearance of chemical jaundice. Okay, so this is pretty much in keeping with this, but not in condition called usual. Bassinger. Okay, so your past syndrome basically is a condition where you have, uh, reduction in the activity off the conjugating enzyme udp google on assault transferase enzyme on. Typically, patients can get drawn. Listen, situations when they're stressed when that fasting on. So that's the likely reason why this patient is doing list. Okay on, because there's nothing other than that there's nothing else notable. So it's unlikely to be any of these other orient causes. Okay. Uh, so, yeah, so Jonas and you guys can be triggered by fasting and stress. Good. Uh, we just remove this medication. Yeah, if you guys in a void drawing on the screen, that would be appreciated. Okay, so let's look through some of the other courses of jaundice. So we're talking about your best syndrome, so that is basically a problem with conjugation. Okay, so who's your message? And basically, you have a reduced activity off medicines on. You know, people can start countries, and that leads to increased uncomplicated bilirubin in the blood. Okay, that lead to don't rest in situations where patients are fasting or stressed, for example. Um So, yes, that was quick. Question on your best. Um Okay, so six, moving on Teo. Basically new needle doing this stuff. Very important topic, uh, of pediatrics, but should be very, very important topic to you. Learn about. Yes. If you guys know, uh, pretty Notorious. See, as soon as he has a lot of kids in his family. So that's what business is about. Okay. Okay, so that's, um most of you went for D is theological. Jonas, this is a tough ST A, but we'll go through that. The correct answer is actually eat case of Cleveland Nausea syndrome on this is very important concept in pediatrics for some dumb units of this. So we'll talk to different clothes and you're still doing this. But most the most common most commonly need it need to join us is physiological. Okay. Most donors in need in units It's physiological. Uh, but can anyone tell me why is this no more likely to be a pathological cause of jaundice? What in this SP tells you that it's more likely to be pathological? Yeah, I get. So you guys got it? So the baby's basically become jaundiced within 20 or 24 hours of birth. Forget his babies. 20 household Onda peer name and is jaundiced. Okay on. We'll talk about it, but don't us in a baby. Last 24 hour in a less than 24 hour old baby is almost always highly suggestive. A part of our actual joined us. Okay? You can't say the baby has physiological donors that they have that join us within the first day of life. Okay, so that's why the answer is not a physiological coolness on in terms of eso in terms of the other option and so recent compatibility. So I've told you there's no evidence of hemolysis. Okay, s so it's unlikely to be resistant compound to incompatibility. Based on this experience steps this of patient appears observations of General seem okay, Okay. And your best and drums. Um, there's normal liver function tests. Okay, so I'll have all of these options that's creating the John Syndrome is the only one that's still fits. Okay, as a cause off a have too much school. Join us within 24 hours. Okay, but the key now I really want you guys to remember is that, uh, jaundice within 24 hours of is almost always pathological. Okay, it means that you have to investigate the baby for a cause of big jaundice. Okay, You can't just say the baby is physiology. You joined us. And that will self resolved. You need to do so. You need to investigate and treated appropriately. Next question. Still on the topic of units of Lantus for you and Maggie. Okay, we'll get that. He must have you had a you know, Have you already go so well the most? You've got it, right? So mostly one from DEA. And that is the correct answer. I don't know. I don't know, ultrasound. So? So through this. So we got my key to my uncle's infant. Who is your list again? She's our normal growth and development. So for the past two months, I've told you on she seemed otherwise Well, but I told you that march is exclusively breast feeding it. Okay, so I'm slightly might be giving a clue. That could be breastfeeding, breastfeeding. Join us. But this case, it's not okay, and we'll go through why? She has my pill. Very pale stools on also blood test show and elevated Conjugated Billy Rubin. So you tell me, what is the most likely diagnosis here? What's the diagnosis? Pregnant in three atresia. And why's it Will your treasure? What tells you what's the most important reason why it's really region? Yeah, They'll stools increased conjugated billirubin. Okay. And also the two month old infant as well. That's what suggested as well. So the most important cause off conjugated increased conjugated Do you have been in units? Is in babies is very, very atresia. Okay, that's the really important diagnosis that you don't want to miss in babies. Okay? Can you tell me why is it important to recognize biliary atresia? Really? What's the big problem? Was the thing you worry about with liver atresia. Why do we? Why do Why do we never want to miss failure? Treater in Davis? What do they? What do they want to babies have a risk of getting collectors and not know it, that babies with biliary atresia are not at risk of connect us. Okay, we'll go through. Why? But the big thing they were at risk off is liver failure. Okay, I'm glad someone said Connect risk, but it's important. It's an important point. Cases in biliary atresia are not a risk off connect tress. Patients are risk off liver failure. Okay, billion reasons and bury is if the the atresia goes untreated. Patient have a high risk of going home to get, uh, early liver cirrhosis on day early liver failure. And that's a very high mortality rate in babies. Okay, that's it. That's why it's very important to recognize you treat it very early. And so the main thing that point to it again is the increased conjugated Billy Rubin. I will go through what, uh, but the main diagnostic investigations, except initially for biliary atresia, is to do another ultrasound. Okay, the pediatrician causes increased conjugated big. You've been in infants, so that's talkin units or jaundice. Okay. And highlight. Some of the principles are different principles. I just talked about so many units of Lantus is most commonly due to physiological jaundice. Uh, can anyone tell me what? One of the different reasons why babies can physiologically be jaundice? Why is it often normal for babies? To be honest, intent of the physiology? What happens in babies? Immature ends. I initial liver enzymes. Good. You have breast milk. Jaundice is also basically part of a physiological journalists. Um, yeah. So it'll he in destruction? Yes, a red blood cells this high turnover. But that's a very good These are all important reasons. Why patients babies Often I've just jaundiced. Okay, so again, So you bones are susceptible to high levels of bilirubin because hemoglobin levels are very high and fetal hemoglobin, their life span is very short itself, so Okay, so that naturally predisposed him? Um, I I, uh, about the enzymes are immature is Well, okay, so a lot of the liver congregating in time, they're not that well developed. And it's not not many, many of them. So it's not as effective. Conjugating on. Also, the key thing to remember physiological on this because of these reasons, it's class will cause a uncontradicted. Billy Ruben. Okay, remember, constipated bilirubin is not physiological. Okay, You see conjugated be here when you're thinking about Well, you were treated okay, physiological. Jaundice is causes increased uncontradicted. Okay, there's some reason I don't Neonatal Jonas. Okay, uh, go through the some of the key principles, but we've talked through some of the principles of busy ultrasound is so it's increased. Uncomplicated. Billy Ruben, typically a Kurds. It has it because it's less than 24 hours that after lunch, for on it, because greater that than two weeks after both. That's also often considered a half pathological. Okay, but usually with physiological jaundice that presents 2 to 3 days after babies are born. Okay, so usually when they get out of the units, almost three and things that's gonna parents often see that they're jaundiced and usually depends after the end of the first week. Okay, that's a classic story of physiological doing this. Okay, but remember, less than 24 hours old or Britain in two weeks after birth, that's when you're thinking about the quality. Okay, on this is there's an important distinguishing the distinguisher meant to make with your local joining us in terms off breast milk, jaundice and breast feeding jaundice. So he's above basically, within the context off is the logical jaundice. So breastfeeding joined us. Basically is a It's a problem with want it e. Okay. So babies are not getting enough breast feeding. And for various reasons, that's leading to join us again. Breast, Middle joint. This is basically a problem with polity off the breast milk. Okay. For various different reasons. That's leading to a continuation off the physiological dryness. Okay, anything is, these are benign conditions, but you still need to recognize and treat them accordingly. Okay, so with both these diseases that you don't tell them to stop breastfeeding, you tell them to keep on rescuing again. If need be, you might have yet you consider the rehydration, and you might consider a little feeds as well supplementing. And if then, if the bilirubin is severe, you might consider it treatment with phototherapy. Okay, but the key thing is that these are diagnosis off exclusion. Uh, there are mobile in closes off after logical jaundice. But again, you don't tell Mom to stop breastfeeding if they have any of these conditions. Okay, so that's physiological donors. Okay, All of these this is basically still referring to physiological. Don't this this They're still benign. Now the very there is causes off pathological jaundice in units again. This we'll talk to you some of the different ones. So he, um a list? This is a big one in units. Okay. Obviously a big thing you worry about within the 1st 24 hours off ages. Things like humanity disease off the newborn. When mom's antibody start attacking, the baby's got blood cells is very supermassive disorders. Quickly judge your best syndrome. So we talked about them on down. So patients who have increased uncontradicted river as as a cause of jaundice the patients aren't risk off connector us. Okay, so let's talk about connectors quickly. So collect dresses, basically referring to you and careful apathy due to high levels off the ribbon. Okay, So bilirubin basically damaging certain parts of the brain like the basal ganglia, brain stem and things. So and that's leading to. And careful Opti. Okay, that's what connects us is can you just tell me why do why do why do conditions that only cause uncontradicted bilirubin? Ah, have a risk off spin it rest Compatic conditions that cause only high contrated Give them Why is it only the high unconscious get ability. Have been that causes Connect us. Yeah, very good. You guys know you stop. So remember, remember, everything goes back to the physiology. Okay, So uncomplicated. Bilirubin is lipid soluble. Okay, so it's a it's still able. It's able to cross the blood brain barrier on cause damage to the basal ganglia in Princeton. Okay, Conjugated Big Ruben on the other, on the other hand, is not like it's all well, it's only water sort of book, so it can't cross the blood brain barrier and course connect tress. Okay, so that's why conditions like Billy atresia, uh, you know, associated with causing, uh, connect tress. Okay, because conjugated Billy Rubin can't cross the blood brain barrier to cause damage. Okay, that's why matrices Oh, you only you. That's why the answer to that question about biliary atresia can't You can't talk about connecting us with that condition, okay? Because it's only associate with the conditions that cause high. Unfortunate. Did you women okay? Yeah. Someone That's what's the danger off connect tress collectors. Is that a very dangerous? Okay, it, uh, these risk of based on neurological problems and deficits. Often babies get things like cerebral palsy and things. It's quite rather these days, Okay, but it's very sad. Uh, very dangerous condition. Babies. Yes, that's connected. So that's the key things to differentiate between uncomplicated and conjugated. You have been okay in terms of connect wrists. Sepsis is a big thing you want to exclude is well, in a new neat presenting with jaundice. Okay of various infections, for whatever reason, leak with it. Because the septicemia babies can often present with the needs of donors. Okay, along with other features. But that's it's in a newborn. Sorry. Noon. It'll you need to be doing this. You want to rule out sepsis as well. Okay. You want to do a septic screen? Uh, yeah. That's the key things you want to be thinking about in terms of the different causes. Often you need to do on this treatments again, exclude sepsis. Uh, you want to put the bilirubin on a treatment press? Oh, Russell. Buff. Okay. So various trust will have these grafts where you can put the babies bilirubin level and, uh, according to the gestation agent things. So and you can see if it's elevated. If that's a level you need to treat Okay. Eso in terms of treatment. And so if they meet the trestle Okay, then you can try phototherapy. Okay, so phototherapy is basically this only works for conditions. I have high uncontradicted Billy Ruben. Okay, so Phototherapy will basically convert uncomplicated Billy Rubin into, uh, water soluble molecules. Okay. And then the baby can excrete the bilirubin out, okay. And that can be sitting down to give you been okay if someone's bigger been is super, super high. Okay, that might be considered for exchange transfusions. Um, this is basically, uh, sort of that dialysis you basically removed on newborns blood and replace it with compatible donor, A compatible donor. Okay, but this is for severe Mean if it'll join this. Okay, Most patients will just have that there be on exchange something. Fusion can be done. Just blow just in here to join us. This is a little summary table on some of the inherited Have a bilirubin, bilirubin, even a syndromes that might come up in your final exams. Okay. Off you might get these sort of questions about these rag genetic diseases. Job a central is like is the most common course of jaundice generally, but They also have these weird and wonderful genetic syndromes. A swell, uh, but you can read about quickly, um, biliary atresia as well, Which we talked about that SPF. So remember, the atresia basically is a problem where you have absence or a very poorly developed bile duct symptom about that system. Okay. And again, the big problem with biliary atresia is that if it goes untreated, it's undetected for extended period of time. Babies are risk off cirrhosis on subsequent lift failure. Okay, feature. So baby's classically present with prolonged neonatal journalists. Okay, uh, you get a college sells and dark urine and we'll talk about this. Why more during when we start talking about obstructive don't it's But babies often present with as pale color stools and dark urine about, um ugly. And remember, it's causing increased conjugated Billy Rubin. So there is no risk of connect us with biliary atresia. Okay, Abdominal ultrasound is usually enough to diagnose it on in terms of treatment. So some pain initially, you can do this procedure called a porter and Rostami basically connecting the intestines to whatever remaining of to deliver. Okay, sort of bypassing the be pulling about the bowel duct system. But most babies should be considered for a liver transplant. Okay. And also, it's been case should be given to reduce the risk off. Um, I am allergic disease. Often you born okay, cause remember, if you're not producing bile, then you're not gonna be absorbing vitamin K. So, uh, babies can get vitamin K deficiency, so you can give it one k to prevent to prevent the risk off leading. Okay, which could be dangerous in a new ball. Okay. I was near needs of donors. Okay, That was a lot off various tricky medical concepts, but hopefully that's well, believe we kneel down. Quite a lot of important stuff in Don't miss that. So we're back to Homer. Remind me to send the Google for muscle. Um, no, I didn't. I send it up now. I sent it to you in the shots. Yeah. I mean, I see the message. Should I send it up now? I took, you know. Well said, I don't know. Come call it. I guess. Eso having mostly you got It s so we got a bit of mostly went for beat. That this correct answer. We got a couple of you went for ius. Well, eso yeah, Kirk as it is d so high levels off estrogen and the blood. So let's look through this. And this is hopefully a much three simple SPH virus is basically asking, what is the mechanism off on everything for again? Mechanism for that is high levels of Eastern in the blood. Okay, rebound. You still a meeting for eso? So this is basically talking about homo, as it was a long time alcoholic. Okay. And you've basically got a lot of features off liver failure. Okay, so this is a lot a lot of peripheral stigmata off currently the diseased on also signs off decompensated liver disease as well. Okay, so let's let's go through all of these different teachers. So hematemesis so given time to say so, Uh, what he was Human tennis is indicating in a patient with chronic liver disease What is this? What is it like the coast virus is very good. Okay, So again, it's a sign of decompensated liver disease. Disorientated to time and place. What are we thinking about that? And careful up the very good. Uh, what so abdominal distention So don't understand. That's what we're thinking about what we think about ascites there. Shifting dollars again. Confirming ascites. Put Medusa. What is kaput. Medusa. A sign off. What is that? Indicating both the life. Attention. Very good. Okay, so again, he's all powerful stigmata of chronic liver disease. Uh, flapping tremor. You guys know Astor access sign of Patrick and Kappa Lot of the red palms. That's that's ESPS that palmer erythema again. That happens because, uh, people that happens because of the lack of estrogen getting that the tablet is leading to Palmer erythema on. He's also got no lymphedema was Well, probably from the portal. Hypertension? Yes. That's basically this questions basically asking about the stigma of liver disease because I think this is a very common cause of jaundice. Okay, decompensated liver disease on the key features you want to be thinking about is join us. Okay. Eh, So let's talk about crime liver disease now. Uh, firstly, so remember, we'll go back to this diagram. We're talking about practice teller jaundice now. Okay, So basically liver disease as a cause of jaundice. So if you have a disease, liver disease, outside, you know you're gonna see a bunch of different problems. You could have problem with conjugation which could lead to increased uncontradicted Billy Rubin and the blood. Okay. And you can also have a problem with excretion as well. And that can lead Teo conjugated Billy Rubin leaking into the blood as well. Okay, so again, if you have a disease, liver disease, about a scientific problems with conjugation on excretion with Philly to increase in both uncomplicated Billy Ruben on conjugated. Okay, so you could get basically a mixed picture off donuts. Okay. Also, because if the liver's damaged just well, it's not gonna be able to the entropy attic circulation can be disrupted basically on, so you can end up with morula pill energy and ending up in the blood on going to the kidneys, leading to increase your ability gyn in the urine as well. Okay, but the most important clinical indicators of a part of salad Gian best is a mixed picture of your liver profile. Okay, so this is that little table I took from our the hepatology for final stock. I did a couple of months ago. Okay. Basically summarizing all the different features off chronic liver disease. Okay. Not gonna go through all that. But remember, we have purple stick mater of liver disease. Okay? Things like things that we talked about. Okay, Like mom, Parathenar can come ask you, uh, explain a magnet is all just general stick marker of liver disease. We also have a lot of symptoms which are signs off decompensation. Okay, signs. Which means that the liver is no longer able to maintain normal home your faces on function on the body on some of the key things you want to be looking out for. I've joined us, okay? As well as things like and get up the color blocked the ascites on by variceal bleeding GI bleeding as well. Okay, so these old signs of decompensation in a patient's okay. Also a little slight on LFTs. Okay, I just threw this in here. Just revise some quick stuff. You guys. So remember, with liver function tests were four key enzymes of measuring. Okay, I'll t e s t a l p and g t. If you have raised Ailton easy, that's highly suggestive. Off top seller damage. Okay, if you have primarily increase in your increase in your heel being fidgety, that's indicating more of Ah, cholestatic picture. Okay, something is blocking the flow of bile in the well, That's okay. But remember, you also have other causes off raised a be a swell because they also found in other tissues, like your bone and your placenta. Okay, so if you have disorders that lead to increased bone turnover totally, that can lead to an increase in a lot. Be a swell. Can you guys just list any conditions that can lead to I? I'll be, like, outside of liver failure outside of outside of Corti Stasis. Sorry. And it's very good. It's. And again, everything else is just is very important. One only mats pregnancy. Good. Because it could be found in the center. Yeah, it doesn't very valid courses off a race. A little good. Uh, yeah. Those Those are the sort of keep things you want to be thinking about it. So this is a pretty enzymes. And also, remember, if you have a little above 1002 main causes I like to think about okay. Is a schematic tight. That place Okay, used. I see. These are the two I like. That closes off a significantly elevated. You can get with I'll hepatitis and autoimmune hepatitis. But I like to think many about these two. Well, okay. Uh, so again, remember, these are all elevation in these enzymes. The hell they only go up when the liver is damaged. Okay, the ones have less. The things I've listed here. These other measurements off liver function proteins open times of measuring the halting function of the liver. Billy Rubin measuring the liver's ability to congregate and excretely Ruben albumin platelets goes these awful the's olds or synthetic Marcus. Okay. He's all measuring the actual function of the liver. Okay, whereas all of these enzymes, then they only go up if the liver is actually damaged. Okay. So often patients with have compensated liver disease. They often have normal liver enzymes. Okay, but these parameters might be damaged. Okay, so that's where you really want to be thinking about with liver disease and allergies in general. Okay. I think we got one more SPF after this on. Then we will wrap it up. Very good having most of you got this. This was that was quite nice for this SPH most. I was just I was trying to come up with some exposure to write about summer, but yeah, So mostly you got it right. So, see, um, so it's once a diagnosis. It, um uh, basically, basically giving you the night. This is that? Yes. Someone said pancreatic cancer, but again, So this is a Selma's. You got pancreatic cancer? She's a smoker. Okay, so I got kind of cancer is very strong. Association with smoking is well and basically questions asking which of the following two and markers is used to assess response to treatment and pancreatic cancer. And the answer is, see a 19 9 eso. Yeah. So this is basically a table to summarize the different tumor, Marcus. Okay, so everything is is really a medication slight. Not gonna go through it, but have a read events, and I should be useful. Be a revision. I think this is a loss of speak on. Then we will wrap it up. Initially was just just a bit of confusion with the previous question. It seems that the table has a bit of country right outside activity. Okay, okay with that, I think mostly you got Yeah, you there was let Yeah, mostly. You got one for seeing us for cancer, so anti mitochondrion antibodies. Okay, uh, can you tell me what's the most likely diagnosis? Yeah, BBC Very good. Uh, well, that that yet to this most likely diagnosis BBC primary biliary cholangitis. So basically, we're gonna move on to talk about obstructive don't this. Okay, so this is a question talking about obstructive jaundice. So we got march middle aged woman with generalized pruritis. Okay, To be honest, in an SBA that pretty much gives the diagnosis off PVC on its own. Okay, remember an SBA line? Middle aged woman with generalized writers Ask highly indicative of PVC. She's also tired on D also has features of pain and power during cold weather. Okay, so what is that describing? What's that? Most likely describing in the context off, uh, a lot immune diseases. Yeah. Great notes. Okay, So remember, general rule and medicine, alternative is east. There's often because during cold weather, that's classic description for being off phenomena. Okay on. She's doing this like I said. Okay, remember PBC BBC, you're getting blockage off 1000 destruction of bile ducts inside the liver. So that lead to obstruction the flow off Billy Rubin, which would be to go on this. Okay? And classically remember it. You're getting cholestasis. So you'll get elevated GGT and LP, okay. And because of the obstruction, you elevated country get a bilirubin, and a lot of this honest, you know, for PBC as well. Okay, um, so in terms of other options, so you know, Certainly. What's anti STL 77. You guys don't remember from my rheumatology? Yes. It's a step. Next closed is very good. Uh, antidouble stranded DNA were what we see? Nothing. Yeah, Lupus s a very good anti smooth muscle antibodies. Yep. Autoimmune hepatitis, attack one autoimmune, hepatitis P. Anca. What? We see Pankin. Yeah. Eso also decline. It is. Yeah. You can't. You can't, you know, stricter. Litis you typically you would think about vasculitis. Okay. Very different. You have various different vascular disease, which can be positive for P anca. Okay. Things like, uh, I guess in a village granulomatosis with poorly enjoy this case. Is that the p Anca positive? Sometimes it'll known as, uh, transit syndrome as well. Eh? So yeah, that that's what the other antibodies typically positive antibiotic Andrea antibodies are the ones that are classically up a primary, but we call inject. It's yeah, So remember, as a general rule of raspy is generalized arthritis in a middle aged woman is really indicated off PPC okay to final type of jaundice. Okay, Posthepatic jaundice s o. Basically, it's a problem in the biliary system. So if you have problem the bigger system where conjugated bit of is not a flow properly your conjugated be, but it's gonna go up, and that's going to lead to elevation in your conjugated bilirubin. Okay, so I think I'm about to animate that the Arab conjugated believe it'll leak into the blood and that lead to increased conjugated bilirubin. Also, if you have increased conjugated bigger, but none of the conjugated bilirubin is going to end up in the in the bile and end up in the intestine. So you're gonna get reduction in your ability, okay? If you have a reduction in your ability and that's going to lead to reduction in stroke ability being bridges, and remember we went to, um, a room with the start of the like to reset stoke ability is the product that gives stools that characteristic brown pigmentation. Okay, so lack of stoke Oberlin is going to lead to pale color stools. Okay, that's classic features obstructer jaundice on. Remember, also, if you have, if you're not having your opinion job because you're gonna have less being recycled, So if less is going to be taken up again to the portal system and tomorrow attic circulation, you're not gonna have any your ability, genetic up in the urine. So another classic future off obstructive jaundice is negative. You're a banana gyn on urinalysis, okay? And yes, I like we said to the conjugated you've been will also go up. Okay, because none of the conjugated is moving through the system. So again, three key things to run with obstructive jaundice in terms off these, in terms of the bilirubin, you get increased constipated bilirubin and the blood you get pale a quality girls because no stick ability is being produced. And you also get that stomach Did Ah, your ability gyn in the urine. Okay, those are keep each is to be thinking about. Also because of that increased conjugated bilirubin in the blood. Remember, conjugated bilirubin is water soluble. Okay, so it can be excreted by the kidneys into the urine. Uh, so that could lead to constipated because we've been ending up in the urine on that could lead to dark urine. Okay, so you get doctor in an obstructive don't. It's because you're getting increased constipated Billy Rubin and making up in the urine. Okay, so that's obstructive. Don't listen again. Just quickly. Highlights of the key things. So because you're having obstruction in the flow of bile, Okay, you're getting Cody Stasis. You're a healthy, and GT will go up. Typically, analyses and also of that later stages of that starts to lead. To participate, damage you can get increasing else. And ST we talked about increased conjugated Billy Rubin on you also get conjugated Been you've been in your urine is always going to document. Okay, cause remember, conjugated bilirubin is pigmented, which could be too talking off your urine. And also because it's water soluble. You got negative. You know, Bill, engineer your analysis and you get pale stools because of the lack off staple in. Okay. It's a summary table off the differences in alternately liver disease to this. Okay, comparing ultimate hepatitis PBC and primary sclerosing cholangitis. Okay, these are all important autoimmune liver diseases. Okay, So have a read of some of the key points and differences between them on this is a little cheat sheet made Teo. Okay. Summarize a lot of the investigations for the different course of jaundice. Okay, basically comparing which ones? Where? When Billy Rubin goes up, when is the urinary your ability and negative and things? When when is the stool color change is basically teaching. That basically summarizes the key diagnostics and join us to remember is that hopefully will be useful for your revision on? Yeah, that's it for me. So thanks for tuning in today, guys. Uh, we finished. I say much for me. I said, usually I'm not taking a long time to finish, but thanks for tuning. Uh, have you enjoyed, uh, was run through? A lot of we didn't just talk about your illness that we come in a lot of different concepts in medicine, but I hope that was useful. I see you guys soon