Cause Of Jaundice Research Articles

Etiologies and In-Hospital Outcomes of Nonhemolytic Jaundice among Infants at King Abdulaziz University Hospital (KAUH)

Background: most of articles addressed the underlying causes and management of Neonatal Nonhemolytic Jaundice, however only a few have investigated nonhemolytic jaundice among infancy which can turn fatal in severe case, however can be prevented by early diagnosis. Aim of the Work: was to investigate the most common etiologies of nonhemolytic jaundice among infants presented to at King Abdulaziz University Hospital (KAUH) which may help pediatricians to rearrange their differential diagnosis about nonhemolytic jaundice in infants. Material and Methods: this is a retrospective observational study of all infants aged between 1-12 months, conducted at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia from January 2016 to November 2017. Data collection was done using Microsoft Excel while data analysis was done using SPSS version 21. Chi -square test was used to test if associations would be appropriate. Results: out of total 105 patients enrolled in this study, complete data set was available for 88 only patients during 2012. The mean age at presentation in months was 2.73 (± SD 2.21) range from 1 to 12 months. Among the sample, the final outcome was as follows ; 59 (67%) jaundice-free, 14 (15.9%) still diseased and 15 (17%) dead. Sepsis was the most common cause of jaundice with 33 cases (37.5%), followed by biliary atresia 10 cases (11.4%) and congenital hypertrophic pyloric stenosis 7 cases (8%). On the other hand, the least common causes were rare diseases like wolman syndrome, crigler-najjar syndrome and autoimmune hepatitis and each of them represents 1 case. The overall number of deaths in our study was 15 (17%). Seven of them were due to sepsis and 2 were due to biliary atresia. Conclusion: we hope to help the local physicians in Jeddah to arrange their differential diagnosis of nonhemolytic jaundice among infants and deal with it seriously, due to the high incidence of critical illness and death.

Clinical value of single photon emission computed tomography imaging in differential diagnosis of neonatal obstructive jaundice

Objective To investigate and explore the clinical value of single-photon emission computed tomography(SPECT) imaging in the differential diagnosis of neonatal obstructive jaundice. Methods From January 2012 to April 2017, 130 cases of suspected neonatal obstructive jaundice in the First Hospital of Jiaxing were enrolled in the study.All patients were given SPECT hepatobiliary scintigraphy, were injected 99mTc-EHIDA imaging agent, 99mTc-MIBI imaging agent, diagnosis of hepatobiliary scintigraphy after the acquisition.The result of operative cholangiography was viewed as the gold standard, the diagnostic sensitivity, specificity, accuracy of simple 99mTc-EHIDA SPECT imaging examination, combined with SPECT imaging agent in the diagnosis of neonatal obstructive jaundice were calculated and compared.The coincidence rate of differential diagnosis of different etiologies of neonatal obstructive jaundice was also compared. Results The diagnostic sensitivity, specificity and accuracy of combined with SPECT imaging agent in the diagnosis of neonatal obstructive jaundice were 94.23%, 96.15%, 94.61%, respectively, which of simple 99mTc-EHIDA imaging agent SPECT were 83.65%, 76.92%, 82.31%, respectively, the differences were statistically significant(χ2=5.915, 4.127, 9.646, all P<0.05). The coincidence rates of extrahepatic biliary atresia, hepatitis syndrome of the two kinds of SPECT imaging agents combined examination were 96.05%, 96.43%, respectively, which were significantly higher than those of the 99mTc-EHIDA imaging agent SPECT examination (84.21%, 85.00%)(χ2=5.991, 5.250, all P<0.05). Conclusion SPECT imaging in the diagnosis of neonatal obstructive jaundice has high sensitivity and accuracy, especially in combination with 99mTc-EHIDA imaging agent, 99mTc-MIBI imaging agent can identify and distinguish different causes of jaundice, and provide a reliable basis for clinical treatment. Key words: Jaundice, neonatal; Jaundice, obstructive; Diagnosis; Single-photon emission computed tomography

Clinical and biochemical characteristics of infants with prolonged neonatal jaundice.

Protocols for investigating neonatal prolonged jaundice vary and the yield from screening has not been assessed. International guidelines recommend establishing cholestasis before proceeding to investigate the underlying pathology. However, in most hospitals administered by the Hospital Authority, full liver function is checked at the first neonatal jaundice clinic visit. To study the diagnostic yield of this approach, we carried out a retrospective study of all infants referred for prolonged jaundice. Attendance records from the neonatal jaundice clinic at the Tuen Mun Hospital, Hong Kong, the clinical management system, and electronic patient records were used to retrieve epidemiological, clinical, and laboratory data, and patients' clinical progress. During the 8-month study period from 8 July 2015 to 8 March 2016, 1164 infants were referred to the neonatal jaundice clinic for prolonged jaundice. Among them, 16 (1.4%) infants had conjugated hyperbilirubinaemia. Diagnoses included biliary atresia (n=1), cytomegalovirus (CMV) infection (n=3), neonatal hepatitis syndrome (n=2), and transient cholestasis (n=10). In total, 98 (8.42%) infants had elevated alanine transaminase levels. Diagnoses included biliary atresia (n=1), hepatic congestion related to congestive heart failure (n=1), CMV infection (n=5), neonatal hepatitis syndrome (n=16), and non-specific elevated alanine transaminase (n=75). In total, 59 infants had elevated alkaline phosphatase levels. A stepwise approach is recommended, in which full liver function is checked and the underlying cause of jaundice is investigated only after confirming cholestasis.

Unusual Cause of Severe Jaundice in an HIV Infected Patient

Lobar pneumonia as a cause of jaundice with non-obstructive conjugated hyperbilirubinemia is an uncommon complication of pneumococcus. More commonly seen in immunocompromised and elderly patients, it is believed that the offending microbe produces a toxin that directly causes hepatocellular injury and impairment of bilirubin excretion. Biopsies of patients with pneumococcal pneumonia-associated jaundice commonly depict patchy areas of hepatic necrosis and dilated biliary canaliculi without metastatic foci of infection. In the pre-antibiotic era, the prevalence of jaundice in patients with lobar pneumonia was reported to be about 14% and carried significant mortality rates. Seen less commonly today, mortality rates of invasive pneumococcal disease remain as high as 5% to 35%. We present a case of a 29 year-old-male with no medical history presented with subjective fevers, productive cough, dark urine and myalgias for three days. He was profoundly jaundiced without stigmata of chronic liver disease. Computerized tomography (CT) of the chest revealed a right lower lobe pneumonia. The patient had leukocytosis, significant elevation of transaminases, hyperbilirubinemia and was found to be influenza positive. Antibody for human immunodeficiency virus (HIV) was also positive and later confirmed with polymerase chain reaction (PCR). An extensive workup for his jaundice and hyperbilirubinemia was unrevealing and it was deemed that his clinical signs were a result of invasive pneumococcal infection from his pneumonia. The patient was treated with antimicrobials and highly active antiretroviral therapy (HAART). He ultimately had complete resolution of his jaundice and laboratory abnormalities. Although seen infrequently today, unusual manifestations of pneumococcal infection still occur and may be unrecognized in practice.

Gallstones and "liver obstruction" in medical texts ofantiquity

Gallstones are rarely mentioned in the medical texts of antiquity. The physician, Alexander of Tralles mentions-for the first time-stones in the gallbladder as a possible cause for obstructive jaundice. This designation is found in his textbook on medicine under the heading "obstruction of the liver". Based on that observation, we describe the ancient history of hepatic obstruction and investigate the connection with the rare reference of gallstones in the medical texts of antiquity. First, we evaluated the medico-historical literature on bile-stones and liver obstruction in antiquity, which has been published since 1900. The identified ancient sources we have analyzed for the purposes of etiology, diagnostics and therapy. Second, we searched for additional ancient sources with a combined keyword search in Greek and Latin text databases to check the completeness of the mentions of gallstones and liver obstructions known from the research literature. There are two mentions of stones in the liver and gallbladder: Aristotle probably describes stones in the liver of slaughtered sacrificial animals and the late-antique physician, Alexander of Tralles, in the gallbladder of humans. The mechanical obstruction of the bile ducts as a cause of jaundice has been known since Diocles of Karystos (4th century BC). For the first time, Galen of Pergamon describes the disease pattern of a liver obstruction (2nd century AC). This was due to the coagulation of the yellow bile, one of the four humors of ancient humoral pathology. Although gallstones were rarely mentioned, the clinical presentation of gallstone disease was known to ancient authors of medical texts and was referred to as liver obstruction.

Jaundice Outbreak in Biratnagar Municipality of Eastern Nepal: A Microbiological perspective

Background and Objectives: Hepatitis is a common cause of jaundice. Hepatitis A and Hepatitis E are enterically transmitted viral diseases. This study investigated an outbreak of viral hepatitis at Biratnagar, Morang district, Nepal, during April 2014. Materials & Methods: An expert team from Microbiology and Public health of BPKIHS inspected the area and blood samples from 90 suspected cases of jaundice were obtained and subjected for IgM and IgG antibody detection against HAV and HEV. Water samples from 10 different areas of affected region were also collected and checked for presence of coliform by membrane filtration method to confirm the suspicion of fecal contamination of water supply. Results: An outbreak Hepatitis E and Hepatitis A occurred in Biratnagar. Out of 90 blood samples, 45 were reactive for hepatitis E IgM, nine were reactive for Hepatitis A IgM. Three samples among these were reactive for both Hepatitis A and Hepatitis E. The liver function tests of the positive cases were deranged while the negative cases had normal LFT. Among the 10 water samples, five of them grew coliforms which confirmed the fecal contamination of drinking water supply. Conclusion: A large outbreak of Hepatitis A and Hepatitis E occurred in a Biratnagar which had spread through the drinking of contaminated water. The outbreak was confirmed both by Epidemiology and Disease Control Division of Nepal government and BPKIHS which led to the identification of source and control of the outbreak.

Comparative study of Ultrasonography with Fine Needle Aspiration Cytology in the diagnosis of causes of Obstructive Jaundice

Introduction: Surgical jaundice or obstructive jaundice is one of the common causes of jaundice. It is important cause of morbidity and mortality in an adult commonest at 40-60 years of age and the incidence is increasing day by day. The purpose of this study was to use easily available ultrasonography in the diagnosis of causes of obstructive jaundice and to determine its effectiveness by comparing with Fine Needle Aspiration Cytology (FNAC).Methods: Non- randomized, prospective study of 35 cases with clinical features of jaundice and altered bio-chemical test was conducted over a period of one year. The ultrasound findings were compared with FNAC to characterize the cause of obstruction.Result: Out of 35 cases, 24 cases were subjected to USG guided FNAC for suspicion of malignancy for confirmation. USG showed 18(51%) had benign causes, 11(31%) malignant and 6(17%) were indeterminate. FNAC result showed 13 (54%) were malignant. Over all accuracy of USG in determination of cause of obstruction is high as 83%. The efficacy of the USG is acceptable when compared with histopathology (P value is 0.6816).Conclusion: Ultrasonography correctly predicted the causes of obstruction whereas in malignant cases, when combined with other modality, accuracy of diagnosis can be increased.NJR VOL 4 No. 2 ISSUE 7 July-December, 2014, page: 1-5

An Epidemiological Study of Hepatitis Outbreak in Cuttack City, Odisha

Hepatitis is a highly infectious disease caused by a number of viruses. A study was undertaken in a ward of Cuttack City, where suddenly a number of cases of Jaundice reported. A team from the departments of Community Medicine visited the ward and collected the data by door to door survey. A total of 281 houses were surveyed and data was obtained. There were a total number of 55 jaundice cases. The cases reported with symptoms of fever, anorexia, yellow sclera and yellow urine. 64.3% of cases used Municipality source of water. 7.3% used the water for drinking purpose after boiling and filtration. 28% of houses did not have sanitary latrine, 85.5% from all the jaundice cases used the water for drinking purposes. The young adults were mostly affected. The cause of jaundice could be due to contamination of water supply by Municipality because of leakage and the causative agent was Hepatitis E Virus.

Probiotics for the prevention or treatment of hyperbilirubinaemia in late preterm and term neonates

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To determine the safety and efficacy of probiotics supplementation in preventing hyperbilirubinaemia among late preterm (born at gestational age (GA) 34 weeks to 36 weeks and six days) and term neonates (≥ 37 weeks) To determine the safety and efficacy of probiotics supplementation in treating hyperbilirubinaemia among late preterm (born at 34 weeks to 36 weeks and six days) and term neonates (≥ 37 weeks) Subgroup analyses will include gestational age at birth (term vs late preterm), cause of jaundice (haemolytic vs non-haemolytic jaundice), mode of feeding at the time of enrolment (exclusive breastfeeding vs mixed feeding/formula feeding), and types of probiotics used.

The prevalence of neonatal jaundice due To Rh isoimmunization and ABO incompatibilityAdmitted to the maternity and children Teaching hospital in Al-diwaniya city

Jaundice is a common neonatal problem. 65% of newborns develop clinical jaundice with bilirubin level above 5 mg/ dl during the first week of life. Hyperbilirubinemia can be toxic, with high level resulting in encephalopathy known as Kernicterus. Rh and ABO incompatibility are one of the causes of neonatal jaundice due to immune hemolysis of RBC in infants. The aim of the study was to measure the prevalence of the neonatal jaundice caused by Rh and ABO incompatibility and identify the type of therapy they received, and to find the relation of gestational age with the cause of jaundice and their treatment, also with the incidence of exchange transfusion to each one (find the relation of Term or Preterm babies with ABO or Rh incompatibility as causes of their jaundice). A total number of 55 neonates who were admitted to the maternity and children teaching hospital in Al-Diwaniya city were studied for the incidence of ABO and Rh incompatibility as causes of neonatal jaundice. Their treatment also subjected to the study. The study found that the prevalence of neonatal jaundice due to ABO incompatibility were 81.8% and due to Rh isoimmunazation were 56.3%, and due to both were 38.1%. 65.4% male and 34.5% female with M: F ratio 1.8:1. 80% of full-term babies their jaundice due to ABO incompatibility where as 86.6% of preterm babies their jaundice due to Rh isoimmunization. All babies with jaundice treated with phototherapy, 15 patients (27.2%) were treated with exchange transfusion and 15 patients (27.2%) were treated with both (phototherapy and ET).Neonatal jaundice due to Rh isoimmunization is less frequent and more sever than due to ABO incompatibility and mostly required exchange transfusion particularly if the neonate is preterm. Anti-D is most important and effective therapy for prevention of Rh isoimmunization, maternal education is required.

Diagnosis and evaluation of hyperbilirubinemia.

Jaundice, the physical finding associated with hyperbilirubinemia, results when the liver is unable to properly metabolize or excrete bilirubin. The purpose of this review is to examine some of the most common causes of jaundice in adults, provide insight into the diagnostic evaluation of jaundice, and review information on the outcomes of patients with jaundice. An elevated level of bilirubin almost always indicates the presence of an underlying disease state. The best approach to evaluating a patient with jaundice is to start with a careful history and physical examination, followed by imaging assessment of the biliary tree and liver. There are algorithm models that incorporate bilirubin levels in their predictor models for outcomes in patients with chronic liver disease (i.e., the model for end-stage liver disease). However, there are few studies that have examined the outcomes of patients with jaundice. Evaluation of patients with jaundice starts with a careful history and physical examination, followed by directed imaging of the biliary tree and liver. Although jaundice is generally believed to be a serious medical condition, there is little literature that addresses outcomes in patients with jaundice.

Intelligent diagnosis of jaundice with dynamic uncertain causality graph model.

Jaundice is a common and complex clinical symptom potentially occurring in hepatology, general surgery, pediatrics, infectious diseases, gynecology, and obstetrics, and it is fairly difficult to distinguish the cause of jaundice in clinical practice, especially for general practitioners in less developed regions. With collaboration between physicians and artificial intelligence engineers, a comprehensive knowledge base relevant to jaundice was created based on demographic information, symptoms, physical signs, laboratory tests, imaging diagnosis, medical histories, and risk factors. Then a diagnostic modeling and reasoning system using the dynamic uncertain causality graph was proposed. A modularized modeling scheme was presented to reduce the complexity of model construction, providing multiple perspectives and arbitrary granularity for disease causality representations. A "chaining" inference algorithm and weighted logic operation mechanism were employed to guarantee the exactness and efficiency of diagnostic reasoning under situations of incomplete and uncertain information. Moreover, the causal interactions among diseases and symptoms intuitively demonstrated the reasoning process in a graphical manner. Verification was performed using 203 randomly pooled clinical cases, and the accuracy was 99.01% and 84.73%, respectively, with or without laboratory tests in the model. The solutions were more explicable and convincing than common methods such as Bayesian Networks, further increasing the objectivity of clinical decision-making. The promising results indicated that our model could be potentially used in intelligent diagnosis and help decrease public health expenditure.

A Prospective Study on Exchange Transfusion in Neonatal Unconjugated Hyperbilirubinemia – in a Tertiary Care Hospital, Nepal

An exchange transfusion involves replacing patient's blood with donor blood in order to remove abnormal blood components and circulating toxins while maintaining adequate circulating blood volume. To observe the incidence, causes of jaundice requiring Exchange and any adverse event of exchange transfusion in newborns with unconjugated hyperbilirubinemia. Prospective study undertaken at Neonatal Intensive Care Unit (NICU) of Manipal Teaching Hospital, Pokhara, Nepal from March 2014 to April 2015. For both mothers and neonates blood group and Rh typing and for all newborns pre and post exchange complete blood count with peripheral smear, serum bilirubin, hemoglobin, calcium, potassium, random blood sugar, C-reactive protein and blood culture and where ever required Direct Coombs test, reticulocyte count, G6PD activity and thyroid function test were done. The incidence, indications, positive outcome, complications and mortality were noted. Out of 481 cases of unconjugated hyperbilirubinemia 29 (6%) required exchange transfusion. 55.2% Pathological Jaundice [13.8% ABO incompatibility, sepsis and hypothyroidism was commonest causes] and 44.8% exaggerated physiological jaundice [27.6% with no underlying pathology, 10.3% preterms 3.4% cephalhematoma] required exchange transfusion. Post transfusion, bilirubin level decreased significantly (p < 0.001). The commonest adverse events noted were anemia (89.7% / p < 0.018), hyperglycemia(51.7% / p < 0.001), hypocalcaemia (48.3% / p < 0.001)), sepsis(10.3%), hypernatremia (13.8%), hyperkalaemia, bradycardia, apnea and feed intolerance (6.9%). None of them had kernicterus and there was no mortalities. Exchange transfusion is an effective procedure to decrease bilirubin levels but is associated with many complications. Hypothyroidism was one of the commonest cause of jaundice requiring Exchange transfusion.

Hepatobiliary ascariasis

Ascaris lumbricoides is one of the commonest parasite seen in the developing world. A multitude of complications can be caused by this parasite. Hepatobiliary ascariasis (HBA) can be very deceptive in its presentation. A high index of suspicion is therefore necessary to diagnose biliary infestation presenting as jaundice. A case of obstructive jaundice due to biliary ascariasis is presented to highlight this deceptive cause for jaundice.

Robots, Augmented Intelligence, and Things Only Humans Can Do

Healthcare TransformationVol. 1, No. 4 Open AccessRobots, Augmented Intelligence, and Things Only Humans Can DoStephen K. Klasko and Editor-in-ChiefStephen K. KlaskoSearch for more papers by this author and Editor-in-ChiefSearch for more papers by this authorPublished Online:1 Dec 2016https://doi.org/10.1089/heat.2016.29028.skkAboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail It's been a year of Healthcare Transformation—this is our fourth issue. We wanted to be bold and provocative, and each issue has carried ideas that could save the planet … or at least set healthcare delivery on an optimistic path. We've talked to legends, such as Andrew Young. We've talked to pioneers, such as Bernie Marcus. We've talked to leaders, such as Aneesh Chopra.In this issue, we are honored to have a rare interview with Judy Faulkner, the founder of Epic, the nation's leading (and dominant) provider of electronic health records (EHRs). Whatever you think of EHRs, there is little question that the opportunity is clear: to create the digital concierge, as she calls it, that can flag “rising risk” for thousands of patients at a time. Judy Faulkner's story is pure—the computer science student who found a problem and sought to solve it. She is the only computer scientist and woman running a major health tech company. We are delighted she agreed to imagine the future with us.In addition to Faulkner's story, this issue tackles the intersection of digital technology and human health: EHRs, wearables, high speed genetic analysis. Could your doctor be a robot?I'm going to make a prediction:The future of healthcare will not be found in artificial intelligence (AI), although AI will contribute more than we imagine. The future of healthcare will not be found in augmented reality (AR), although AR will transform our experiences.My prediction is that healthcare will be driven by augmented intelligence that places the locus of meaning back at home—back with the patient—and allows the physician to get back to the role of guide.The one thing human beings can do that no robot can do is be human. We can help patients, families, and communities make sense of what's happening. We can help build meaning, and we can build motivation, even at the end of life.To find the physician of the future requires a revolution in medical education, not incremental reform. For a century, we've selected and trained doctors to be memorization machines. If an applicant to medical school can remember 19 causes of jaundice, that applicant beat the one who could only remember 17. But we don't need that level of memorization. There will be a robot who can remember all signs of an illness, and correlate those signs with personalized genetic markers, with risk profiles, and with evidence-based protocols for treating that patient.If a robot can do that, what we need are doctors who can do what robots cannot do. We need doctors who can answer your question when you ask, “What does this mean?”I often use the case of an obstetrician delivering a baby who unexpectedly has Down syndrome. What the parents need at that moment is not someone who can define Trisomy 21 and run through a list of potential health and developmental challenges for babies with this diagnosis.What the parents need is a doctor who can say, “What this means is that you've delivered a beautiful baby. It means your baby will grow, and love, and be loved. It means we'll find parents with other beautiful babies like yours so that you can talk with them and learn from them what's unique about your child.”Each of the patient advocates profiled in this issue has faced the need to create meaning. Emily Kramer-Golinkoff, Nicole Johnson, and Mark Laabs each face rare, life-threatening, soul-destroying illnesses. None caved in. Each has found meaning disrupting traditional organizational practices and accelerating science.I'm especially struck with Emily's observation: that science is a network of communities. When we engage with patients, we reconfigure those networks. We speed and focus our work.And we find meaning.FiguresReferencesRelatedDetailsCited byAnalysis of Nurse’s Reflection on Success or Failure of Blood Withdrawal by Vein TypesAugmented Intelligence and NursingNursing Education Perspectives, Vol. 38, No. 2 Volume 1Issue 4Dec 2016 Information© Stephen K. Klasko 2016; Published by Mary Ann Liebert, Inc.To cite this article:Stephen K. Klasko and Editor-in-Chief.Robots, Augmented Intelligence, and Things Only Humans Can Do.Healthcare Transformation.Dec 2016.209-211.http://doi.org/10.1089/heat.2016.29028.skkcreative commons licensePublished in Volume: 1 Issue 4: December 1, 2016Open accessThis Open Access article is distributed under the terms of the Creative Commons Attribution Noncommercial License ( http://creativecommons.org/licenses/by-nc/4.0), which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.PDF download

Epigastric Pain and Jaundice in Patient with Colorectal Adenocarcinoma, with Rare Site of Metastasis

Introduction: Jaundice in patients with colon cancer is usually a result of intrahepatic metastases. Sometimes, it can be caused by extrahepatic obstruction from metastatic lymph nodes. A rarer cause of jaundice in these patients is solitary bile duct metastasis mimicking cholangiocarcinoma. We present a case that demonstrates this, and the steps involved in making an accurate diagnosis. Case Presentation: A 58 year old female with history of colon cancer post resection ten years ago presented with epigastric abdominal pain and jaundice. MRCP showed no liver lesions, but a 15 mm mass located at the pancreatic head or common bile duct concerning for a pancreatic or bile duct neoplasm. EUS was done which showed a 12.5 x 9.8 mm hypoechoic distal bile duct mass. Samples were obtained via FNA which were positive for adenocarcinoma with tumor cells positive for CK20 and CDX2, consistent with intestinal differentiation and negative for CA19-9 and CK7. Discussion: A solitary bile duct tumor from metastatic colon cancer without any hepatic lesions is an unusual finding and can resemble cholangiocarcinoma. These metastasis present, on average, about 45 months after resection of the primary colon tumor. There should be a high index of suspicion for recurrence of primary colon tumor in these patients if they present with a biliary neoplastic lesion due to the treatment implications involved. The histologic findings can also appear similar. Obtaining adequate tissue sample is made possible by EUS/FNA which allows immuno-histochemical staining for intestinal and bile duct markers. The colorectal epithelium is reactive to cytokeratin-20, but not to cytokeratin-7 which stains positive for biliary epithelium. Therefore, a cytokeratin 20-positive and cytokeratin 7-negative immuno-histochemical staining pattern is characteristic of biliary metastasis from colorectal cancer. The expression of CDX2 in adults is restricted to the intestine, from the duodenum to the rectum. CDX2 is regarded as a specific marker of the intestinal epithelial cells that can be utilized for identifying the colorectal origin of metastatic adenocarcinomas. The tumor in our patient stained positive for CK20 and CDX2, thus confirming colorectal origin.Figure 1Figure 2Figure 3

Updated Etiology and Significance of Elevated Bilirubin During Pregnancy: Changes Parallel Shift in Demographics and Vaccination Status.

The most common cause of jaundice during pregnancy in the United States (US) is still attributed to viral hepatitis, despite the dramatic drop in incidence of viral hepatitis in the US. We hypothesized that viral hepatitis is no longer a frequent etiology of jaundice among the pregnant population in the US and sought to identify the contemporary causes of elevated bilirubin during pregnancy as well as to quantify the associated risk to the mother and fetus. Clinical data from all pregnant women who delivered an infant between 2005 and 2011 at a single hospital in Dallas, Texas, were ascertained using prospectively collected computerized databases. Women with elevated total bilirubin (>1.2mg/dl) were analyzed to determine the cause of hyperbilirubinemia and maternal and fetal outcomes. Out of a total of 80,857 consecutive deliveries, there were 397 (0.5%) pregnancies with hyperbilirubinemia. The most common etiology was gallstones (98/397=25%), followed by preeclampsia/eclampsia/HELLP (94/397=24%) and intrahepatic cholestasis of pregnancy (53/397=13%). Adverse infant outcomes, including stillbirths, fetal malformations, neonatal deaths, and small for gestational age births, were more common in the women with hyperbilirubinemia during pregnancy, but there were no maternal deaths. Acute viral hepatitis is no longer a common cause of jaundice in pregnant women in the US. In the current era, gallstones and preeclampsia-related disorders are the most common causes of jaundice in pregnant women. Disorders that cause elevated maternal bilirubin during pregnancy are associated with increased risk for the fetus.

Exchange Transfusion for Neonatal Hyperbilirubinemia in Johannesburg, South Africa, from 2006 to 2011.

Background. Severe hyperbilirubinaemia requiring exchange transfusion has become less common in recent years; however, kernicterus still occurs. The aim of this study was to review babies undergoing exchange transfusion for severe hyperbilirubinaemia in a Johannesburg hospital. Methodology. This was a retrospective review of babies who required exchange transfusion in both the neonatal and the paediatric wards from June 1, 2006, to December 31, 2011. Results. There were 64 patients who underwent 67 exchange transfusions. Isoimmune haemolysis (both Rh and ABO incompatibility) was the cause of jaundice in 9/64 (14%). Most babies who underwent exchange transfusion were sick or preterm and were admitted in hospital after birth (38/64; 59.5%); three of these babies died, but not during the exchange transfusion (3/38; 7.9%); all three had signs suggestive of neonatal sepsis. The remaining 26 babies (40.6%) were readmitted to the paediatric wards for exchange transfusion. Six of these babies (6/26; 23.0%) had signs of kernicterus. The most significant complication of exchange transfusion was apnoea requiring mechanical ventilation in three patients (3/64; 4.6%). Conclusion. Despite a relatively low number of babies undergoing exchange transfusion, kernicterus still occurs and must be prevented. Proper protocols for screening and management of severe hyperbilirubinaemia need to be enforced.

Reticulocytosis: the unevaluated parameter in neonatal jaundice requiring phototherapy

Background: Majority of the jaundiced neonates requiring phototherapy do not have an identifiable cause for the jaundice. Reticulocyte count more than 4% on day 3 of life is called reticulocytosis in neonates. So far no studies have evaluated the prevalence of reticulocytosis among jaundiced neonates requiring phototherapy. Objective of the study was to identify babies with only reticulocytosis as cause for jaundice and identify factors contributing to reticulocytosis. Methods: An observational study was carried out over a period of one year in the neonatal unit of a tertiary care hospital on 200 jaundiced neonates requiring phototherapy for determining the incidence of jaundice with unknown etiology. This data was analysed for prevalence of reticulocytosis and its contributing factors. Results: 67 of 200 babies with jaundice had reticulocytosis. An etiology for the reticulocytosis was found in 37 babies. 12 of the remaining 30 babies had dehydration (weight loss more than 10%) contributing to jaundice. 18 babies had no identifiable cause for the reticulocytosis. Mildly significant correlation was found with sibling history of neonatal jaundice (p = 0.052). No significant correlation was found with any other contributing factors. Conclusions: Reticulocyte count should be done for any baby with jaundice requiring phototherapy. Screening for irregular antibodies and genetic studies need to be promoted along with routine tests, to identify the cause for reticulocytosis after working out the costs involved.

Clinico-demographic profile of hyperbilirubinemia in neonates admitted to a tertiary care hospital

Background: The purpose of this study was to find etiological and other associated factors of neonatal hyperbilirubinemia at a tertiary care hospital SGRRIM&HS Patel Nagar Dehradun Uttrakhand, India. Jaundice is a common problem in neonatology. Early recognition of the cause of jaundice is very important as delay in management may lead to serious complications or even death. Methods: In present study, newborns with jaundice were evaluated during a 12 months period between January 2015 – December 2015. 195 newborns with jaundice were enrolled in the study. Data regarding demographic profile of new born, physical examination and laboratory investigations were gathered and analyzed to interpret the common etiologies giving rise to neonatal hyperbilirubinemia. Results: Out of 195 cases of neonatal hyperbilirubinem, 40 cases belonged to physiological jaundice. Breast feeding jaundice-121 cases, breast milk jaundice-5 cases, jaundice due to prematurity-8 cases and pathological jaundice-21 cases (6 were of ABO incompatibility, 4 neonatal sepses, 4 Rh incompatibility, 4 G6PD deficiencies, 2 neonatal hypothyroidism and 1 congenital biliary atresia). Conclusions: Present study concludes that breast feeding jaundice forms the bulk of cases of neonatal hyperbilirubinemia in our hospital, followed by physiological jaundice, jaundice of prematurity, ABO Incompatibility, breast milk jaundice, neonatal sepsis, Rh incompatibility, G6PD Deficiency, neonatal hypothyroidism and congenital biliary atresia.