Jaundice: Difference between revisions

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''For neonatal jaundice please see the [[Neonatal jaundice]] page''
==Background==
==Background==
[[File:Heme Breakdown.png|thumb|Cycle of heme breakdown and excretion.]]
*Bilirubin is end product of heme metabolism
*All bilirubin products in the body are initially unconjugated and is transported bound to albumin into hepatocytes t o becombined with glucuronic acid into conjugated bilirubin
*Conjugated bilirubin is then excreted into biliary tract
*Only conjugated bilirubin is water-soluble (present in urine)
*Normal bilirubin level is <1.1 (70% unconjugated)


===Jaundice Types===
'''Prehepatic (overproduction):'''
*[[hemolytic anemia|Hemolysis]]
*Primarily unconjugated bili
'''Hepatic (inadequate processing):'''
*[[viral hepatitis|Viral]], [[alcoholic hepatitis|alcohol]], toxin
*Primarily unconjugated bili
'''Posthepatic (underexcretion):'''
*Pancreatic tumor, [[choledocholithiasis]]
*Primarily conjugated bili


- One end product of heme metabolism; remainder from myoglobin
==Clinical Features==
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]]
*Yellow skin, sclera
*+/- dark urine


- All bilirubin products in the body are initially UNconjugated
==Differential Diagnosis==
{{Jaundice DDX}}


- Transported from albumin into liver cells; combined with glucuronic acid into conjugated bilirubin
==Evaluation==
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]
[[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]]
*Urine pregnancy
*CBC
*Chemistry
*[[LFTs]]
**Hepatocyte injury: AST, ALT, alk phos
**Hepatocyte catabolic activity: Bilirubin
*[[liver disease induced coagulopathy|Coags]]
**Hepatocyte synthetic function
*Albumin
**Hepatocyte synthetic function
*Ammonia
**Hepatocyte catabolic activity
*[[viral hepatitis|Acute hepatitis panel]]
*Lipase
*[[Urinalysis]]
*?[[RUQ ultrasound|US]] vs. CT vs MRCP
*?Retic count
*?Haptoglobin/LDH
*?APAP/ASA/Utox/ETOH


- Excreted into the biliary tract in conjugated form
===[[Liver function tests]]===
====Transaminases====
*Transaminases  in hundreds associated with mild injury; thousands suggests extensive injury
*Elevations <5x normal typical of alcoholic liver disease
*AST:ALT ratio > 2 common in [[acute alcoholic hepatitis]] (alcohol stimulates AST production)
*May be normal in end-stage liver failure
*ALT more specific marker of hepatocyte injury than AST
====Alk phos====
*Mild to moderate elevations accompany virtually all hepatobiliary disease
*Elevations > 4x normal suggest cholestasis
====GGT====
*Elevation in setting of hepatitis suggestive of alcoholic etiology
====LDH====
*Moderate elevations are seen in all hepatocellular disorders and cirrhosis
*Hemolysis results in elevation of LDH and unconjugated bili
====[[hyperammonemia|Ammonia]]====
*Elevation does NOT correlate with acute worsening of hepatic function in cirrhotic patient
*Serves as marker of generalized decline than as diagnostic tool or therapeutic end point


== ==
====Coagulation Markers (PT/PTT/INR)====
*Marker of synthetic function
*Correlation between PT prolongation and clinical outcome in fulminant liver disease
====Albumin====
*Marker of synthetic function
**Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease
*Low levels also seen in malnutrition


 
==Management==
==Workup==
*Management is dependent on the diagnosis of either conjugated or unconjugated hyperblirubinemia and the severity of the elevation
 
 
1) Icon
 
2) CBC
 
3) Chem 7
 
4) LFTs
 
5) Lipase
 
6) UA
 
7) Coags
 
8) ?Ammonia
 
9) ?US vs. CT
 
10) ?Retic count
 
11) ?Haptoglobin/LDH
 
12) ?Tylenol/ASA/Utox/ETOH
 
 
==Diagnosis==
 
 
Masqueraders:
 
-Carotenemia
 
-Quinacrine ingestion
 
-Dinitrophenol, teryl (explosive chemicals)
 
 
NB: Only bilirubin stains the sclera
 
 
==DDX==
 
 
I. Indirect >> direct (Hematologic)
 
[near nl AST/ALT/Alk P/PT/PTT]
 
    A. Hemolytic
 
          i) G6PD
 
          ii) Drug related
 
          iii) Autoimmune
 
    B. Hematoma resorption
 
    C. Infective erythropoiesis
 
    D. Gilbert's
 
I. Direct >> indirect
 
    A. Increased Alk P (Obstructive)
 
    [nl to mild inc AST/ALT]
 
          1) Choledocholithiasis
 
          2) Cholecystitis
 
          3) Cholangitis (Ascending)
 
          4) AIDS cholangiopathy
 
          5) Stricture
 
          6) Neoplasm
 
              i) Panc head
 
              ii) Gallbladder
 
              iii) Primary liver
 
              iv) Metastatic
 
          7) Obstructing AAA
 
    B. Nl Alk P (Hepatocellular/cholestatic)
 
    [greatly elevated AST/ALT]
 
          1) Viral hepatitis
 
          2) Fulminant hepatic failure
 
          3) ETOH hepatitis
 
          4) Ischemia
 
          5) Toxins
 
              i) isoniazide
 
              ii) phenytoin
 
              iii) acetaminophen
 
              iv) ritonavir
 
              v) halothane
 
              vi) sulronamide
 
          6) Autoimmune hepatitis
 
              i) 1 biliary cirhosis
 
          7) HELLP syndrome
 
          8) Congestive
 
              i) CHF
 
              ii) Sepsis
 
 
===Pregnancy Related===
 
 
1) HELP
 
2) Acute fatty liver
 
3) Hyperemesis gravidarum
 
4) Cholestasis of pregnancy
 
 
===Transplant Related===
 
 
1) Transplant regection
 
2) Graft-vs-host
 
 
===Peds Related===
 
 
Inborn error of metabolism
 
Physiologic neonatal
 
=== ===
 
 
===Additional DDX===
 
 
Reye's syndrome
 
TPN
 
Heatstroke
 
Budd-Chiari (with acute ascites)
 
Wilson's
 
Sarcoidosis
 
Amyloidosis
 


==Disposition==
==Disposition==
 
===New Onset Jaundice Admission Criteria===
 
*Transaminase >1,000 IU/L
NEW ONSET JAUNDICE ADMIT CRITERIA
*Tbil >10mg/dL
 
*Evidence coagulopathy
1) Transaminase >1000IU/L
 
2) Tbil >10mg/dL
 
3) Evidence coagulopathy
 


==See Also==
==See Also==
*[[Neonatal Jaundice]]
*[[Acute hepatitis]]
*[[Viral hepatitis]]
*[[Acute hepatic failure]]
*[[Cirrhosis]]
*[[Ascites]]


 
==References==
Peds: Neonatal Jaundice
<references/>
 
GI: Viral Hepatis
 
 
==Source ==
 
 
3/14/06 DONALDSON (adapted from Rosen), H-N
 
 
 


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]

Latest revision as of 05:59, 20 August 2022

For neonatal jaundice please see the Neonatal jaundice page

Background

Cycle of heme breakdown and excretion.
  • Bilirubin is end product of heme metabolism
  • All bilirubin products in the body are initially unconjugated and is transported bound to albumin into hepatocytes t o becombined with glucuronic acid into conjugated bilirubin
  • Conjugated bilirubin is then excreted into biliary tract
  • Only conjugated bilirubin is water-soluble (present in urine)
  • Normal bilirubin level is <1.1 (70% unconjugated)

Jaundice Types

Prehepatic (overproduction):

Hepatic (inadequate processing):

Posthepatic (underexcretion):

Clinical Features

Jaundice of the skin
Pediatric jaundice with icterus of sclera.
  • Yellow skin, sclera
  • +/- dark urine

Differential Diagnosis

Jaundice

Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis

Masqueraders

Only bilirubin stains the sclera

  • Carotenemia
  • Quinacrine ingestion
  • Dinitrophenol, teryl (explosive chemicals)

Evaluation

Evaluation algorithm
Lab test for jaundice
  • Urine pregnancy
  • CBC
  • Chemistry
  • LFTs
    • Hepatocyte injury: AST, ALT, alk phos
    • Hepatocyte catabolic activity: Bilirubin
  • Coags
    • Hepatocyte synthetic function
  • Albumin
    • Hepatocyte synthetic function
  • Ammonia
    • Hepatocyte catabolic activity
  • Acute hepatitis panel
  • Lipase
  • Urinalysis
  • ?US vs. CT vs MRCP
  • ?Retic count
  • ?Haptoglobin/LDH
  • ?APAP/ASA/Utox/ETOH

Liver function tests

Transaminases

  • Transaminases in hundreds associated with mild injury; thousands suggests extensive injury
  • Elevations <5x normal typical of alcoholic liver disease
  • AST:ALT ratio > 2 common in acute alcoholic hepatitis (alcohol stimulates AST production)
  • May be normal in end-stage liver failure
  • ALT more specific marker of hepatocyte injury than AST

Alk phos

  • Mild to moderate elevations accompany virtually all hepatobiliary disease
  • Elevations > 4x normal suggest cholestasis

GGT

  • Elevation in setting of hepatitis suggestive of alcoholic etiology

LDH

  • Moderate elevations are seen in all hepatocellular disorders and cirrhosis
  • Hemolysis results in elevation of LDH and unconjugated bili

Ammonia

  • Elevation does NOT correlate with acute worsening of hepatic function in cirrhotic patient
  • Serves as marker of generalized decline than as diagnostic tool or therapeutic end point

Coagulation Markers (PT/PTT/INR)

  • Marker of synthetic function
  • Correlation between PT prolongation and clinical outcome in fulminant liver disease

Albumin

  • Marker of synthetic function
    • Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease
  • Low levels also seen in malnutrition

Management

  • Management is dependent on the diagnosis of either conjugated or unconjugated hyperblirubinemia and the severity of the elevation

Disposition

New Onset Jaundice Admission Criteria

  • Transaminase >1,000 IU/L
  • Tbil >10mg/dL
  • Evidence coagulopathy

See Also

References

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