Jaundice: Difference between revisions
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===Liver Function Tests===
===Liver Function Tests===
*Transaminases
====Transaminases====
**Transaminitis in hundreds a/w mild injury; thousands suggests extensive injury
*Transaminitis in hundreds a/w mild injury; thousands suggests extensive injury
**Elevations <5x normal typical of alcoholic liver disease
*Elevations <5x normal typical of alcoholic liver disease
**AST:ALT ratio > 2 common in alcoholic hepatitis (alcohol stimulates AST production)
*AST:ALT ratio > 2 common in alcoholic hepatitis (alcohol stimulates AST production)
**May be normal in end-stage liver failure
*May be normal in end-stage liver failure
**ALT more specific marker of hepatocyte injury than AST
*ALT more specific marker of hepatocyte injury than AST
*Alk phos
====Alk phos====
**Mild to moderate elevations accompany virtually all hepatobiliary disease
*Mild to moderate elevations accompany virtually all hepatobiliary disease
**Elevations > 4x normal suggest cholestasis
*Elevations > 4x normal suggest cholestasis
*GGT
====GGT====
**Elevation in setting of hepatitis suggestive of alcoholic etiology
*Elevation in setting of hepatitis suggestive of alcoholic etiology
*LDH
====LDH====
**Moderate elevations are seen in all hepatocellular disorders and cirrhosis
*Moderate elevations are seen in all hepatocellular disorders and cirrhosis
**Hemolysis results in elevation of LDH and unconj bili
*Hemolysis results in elevation of LDH and unconj bili
*Ammonia
====Ammonia====
**Elevation doesn't correlate w/ acute worsening of hepatic function in cirrhotic pt
*Elevation doesn't correlate w/ acute worsening of hepatic function in cirrhotic pt
**Serve as marker of generalized decline than as diagnostic tool or therapeutic end point
*Serve as marker of generalized decline than as diagnostic tool or therapeutic end point
*Coags
====Coagulation Markers (PT/PTT/INR)====
**Marker of synthetic function
*Marker of synthetic function
**Correlation between PT prolongation and clinical outcome in fulminant liver disease
*Correlation between PT prolongation and clinical outcome in fulminant liver disease
*Albumin
====Albumin====
**Marker of synthetic function
*Marker of synthetic function
***Half-life is 3wk so less useful than PT in evaluating fulminant liver disease
**Half-life is 3wk so less useful than PT in evaluating fulminant liver disease
**Low levels also seen in malnutrition
*Low levels also seen in malnutrition


==Differential Diagnosis==
==Differential Diagnosis==

Revision as of 14:27, 10 May 2015

Background

  • Bilirubin is end product of heme metabolism
    • All bilirubin products in the body are initially unconjugated
    • Transported from albumin into hepatocytes; combine with glucuronic acid into conj bili
      • Excreted into biliary tract in conjugated form
  • Only conjugated bilirubin is water-soluble (present in urine)
  • Nl bilirubin level is <1.1, 70% unconjugated

Jaundice Types

  • Prehepatic (overproduction)
    • Hemolysis
    • Primarily unconj bili
  • Hepatic (inadequate processing)
    • Viral, alcohol, toxin
    • Primarily unconj bili
  • Posthepatic (underexcretion)
    • Pancreatic tumor, choledocholithiasis
    • Primarily conj bili

Liver Function Tests

Transaminases

  • Transaminitis in hundreds a/w mild injury; thousands suggests extensive injury
  • Elevations <5x normal typical of alcoholic liver disease
  • AST:ALT ratio > 2 common in 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 unconj bili

Ammonia

  • Elevation doesn't correlate w/ acute worsening of hepatic function in cirrhotic pt
  • Serve 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 3wk so less useful than PT in evaluating fulminant liver disease
  • Low levels also seen in malnutrition

Differential Diagnosis

Classification of Hyperbilirubinemia.jpeg
  • Indirect >> direct: (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
    • Hemolytic
      • G6PD
      • Drug related
      • Autoimmune
    • Hematoma resorption
    • Infective erythropoiesis
    • Gilbert's
  • Direct >> indirect: Increased Alk P (Obstructive) [nl to mild inc AST/ALT]
  • Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]

Pregnancy Related

Transplant Related

  • Transplant rejection
  • Graft-vs-host

Peds Related

  • Inborn error of metabolism
  • Physiologic neonatal

Additional Differential Diagnosis

Masqueraders

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

Only bilirubin stains the sclera

Diagnosis

Evaluation algorithm

Workup

  • Urine pregnancy
  • CBC
  • Chemistry
  • LFT
    • 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
  • UA
  • ?US vs. CT
  • ?Retic count
  • ?Haptoglobin/LDH
  • ?APAP/ASA/Utox/ETOH

Disposition

New Onset Jaundice Admission Criteria

  • Transaminase >1000IU/L
  • Tbil >10mg/dL
  • Evidence coagulopathy

See Also

References

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