Jaundice: Difference between revisions

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''For neonatal jaundice please see the [[Neonatal jaundice]] page''
==Background==
==Background==
#One end product of heme metabolism; remainder from myoglobin
*Bilirubin is end product of heme metabolism
#All bilirubin products in the body are initially UNconjugated
*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
#Transported from albumin into liver cells; combined with glucuronic acid into conjugated bilirubin
*Conjugated bilirubin is then excreted into biliary tract
#Excreted into the biliary tract in conjugated form
*Only conjugated bilirubin is water-soluble (present in urine)
*Normal bilirubin level is <1.1 (70% unconjugated)


==Workup==
===Jaundice Types===
#Icon
'''Prehepatic (overproduction):'''
#CBC
*Hemolysis
#Chem 7
*Primarily unconjugated bili
#LFTs
'''Hepatic (inadequate processing):'''
#Lipase
*Viral, alcohol, toxin
#UA
*Primarily unconjugated bili
#Coags
'''Posthepatic (underexcretion):'''
#?Ammonia
*Pancreatic tumor, [[choledocholithiasis]]
#?US vs. CT
*Primarily conjugated bili
#?Retic count
#?Haptoglobin/LDH
#?Tylenol/ASA/Utox/ETOH


==Diagnosis==
==Clinical Features==
Masqueraders:
#Carotenemia
#Quinacrine ingestion
#Dinitrophenol, teryl (explosive chemicals)


NB: Only bilirubin stains the sclera


==DDX==
==Differential Diagnosis==
#Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
[[File:Classification of Hyperbilirubinemia.jpeg|thumb]]
##Hemolytic
===Indirect Hyperbilirubinemia===
###G6PD
*Hemolytic
###Drug related
**[[G6PD]]
###Autoimmune
**Drug related
##Hematoma resorption
**[[Autoimmune hemolytic anemia]]
##Infective erythropoiesis
*Hematoma resorption
##Gilbert's
*Ineffective erythropoiesis
#Direct >> indirect
*Gilbert's
##Increased Alk P (Obstructive) [nl to mild inc AST/ALT]
===Direct (Conjugated) Hyperbilirubinemia===
##Choledocholithiasis
*[[Choledocholithiasis]]
##Cholecystitis
*[[Cholecystitis]]
##Cholangitis (Ascending)
*Ascending [[cholangitis]]
##AIDS cholangiopathy
*[[AIDS]] cholangiopathy
##Stricture
*Stricture
##Neoplasm
*Neoplasm
###Panc head
**Pancreatic head
###Gallbladder
**Gallbladder
###Primary liver
**Primary liver (e.g. [[hepatocellular carcinoma]]
###Metastatic
**Metastatic
##Obstructing AAA
*Obstructing [[AAA]]
#Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]
===Hepatocellular damage===
##Viral hepatitis
''Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase''
##Fulminant hepatic failure
*[[Viral hepatitis]]
##ETOH hepatitis
*[[Acute liver failure|Fulminant hepatic failure]]
##Ischemia
*[[alcoholic hepatitis]]
##Toxins
*Ischemia
###isoniazide
*Toxins
###phenytoin
**[[Isoniazid]]
###acetaminophen
**[[Phenytoin]]
###ritonavir
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]]
###halothane
**Ritonavir
###sulronamide
**Halothane
##Autoimmune hepatitis
**Sulronamide
###1 biliary cirhosis
*[[Autoimmune hepatitis]]
##HELLP syndrome
**Primary biliary cirrhosis
##Congestive
*[[HELLP Syndrome]]
###CHF
*Congestive Hepatopathy
###Sepsis
**[[CHF]]
**[[Sepsis]] (Shock Liver)


===Pregnancy Related===
===Pregnancy Related===
#HELP
*[[HELLP Syndrome]]
#Acute fatty liver
*Acute fatty liver
#Hyperemesis gravidarum
*[[Hyperemesis gravidarum]]
#Cholestasis of pregnancy
*[[Cholestasis of pregnancy]]


===Transplant Related===
===Transplant Related===
#Transplant regection
*[[Transplant complications|Transplant rejection]]
#Graft-vs-host
*[[Graft-vs-host disease]]


===Peds Related===
===Pediatric Related===
#Inborn error of metabolism
*[[Inborn error of metabolism]]
#Physiologic neonatal
*[[Neonatal jaundice]] (physiologic)


===Additional DDX===
===Additional Differential Diagnosis===
#Reye's syndrome
*[[Reye syndrome]]
#TPN
*TPN
#Heatstroke
*[[Heatstroke]]
#Budd-Chiari (with acute ascites)
*[[Budd-Chiari]] (with acute ascites)
#Wilson's
*[[Wilson's disease]]
#Sarcoidosis
*[[Sarcoidosis]]
#Amyloidosis
*[[Amyloidosis]]
 
===Masqueraders===
''Only bilirubin stains the sclera''
*[[Carotenemia]]
*Quinacrine ingestion
*Dinitrophenol, teryl (explosive chemicals)
 
==Evaluation==
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]
[[File:Ddx for jaundice by labs.gif|thumbnail]]
*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
*[[Urinalysis]]
*?US vs. CT
*?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==
==Disposition==
NEW ONSET JAUNDICE ADMIT CRITERIA
===New Onset Jaundice Admission Criteria===
#Transaminase >1000IU/L
*Transaminase >1,000 IU/L
#Tbil >10mg/dL
*Tbil >10mg/dL
#Evidence coagulopathy
*Evidence coagulopathy


==See Also==
==See Also==
Peds: Neonatal Jaundice
*[[Neonatal Jaundice]]
 
*[[Acute hepatitis]]
GI: Viral Hepatis
*[[Viral hepatitis]]
*[[Acute hepatic failure]]


==Source ==
==References==
3/14/06 DONALDSON (adapted from Rosen), H-N
<references/>


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

Revision as of 18:31, 27 January 2019

For neonatal jaundice please see the Neonatal jaundice page

Background

  • 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):

  • Hemolysis
  • Primarily unconjugated bili

Hepatic (inadequate processing):

  • Viral, alcohol, toxin
  • Primarily unconjugated bili

Posthepatic (underexcretion):

Clinical Features

Differential Diagnosis

Classification of Hyperbilirubinemia.jpeg

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
Ddx for jaundice by labs.gif
  • 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
  • Urinalysis
  • ?US vs. CT
  • ?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