Jaundice: Difference between revisions
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''For neonatal jaundice please see the [[Neonatal jaundice]] page'' | |||
==Background== | ==Background== | ||
*Bilirubin is end product of heme metabolism | *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) | *Only conjugated bilirubin is water-soluble (present in urine) | ||
* | *Normal bilirubin level is <1.1 (70% unconjugated) | ||
===Jaundice Types=== | ===Jaundice Types=== | ||
'''Prehepatic (overproduction):''' | |||
*Hemolysis | |||
*Primarily unconjugated bili | |||
'''Hepatic (inadequate processing):''' | |||
*Viral, alcohol, toxin | |||
*Primarily unconjugated bili | |||
'''Posthepatic (underexcretion):''' | |||
*Pancreatic tumor, [[choledocholithiasis]] | |||
*Primarily conjugated bili | |||
=== | ==Clinical Features== | ||
* | |||
** | |||
** | ==Differential Diagnosis== | ||
**AST | [[File:Classification of Hyperbilirubinemia.jpeg|thumb]] | ||
** | ===Indirect Hyperbilirubinemia=== | ||
** | *Hemolytic | ||
* | **[[G6PD]] | ||
** | **Drug related | ||
** | **[[Autoimmune hemolytic anemia]] | ||
* | *Hematoma resorption | ||
** | *Ineffective erythropoiesis | ||
* | *Gilbert's | ||
** | ===Direct (Conjugated) Hyperbilirubinemia=== | ||
** | *[[Choledocholithiasis]] | ||
* | *[[Cholecystitis]] | ||
** | *Ascending [[cholangitis]] | ||
** | *[[AIDS]] cholangiopathy | ||
* | *Stricture | ||
* | *Neoplasm | ||
** | **Pancreatic head | ||
* | **Gallbladder | ||
** | **Primary liver (e.g. [[hepatocellular carcinoma]] | ||
*** | **Metastatic | ||
** | *Obstructing [[AAA]] | ||
===Hepatocellular damage=== | |||
''Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase'' | |||
*[[Viral hepatitis]] | |||
*[[Acute liver failure|Fulminant hepatic failure]] | |||
*[[alcoholic hepatitis]] | |||
*Ischemia | |||
*Toxins | |||
**[[Isoniazid]] | |||
**[[Phenytoin]] | |||
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]] | |||
**Ritonavir | |||
**Halothane | |||
**Sulronamide | |||
*[[Autoimmune hepatitis]] | |||
**Primary biliary cirrhosis | |||
*[[HELLP Syndrome]] | |||
*Congestive Hepatopathy | |||
**[[CHF]] | |||
**[[Sepsis]] (Shock Liver) | |||
===Pregnancy Related=== | |||
*[[HELLP Syndrome]] | |||
*Acute fatty liver | |||
*[[Hyperemesis gravidarum]] | |||
*[[Cholestasis of pregnancy]] | |||
===Transplant Related=== | |||
*[[Transplant complications|Transplant rejection]] | |||
*[[Graft-vs-host disease]] | |||
===Pediatric Related=== | |||
*[[Inborn error of metabolism]] | |||
*[[Neonatal jaundice]] (physiologic) | |||
===Additional Differential Diagnosis=== | |||
*[[Reye syndrome]] | |||
*TPN | |||
*[[Heatstroke]] | |||
*[[Budd-Chiari]] (with acute ascites) | |||
*[[Wilson's disease]] | |||
*[[Sarcoidosis]] | |||
*[[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 | *Urine pregnancy | ||
*CBC | *CBC | ||
Line 59: | Line 109: | ||
*Acute hepatitis panel | *Acute hepatitis panel | ||
*Lipase | *Lipase | ||
* | *[[Urinalysis]] | ||
*?US vs. CT | *?US vs. CT | ||
*?Retic count | *?Retic count | ||
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*?APAP/ASA/Utox/ETOH | *?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 Admission Criteria | ===New Onset Jaundice Admission Criteria=== | ||
*Transaminase > | *Transaminase >1,000 IU/L | ||
*Tbil >10mg/dL | *Tbil >10mg/dL | ||
*Evidence coagulopathy | *Evidence coagulopathy | ||
Line 144: | Line 153: | ||
==See Also== | ==See Also== | ||
*[[Neonatal Jaundice]] | *[[Neonatal Jaundice]] | ||
*[[Acute | *[[Acute hepatitis]] | ||
*[[Viral | *[[Viral hepatitis]] | ||
*[[Acute hepatic failure]] | |||
== | ==References== | ||
<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):
- Pancreatic tumor, choledocholithiasis
- Primarily conjugated bili
Clinical Features
Differential Diagnosis
Indirect Hyperbilirubinemia
- Hemolytic
- G6PD
- Drug related
- Autoimmune hemolytic anemia
- Hematoma resorption
- Ineffective erythropoiesis
- Gilbert's
Direct (Conjugated) Hyperbilirubinemia
- Choledocholithiasis
- Cholecystitis
- Ascending cholangitis
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Pancreatic head
- Gallbladder
- Primary liver (e.g. hepatocellular carcinoma
- Metastatic
- Obstructing AAA
Hepatocellular damage
Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase
- Viral hepatitis
- Fulminant hepatic failure
- alcoholic hepatitis
- Ischemia
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulronamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
- HELLP Syndrome
- Acute fatty liver
- Hyperemesis gravidarum
- Cholestasis of pregnancy
Transplant Related
Pediatric Related
- Inborn error of metabolism
- Neonatal jaundice (physiologic)
Additional Differential Diagnosis
- Reye syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's disease
- Sarcoidosis
- Amyloidosis
Masqueraders
Only bilirubin stains the sclera
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
Evaluation
- 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