Jaundice: Difference between revisions

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==Differential Diagnosis==
==Differential Diagnosis==
[[File:Classification of Hyperbilirubinemia.jpeg|thumb]]
[[File:Classification of Hyperbilirubinemia.jpeg|thumb]]
*Indirect >> direct: ('''Hematologic''') [near nl AST/ALT/Alk P/PT/PTT]
===Indirect Hyperbilirubinemia===
**Hemolytic
*Hemolytic
***G6PD
**G6PD
***Drug related
**Drug related
***Autoimmune
**Autoimmune
**Hematoma resorption
*Hematoma resorption
**Infective erythropoiesis
*Infective erythropoiesis
**Gilbert's
*Gilbert's
*Direct >> indirect: Increased Alk P ('''Obstructive''') [nl to mild inc AST/ALT]
===Direct (Conjugated) Hyperbilirubinemia===
**[[Choledocholithiasis]]
*[[Choledocholithiasis]]
**[[Cholecystitis]]
*[[Cholecystitis]]
**[[Ascending cholangitis]]
*[[Ascending cholangitis]]
**[[AIDS]] cholangiopathy
*[[AIDS]] cholangiopathy
**Stricture
*Stricture
**Neoplasm
*Neoplasm
***Panc head
**Pancreatic head
***Gallbladder
**Gallbladder
***Primary liver
**Primary liver
***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
*Fulminant hepatic failure
**Ischemia
*ETOH hepatitis
**Toxins
*Ischemia
***isoniazide
*Toxins
***[[phenytoin]]
**Isoniazide
***[[Acetaminophen (Tylenol) Toxicity|acetaminophen]]
**[[Phenytoin]]
***ritonavir
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]]
***halothane
**Ritonavir
***sulronamide
**Halothane
**Autoimmune [[hepatitis]]
**Sulronamide
***Primary biliary cirhosis
*Autoimmune [[hepatitis]]
**[[HELLP Syndrome]]
**Primary biliary cirhosis
**Congestive
*[[HELLP Syndrome]]
***[[CHF]]
*Congestive Hepatopathy
***[[Sepsis]]
**[[CHF]]
**[[Sepsis]] (Shock Liver)


===Pregnancy Related===
===Pregnancy Related===
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*Dinitrophenol, teryl (explosive chemicals)
*Dinitrophenol, teryl (explosive chemicals)
''Only bilirubin stains the sclera''
''Only bilirubin stains the sclera''
==Diagnosis==
==Diagnosis==
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]

Revision as of 14:43, 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 Hyperbilirubinemia

  • Hemolytic
    • G6PD
    • Drug related
    • Autoimmune
  • Hematoma resorption
  • Infective erythropoiesis
  • Gilbert's

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

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

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