View source for Jaundice

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''For neonatal jaundice please see the [[Special:MyLanguage/Neonatal jaundice|Neonatal jaundice]] page''

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


==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


==Differential Diagnosis==

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{{Jaundice DDX}}
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==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
*[[Special:MyLanguage/LFTs|LFTs]]
**Hepatocyte injury: AST, ALT, alk phos
**Hepatocyte catabolic activity: Bilirubin
*[[Special:MyLanguage/liver disease induced coagulopathy|Coags]]
**Hepatocyte synthetic function
*Albumin
**Hepatocyte synthetic function
*Ammonia
**Hepatocyte catabolic activity
*[[Special:MyLanguage/viral hepatitis|Acute hepatitis panel]]
*Lipase
*[[Special:MyLanguage/Urinalysis|Urinalysis]]
*?[[Special:MyLanguage/RUQ ultrasound|US]] vs. CT vs MRCP
*?Retic count
*?Haptoglobin/LDH
*?APAP/ASA/Utox/ETOH


===[[Special:MyLanguage/Liver function tests|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 [[Special:MyLanguage/acute alcoholic hepatitis|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

====[[Special:MyLanguage/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==

*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==

*[[Special:MyLanguage/Neonatal Jaundice|Neonatal Jaundice]]
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]]
*[[Special:MyLanguage/Ascites|Ascites]]


==References==

<references/>

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