Jaundice: Difference between revisions
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===Liver Function Tests=== | ===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 | |||
*Coags | |||
**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 | |||
==Workup== | ==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 | |||
==Diagnosis== | ==Diagnosis== | ||
Masqueraders: | Masqueraders: | ||
*Carotenemia | |||
*Quinacrine ingestion | |||
*Dinitrophenol, teryl (explosive chemicals) | |||
NB: Only bilirubin stains the sclera | NB: Only bilirubin stains the sclera | ||
==DDX== | ==DDX== | ||
*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] | |||
**Choledocholithiasis | |||
**[[Cholecystitis]] | |||
**Cholangitis (Ascending) | |||
**[[AIDS]] cholangiopathy | |||
**Stricture | |||
**Neoplasm | |||
***Panc head | |||
***Gallbladder | |||
***Primary liver | |||
***Metastatic | |||
**Obstructing [[AAA]] | |||
*Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT] | |||
**Viral [[hepatitis]] | |||
**Fulminant hepatic failure | |||
**ETOH hepatitis | |||
**Ischemia | |||
**Toxins | |||
***isoniazide | |||
***phenytoin | |||
***[[Acetaminophen (Tylenol) Toxicity|acetaminophen]] | |||
***ritonavir | |||
***halothane | |||
***sulronamide | |||
**Autoimmune [[hepatitis]] | |||
***1 biliary cirhosis | |||
**[[HELLP Syndrome]] | |||
**Congestive | |||
***[[CHF]] | |||
***[[Sepsis]] | |||
===Pregnancy Related=== | ===Pregnancy Related=== | ||
*[[HELLP Syndrome]] | |||
*Acute fatty liver | |||
*Hyperemesis gravidarum | |||
*Cholestasis of pregnancy | |||
===Transplant Related=== | ===Transplant Related=== | ||
*Transplant rejection | |||
*Graft-vs-host | |||
===Peds Related=== | ===Peds Related=== | ||
*Inborn error of metabolism | |||
*Physiologic neonatal | |||
===Additional DDX=== | ===Additional DDX=== | ||
*Reye's syndrome | |||
*TPN | |||
*Heatstroke | |||
*Budd-Chiari (with acute ascites) | |||
*Wilson's | |||
*Sarcoidosis | |||
*Amyloidosis | |||
==Disposition== | ==Disposition== | ||
New Onset Jaundice Admission Criteria | New Onset Jaundice Admission Criteria | ||
*Transaminase >1000IU/L | |||
*Tbil >10mg/dL | |||
*Evidence coagulopathy | |||
==See Also== | ==See Also== | ||
Revision as of 19:37, 13 March 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
- Coags
- 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
- Marker of synthetic function
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
Diagnosis
Masqueraders:
- Carotenemia
- Quinacrine ingestion
- Dinitrophenol, teryl (explosive chemicals)
NB: Only bilirubin stains the sclera
DDX
- Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
- Hemolytic
- G6PD
- Drug related
- Autoimmune
- Hematoma resorption
- Infective erythropoiesis
- Gilbert's
- Hemolytic
- Direct >> indirect
- Increased Alk P (Obstructive) [nl to mild inc AST/ALT]
- Choledocholithiasis
- Cholecystitis
- Cholangitis (Ascending)
- AIDS cholangiopathy
- Stricture
- Neoplasm
- Panc head
- Gallbladder
- Primary liver
- Metastatic
- Obstructing AAA
- Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]
- Viral hepatitis
- Fulminant hepatic failure
- ETOH hepatitis
- Ischemia
- Toxins
- isoniazide
- phenytoin
- acetaminophen
- ritonavir
- halothane
- sulronamide
- Autoimmune hepatitis
- 1 biliary cirhosis
- HELLP Syndrome
- Congestive
Pregnancy Related
- HELLP Syndrome
- Acute fatty liver
- Hyperemesis gravidarum
- Cholestasis of pregnancy
Transplant Related
- Transplant rejection
- Graft-vs-host
Peds Related
- Inborn error of metabolism
- Physiologic neonatal
Additional DDX
- Reye's syndrome
- TPN
- Heatstroke
- Budd-Chiari (with acute ascites)
- Wilson's
- Sarcoidosis
- Amyloidosis
Disposition
New Onset Jaundice Admission Criteria
- Transaminase >1000IU/L
- Tbil >10mg/dL
- Evidence coagulopathy
See Also
Source
- Tintinalli
- Rosen's