Jaundice: Difference between revisions

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''For neonatal jaundice please see the [[Neonatal jaundice]] page''
==Background==
==Background==
[[File:Heme Breakdown.png|thumb|Cycle of heme breakdown and excretion.]]
*Bilirubin is end product of heme metabolism
*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 hepatocytes; combine with glucuronic acid into conj bili
*Conjugated bilirubin is then excreted into biliary tract
***Excreted into biliary tract in conjugated form
*Only conjugated bilirubin is water-soluble (present in urine)
*Only conjugated bilirubin is water-soluble (present in urine)
*Nl bilirubin level is <1.1, 70% unconjugated
*Normal bilirubin level is <1.1 (70% unconjugated)


===Jaundice Types===
===Jaundice Types===
**Prehepatic (overproduction)
'''Prehepatic (overproduction):'''
***Hemolysis
*[[hemolytic anemia|Hemolysis]]
***Primarily unconj bili
*Primarily unconjugated bili
**Hepatic (inadequate processing)
'''Hepatic (inadequate processing):'''
***Viral, alcohol, toxin
*[[viral hepatitis|Viral]], [[alcoholic hepatitis|alcohol]], toxin
***Primarily unconj bili
*Primarily unconjugated bili
**Posthepatic (underexcretion)
'''Posthepatic (underexcretion):'''
***Pancreatic tumor, choledocholithiasis
*Pancreatic tumor, [[choledocholithiasis]]
***Primarily conj bili
*Primarily conjugated bili


===Liver Function Tests===
==Clinical Features==
#Transaminases
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
##Transaminitis in hundreds a/w mild injury; thousands suggests extensive injury
[[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]]
##Elevations <5x normal typical of alcoholic liver disease
*Yellow skin, sclera
##AST:ALT ratio > 2 common in alcoholic hepatitis (alcohol stimulates AST production)
*+/- dark urine
##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==
==Differential Diagnosis==
#Urine pregnancy
{{Jaundice DDX}}
#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==
==Evaluation==
Masqueraders:
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]
#Carotenemia
[[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]]
#Quinacrine ingestion
*Urine pregnancy
#Dinitrophenol, teryl (explosive chemicals)
*CBC
*Chemistry
*[[LFTs]]
**Hepatocyte injury: AST, ALT, alk phos
**Hepatocyte catabolic activity: Bilirubin
*[[liver disease induced coagulopathy|Coags]]
**Hepatocyte synthetic function
*Albumin
**Hepatocyte synthetic function
*Ammonia
**Hepatocyte catabolic activity
*[[viral hepatitis|Acute hepatitis panel]]
*Lipase
*[[Urinalysis]]
*?[[RUQ ultrasound|US]] vs. CT vs MRCP
*?Retic count
*?Haptoglobin/LDH
*?APAP/ASA/Utox/ETOH


NB: Only bilirubin stains the sclera
===[[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
====[[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


==DDX==
====Coagulation Markers (PT/PTT/INR)====
#Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
*Marker of synthetic function
##Hemolytic
*Correlation between PT prolongation and clinical outcome in fulminant liver disease
###G6PD
====Albumin====
###Drug related
*Marker of synthetic function
###Autoimmune
**Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease
##Hematoma resorption
*Low levels also seen in malnutrition
##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
###ritonavir
###halothane
###sulronamide
##Autoimmune hepatitis
###1 biliary cirhosis
##HELLP syndrome
##Congestive
###CHF
###Sepsis


===Pregnancy Related===
==Management==
#HELP
*Management is dependent on the diagnosis of either conjugated or unconjugated hyperblirubinemia and the severity of the elevation
#Acute fatty liver
#Hyperemesis gravidarum
#Cholestasis of pregnancy
 
===Transplant Related===
#Transplant regection
#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==
==Disposition==
New Onset Jaundice Admission 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==
*[[Neonatal Jaundice]]
*[[Neonatal Jaundice]]
*[[Hepatitis]]
*[[Acute hepatitis]]
*[[Viral hepatitis]]
*[[Acute hepatic failure]]
*[[Cirrhosis]]
*[[Ascites]]


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


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

Latest revision as of 05:59, 20 August 2022

For neonatal jaundice please see the Neonatal jaundice page

Background

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):

Hepatic (inadequate processing):

Posthepatic (underexcretion):

Clinical Features

Jaundice of the skin
Pediatric jaundice with icterus of sclera.
  • Yellow skin, sclera
  • +/- dark urine

Differential Diagnosis

Jaundice

Differential diagnosis of hyperbilirubinemia.

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
Lab test for jaundice
  • Urine pregnancy
  • CBC
  • Chemistry
  • LFTs
    • 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 vs MRCP
  • ?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

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