Jaundice: Difference between revisions
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''For neonatal jaundice please see the [[Neonatal jaundice]] page'' | <languages/> | ||
<translate> | |||
''For neonatal jaundice please see the [[Special:MyLanguage/Neonatal jaundice|Neonatal jaundice]] page'' | |||
==Background== | ==Background== | ||
[[File:Heme Breakdown.png|thumb|Cycle of heme breakdown and excretion.]] | [[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 | ||
| Line 7: | Line 11: | ||
*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) | *Normal bilirubin level is <1.1 (70% unconjugated) | ||
===Jaundice Types=== | ===Jaundice Types=== | ||
'''Prehepatic (overproduction):''' | '''Prehepatic (overproduction):''' | ||
*[[hemolytic anemia|Hemolysis]] | *[[Special:MyLanguage/hemolytic anemia|Hemolysis]] | ||
*Primarily unconjugated bili | *Primarily unconjugated bili | ||
'''Hepatic (inadequate processing):''' | '''Hepatic (inadequate processing):''' | ||
*[[viral hepatitis|Viral]], [[alcoholic hepatitis|alcohol]], toxin | *[[Special:MyLanguage/viral hepatitis|Viral]], [[Special:MyLanguage/alcoholic hepatitis|alcohol]], toxin | ||
*Primarily unconjugated bili | *Primarily unconjugated bili | ||
'''Posthepatic (underexcretion):''' | '''Posthepatic (underexcretion):''' | ||
*Pancreatic tumor, [[choledocholithiasis]] | *Pancreatic tumor, [[Special:MyLanguage/choledocholithiasis|choledocholithiasis]] | ||
*Primarily conjugated bili | *Primarily conjugated bili | ||
==Clinical Features== | ==Clinical Features== | ||
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]] | [[File:Jaundice08.jpg|thumb|Jaundice of the skin]] | ||
[[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]] | [[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]] | ||
*Yellow skin, sclera | *Yellow skin, sclera | ||
*+/- dark urine | *+/- dark urine | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
</translate> | |||
{{Jaundice DDX}} | {{Jaundice DDX}} | ||
<translate> | |||
==Evaluation== | ==Evaluation== | ||
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]] | [[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]] | ||
[[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]] | [[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]] | ||
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*CBC | *CBC | ||
*Chemistry | *Chemistry | ||
*[[LFTs]] | *[[Special:MyLanguage/LFTs|LFTs]] | ||
**Hepatocyte injury: AST, ALT, alk phos | **Hepatocyte injury: AST, ALT, alk phos | ||
**Hepatocyte catabolic activity: Bilirubin | **Hepatocyte catabolic activity: Bilirubin | ||
*[[liver disease induced coagulopathy|Coags]] | *[[Special:MyLanguage/liver disease induced coagulopathy|Coags]] | ||
**Hepatocyte synthetic function | **Hepatocyte synthetic function | ||
*Albumin | *Albumin | ||
| Line 43: | Line 57: | ||
*Ammonia | *Ammonia | ||
**Hepatocyte catabolic activity | **Hepatocyte catabolic activity | ||
*[[viral hepatitis|Acute hepatitis panel]] | *[[Special:MyLanguage/viral hepatitis|Acute hepatitis panel]] | ||
*Lipase | *Lipase | ||
*[[Urinalysis]] | *[[Special:MyLanguage/Urinalysis|Urinalysis]] | ||
*?[[RUQ ultrasound|US]] vs. CT vs MRCP | *?[[Special:MyLanguage/RUQ ultrasound|US]] vs. CT vs MRCP | ||
*?Retic count | *?Retic count | ||
*?Haptoglobin/LDH | *?Haptoglobin/LDH | ||
*?APAP/ASA/Utox/ETOH | *?APAP/ASA/Utox/ETOH | ||
===[[Liver function tests]]=== | |||
===[[Special:MyLanguage/Liver function tests|Liver function tests]]=== | |||
====Transaminases==== | ====Transaminases==== | ||
*Transaminases in hundreds associated with mild injury; thousands suggests extensive injury | *Transaminases in hundreds associated with mild injury; thousands suggests extensive injury | ||
*Elevations <5x normal typical of alcoholic liver disease | *Elevations <5x normal typical of alcoholic liver disease | ||
*AST:ALT ratio > 2 common in [[acute alcoholic hepatitis]] (alcohol stimulates AST production) | *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 | *May be normal in end-stage liver failure | ||
*ALT more specific marker of hepatocyte injury than AST | *ALT more specific marker of hepatocyte injury than AST | ||
====Alk phos==== | ====Alk phos==== | ||
*Mild to moderate elevations accompany virtually all hepatobiliary disease | *Mild to moderate elevations accompany virtually all hepatobiliary disease | ||
*Elevations > 4x normal suggest cholestasis | *Elevations > 4x normal suggest cholestasis | ||
====GGT==== | ====GGT==== | ||
*Elevation in setting of hepatitis suggestive of alcoholic etiology | *Elevation in setting of hepatitis suggestive of alcoholic etiology | ||
====LDH==== | ====LDH==== | ||
*Moderate elevations are seen in all hepatocellular disorders and cirrhosis | *Moderate elevations are seen in all hepatocellular disorders and cirrhosis | ||
*Hemolysis results in elevation of LDH and unconjugated bili | *Hemolysis results in elevation of LDH and unconjugated bili | ||
====[[hyperammonemia|Ammonia]]==== | |||
====[[Special:MyLanguage/hyperammonemia|Ammonia]]==== | |||
*Elevation does NOT correlate with acute worsening of hepatic function in cirrhotic patient | *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 | *Serves as marker of generalized decline than as diagnostic tool or therapeutic end point | ||
====Coagulation Markers (PT/PTT/INR)==== | ====Coagulation Markers (PT/PTT/INR)==== | ||
*Marker of synthetic function | *Marker of synthetic function | ||
*Correlation between PT prolongation and clinical outcome in fulminant liver disease | *Correlation between PT prolongation and clinical outcome in fulminant liver disease | ||
====Albumin==== | ====Albumin==== | ||
*Marker of synthetic function | *Marker of synthetic function | ||
**Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease | **Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease | ||
*Low levels also seen in malnutrition | *Low levels also seen in malnutrition | ||
==Management== | ==Management== | ||
*Management is dependent on the diagnosis of either conjugated or unconjugated hyperblirubinemia and the severity of the elevation | *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 >1,000 IU/L | *Transaminase >1,000 IU/L | ||
*Tbil >10mg/dL | *Tbil >10mg/dL | ||
*Evidence coagulopathy | *Evidence coagulopathy | ||
==See Also== | ==See Also== | ||
*[[Neonatal Jaundice]] | |||
*[[Acute hepatitis]] | *[[Special:MyLanguage/Neonatal Jaundice|Neonatal Jaundice]] | ||
*[[Viral hepatitis]] | *[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]] | ||
*[[Acute hepatic failure]] | *[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]] | ||
*[[Cirrhosis]] | *[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]] | ||
*[[Ascites]] | *[[Special:MyLanguage/Cirrhosis|Cirrhosis]] | ||
*[[Special:MyLanguage/Ascites|Ascites]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Symptoms]] | [[Category:Symptoms]] | ||
</translate> | |||
Latest revision as of 23:15, 4 January 2026
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):
Posthepatic (underexcretion):
- Pancreatic tumor, choledocholithiasis
- Primarily conjugated bili
Clinical Features
- Yellow skin, sclera
- +/- dark urine
Differential Diagnosis
Jaundice
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
- Ischemic hepatitis
- Toxins
- Isoniazid
- Phenytoin
- acetaminophen
- Ritonavir
- Halothane
- Sulfonamide
- Autoimmune hepatitis
- Primary biliary cirrhosis
- HELLP Syndrome
- Congestive Hepatopathy
Pregnancy Related
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
- 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