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 | |||
*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):''' | |||
*[[hemolytic anemia|Hemolysis]] | |||
*Primarily unconjugated bili | |||
'''Hepatic (inadequate processing):''' | |||
*[[viral hepatitis|Viral]], [[alcoholic hepatitis|alcohol]], toxin | |||
*Primarily unconjugated bili | |||
'''Posthepatic (underexcretion):''' | |||
*Pancreatic tumor, [[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== | |||
{{Jaundice DDX}} | |||
== | ==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 | |||
*[[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 | |||
=== | ===[[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 | |||
=== | ====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== | ==Disposition== | ||
===New Onset Jaundice Admission Criteria=== | |||
*Transaminase >1,000 IU/L | |||
*Tbil >10mg/dL | |||
*Evidence coagulopathy | |||
==See Also== | ==See Also== | ||
*[[Neonatal Jaundice]] | |||
*[[Acute hepatitis]] | |||
*[[Viral hepatitis]] | |||
*[[Acute hepatic failure]] | |||
*[[Cirrhosis]] | |||
*[[Ascites]] | |||
== | ==References== | ||
<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
- 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