Jaundice: Difference between revisions

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''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.]]
*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)


- One end product of heme metabolism; remainder from myoglobin
- All bilirubin products in the body are initially UNconjugated
- Transported from albumin into liver cells; combined with glucuronic acid into conjugated bilirubin
- Excreted into the biliary tract in conjugated form
== ==
==Workup==
1) Icon
2) CBC
3) Chem 7
4) LFTs
5) Lipase
6) UA
7) Coags
8) ?Ammonia
9) ?US vs. CT
10) ?Retic count
11) ?Haptoglobin/LDH
12) ?Tylenol/ASA/Utox/ETOH
==Diagnosis==
Masqueraders:
-Carotenemia
-Quinacrine ingestion
-Dinitrophenol, teryl (explosive chemicals)
NB: Only bilirubin stains the sclera
==DDX==
I. Indirect >> direct (Hematologic)
[near nl AST/ALT/Alk P/PT/PTT]
    A. Hemolytic
          i) G6PD
          ii) Drug related
          iii) Autoimmune
    B. Hematoma resorption
    C. Infective erythropoiesis
    D. Gilbert's
I. Direct >> indirect
    A. Increased Alk P (Obstructive)
    [nl to mild inc AST/ALT]
          1) Choledocholithiasis
          2) Cholecystitis
          3) Cholangitis (Ascending)
          4) AIDS cholangiopathy
          5) Stricture
          6) Neoplasm
              i) Panc head
              ii) Gallbladder
              iii) Primary liver
              iv) Metastatic
          7) Obstructing AAA


    B. Nl Alk P (Hepatocellular/cholestatic)
===Jaundice Types===


    [greatly elevated AST/ALT]
'''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


          1) Viral hepatitis


          2) Fulminant hepatic failure
==Clinical Features==


          3) ETOH hepatitis
[[File:Jaundice08.jpg|thumb|Jaundice of the skin]]
[[File:Jaundice.jpg|thumb|Pediatric jaundice with icterus of sclera.]]
*Yellow skin, sclera
*+/- dark urine


          4) Ischemia


          5) Toxins
==Differential Diagnosis==


              i) isoniazide
</translate>
{{Jaundice DDX}}
<translate>


              ii) phenytoin


              iii) acetaminophen
==Evaluation==


              iv) ritonavir
[[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


              v) halothane


              vi) sulronamide
===[[Special:MyLanguage/Liver function tests|Liver function tests]]===


          6) Autoimmune hepatitis


              i) 1 biliary cirhosis
====Transaminases====


          7) HELLP syndrome
*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


          8) Congestive
====Alk phos====


              i) CHF
*Mild to moderate elevations accompany virtually all hepatobiliary disease
*Elevations > 4x normal suggest cholestasis


              ii) Sepsis
====GGT====


*Elevation in setting of hepatitis suggestive of alcoholic etiology


===Pregnancy Related===
====LDH====


*Moderate elevations are seen in all hepatocellular disorders and cirrhosis
*Hemolysis results in elevation of LDH and unconjugated bili


1) HELP
====[[Special:MyLanguage/hyperammonemia|Ammonia]]====


2) Acute fatty liver
*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


3) Hyperemesis gravidarum


4) Cholestasis of pregnancy
====Coagulation Markers (PT/PTT/INR)====


*Marker of synthetic function
*Correlation between PT prolongation and clinical outcome in fulminant liver disease


===Transplant Related===
====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


1) Transplant regection


2) Graft-vs-host
==Management==


*Management is dependent on the diagnosis of either conjugated or unconjugated hyperblirubinemia and the severity of the elevation


===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 ADMIT CRITERIA
===New Onset Jaundice Admission Criteria===


1) Transaminase >1000IU/L
*Transaminase >1,000 IU/L
*Tbil >10mg/dL
*Evidence coagulopathy


2) Tbil >10mg/dL
3) Evidence coagulopathy


==See Also==
==See Also==


 
*[[Special:MyLanguage/Neonatal Jaundice|Neonatal Jaundice]]
Peds: Neonatal Jaundice
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
 
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
GI: Viral Hepatis
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]
 
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]]
*[[Special:MyLanguage/Ascites|Ascites]]
 
==Source ==
 
 
3/14/06 DONALDSON (adapted from Rosen), H-N




==References==


<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]
</translate>

Latest revision as of 23:15, 4 January 2026

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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