Jaundice

Background

- 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)

    [greatly elevated AST/ALT]

         1) Viral hepatitis

         2) Fulminant hepatic failure

         3) ETOH hepatitis

         4) Ischemia

         5) Toxins

              i) isoniazide

              ii) phenytoin

              iii) acetaminophen

              iv) ritonavir

              v) halothane

              vi) sulronamide

         6) Autoimmune hepatitis

              i) 1 biliary cirhosis

         7) HELLP syndrome

         8) Congestive

              i) CHF

              ii) Sepsis

Pregnancy Related

1) HELP

2) Acute fatty liver

3) Hyperemesis gravidarum

4) Cholestasis of pregnancy

Transplant Related

1) Transplant regection

2) 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 ADMIT CRITERIA

1) Transaminase >1000IU/L

2) Tbil >10mg/dL

3) Evidence coagulopathy

Source

3/14/06 DONALDSON (adapted from Rosen), H-N

Authors: