Jaundice

Background

• Bilirubin is end product of heme metabolism
  • All bilirubin products in the body are initially unconjugated
  • Transported from albumin into hepatocytes; combine with glucuronic acid into conj bili
    • Excreted into biliary tract in conjugated form
• Only conjugated bilirubin is water-soluble (present in urine)
• Types:
  • Prehepatic (overproduction)
    • Hemolysis
    • Primarily unconj bili
  • Hepatic (inadequate processing)
    • Viral, alcohol, toxin
    • Primarily unconj bili
  • Posthepatic (underexcretion)
    • Pancreatic tumor, choledocholithiasis

Workup

1. Urine pregnancy
2. CBC
3. Chemistry
4. LFT
   1. Hepatocyte injury: AST, ALT, alk phos
   2. Hepatocyte catabolic activity: Bilirubin
5. Coags
   1. Hepatocyte synthetic function
6. Albumin
   1. Hepatocyte synthetic function
7. Ammonia
   1. Hepatocyte catabolic activity
8. Acute hepatitis panel
9. Lipase
10. UA
11. ?US vs. CT
12. ?Retic count
13. ?Haptoglobin/LDH
14. ?APAP/ASA/Utox/ETOH

Diagnosis

Masqueraders:

1. Carotenemia
2. Quinacrine ingestion
3. Dinitrophenol, teryl (explosive chemicals)

NB: Only bilirubin stains the sclera

DDX

1. Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
   1. Hemolytic
      1. G6PD
      2. Drug related
      3. Autoimmune
   2. Hematoma resorption
   3. Infective erythropoiesis
   4. Gilbert's
2. Direct >> indirect
   1. Increased Alk P (Obstructive) [nl to mild inc AST/ALT]
   2. Choledocholithiasis
   3. Cholecystitis
   4. Cholangitis (Ascending)
   5. AIDS cholangiopathy
   6. Stricture
   7. Neoplasm
      1. Panc head
      2. Gallbladder
      3. Primary liver
      4. Metastatic
   8. Obstructing AAA
3. Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]
   1. Viral hepatitis
   2. Fulminant hepatic failure
   3. ETOH hepatitis
   4. Ischemia
   5. Toxins
      1. isoniazide
      2. phenytoin
      3. acetaminophen
      4. ritonavir
      5. halothane
      6. sulronamide
   6. Autoimmune hepatitis
      1. 1 biliary cirhosis
   7. HELLP syndrome
   8. Congestive
      1. CHF
      2. 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

1. Inborn error of metabolism
2. Physiologic neonatal

Additional DDX

1. Reye's syndrome
2. TPN
3. Heatstroke
4. Budd-Chiari (with acute ascites)
5. Wilson's
6. Sarcoidosis
7. Amyloidosis

Disposition

New Onset Jaundice Admission Criteria

1. Transaminase >1000IU/L
2. Tbil >10mg/dL
3. Evidence coagulopathy

See Also

• Neonatal Jaundice
• Hepatitis

Source

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