Jaundice: Difference between revisions

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==Background==
==Background==
 
#One end product of heme metabolism; remainder from myoglobin
 
#All bilirubin products in the body are initially UNconjugated
- One end product of heme metabolism; remainder from myoglobin
#Transported from albumin into liver cells; combined with glucuronic acid into conjugated bilirubin
 
#Excreted into the biliary tract in conjugated form
- 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==
==Workup==
 
#Icon
 
#CBC
1) Icon
#Chem 7
 
#LFTs
2) CBC
#Lipase
 
#UA
3) Chem 7
#Coags
 
#?Ammonia
4) LFTs
#?US vs. CT
 
#?Retic count
5) Lipase
#?Haptoglobin/LDH
 
#?Tylenol/ASA/Utox/ETOH
6) UA
 
7) Coags
 
8) ?Ammonia
 
9) ?US vs. CT
 
10) ?Retic count
 
11) ?Haptoglobin/LDH
 
12) ?Tylenol/ASA/Utox/ETOH
 


==Diagnosis==
==Diagnosis==
Masqueraders:
Masqueraders:
 
#Carotenemia
-Carotenemia
#Quinacrine ingestion
 
#Dinitrophenol, teryl (explosive chemicals)
-Quinacrine ingestion
 
-Dinitrophenol, teryl (explosive chemicals)
 


NB: Only bilirubin stains the sclera
NB: Only bilirubin stains the sclera


==DDX==
==DDX==
 
#Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
 
##Hemolytic
I. Indirect >> direct (Hematologic)
###G6PD
 
###Drug related
[near nl AST/ALT/Alk P/PT/PTT]
###Autoimmune
 
##Hematoma resorption
    A. Hemolytic
##Infective erythropoiesis
 
##Gilbert's
          i) G6PD
#Direct >> indirect
 
##Increased Alk P (Obstructive) [nl to mild inc AST/ALT]
          ii) Drug related
##Choledocholithiasis
 
##Cholecystitis
          iii) Autoimmune
##Cholangitis (Ascending)
 
##AIDS cholangiopathy
    B. Hematoma resorption
##Stricture
 
##Neoplasm
    C. Infective erythropoiesis
###Panc head
 
###Gallbladder
    D. Gilbert's
###Primary liver
 
###Metastatic
I. Direct >> indirect
##Obstructing AAA
 
#Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]
    A. Increased Alk P (Obstructive)
##Viral hepatitis
 
##Fulminant hepatic failure
    [nl to mild inc AST/ALT]
##ETOH hepatitis
 
##Ischemia
          1) Choledocholithiasis
##Toxins
 
###isoniazide
          2) Cholecystitis
###phenytoin
 
###acetaminophen
          3) Cholangitis (Ascending)
###ritonavir
 
###halothane
          4) AIDS cholangiopathy
###sulronamide
 
##Autoimmune hepatitis
          5) Stricture
###1 biliary cirhosis
 
##HELLP syndrome
          6) Neoplasm
##Congestive
 
###CHF
              i) Panc head
###Sepsis
 
              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===
===Pregnancy Related===
 
#HELP
 
#Acute fatty liver
1) HELP
#Hyperemesis gravidarum
 
#Cholestasis of pregnancy
2) Acute fatty liver
 
3) Hyperemesis gravidarum
 
4) Cholestasis of pregnancy
 


===Transplant Related===
===Transplant Related===
 
#Transplant regection
 
#Graft-vs-host
1) Transplant regection
 
2) Graft-vs-host
 


===Peds Related===
===Peds Related===
 
#Inborn error of metabolism
 
#Physiologic neonatal
Inborn error of metabolism
 
Physiologic neonatal
 
=== ===
 


===Additional DDX===
===Additional DDX===
 
#Reye's syndrome
 
#TPN
Reye's syndrome
#Heatstroke
 
#Budd-Chiari (with acute ascites)
TPN
#Wilson's
 
#Sarcoidosis
Heatstroke
#Amyloidosis
 
Budd-Chiari (with acute ascites)
 
Wilson's
 
Sarcoidosis
 
Amyloidosis
 


==Disposition==
==Disposition==
NEW ONSET JAUNDICE ADMIT CRITERIA
NEW ONSET JAUNDICE ADMIT CRITERIA
 
#Transaminase >1000IU/L
1) Transaminase >1000IU/L
#Tbil >10mg/dL
 
#Evidence coagulopathy
2) Tbil >10mg/dL
 
3) Evidence coagulopathy
 


==See Also==
==See Also==
Peds: Neonatal Jaundice
Peds: Neonatal Jaundice


GI: Viral Hepatis
GI: Viral Hepatis


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


[[Category:GI]]
[[Category:GI]]

Revision as of 12:07, 14 March 2011

Background

  1. One end product of heme metabolism; remainder from myoglobin
  2. All bilirubin products in the body are initially UNconjugated
  3. Transported from albumin into liver cells; combined with glucuronic acid into conjugated bilirubin
  4. 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:

  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 ADMIT CRITERIA

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

See Also

Peds: Neonatal Jaundice

GI: Viral Hepatis

Source

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

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