Jaundice: Difference between revisions
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''For neonatal jaundice please see the [[Neonatal jaundice]] page'' | ''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 | *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 | *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 | ||
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===Jaundice Types=== | ===Jaundice Types=== | ||
'''Prehepatic (overproduction):''' | '''Prehepatic (overproduction):''' | ||
*Hemolysis | *[[hemolytic anemia|Hemolysis]] | ||
*Primarily unconjugated bili | *Primarily unconjugated bili | ||
'''Hepatic (inadequate processing):''' | '''Hepatic (inadequate processing):''' | ||
*Viral, alcohol, toxin | *[[viral hepatitis|Viral]], [[alcoholic hepatitis|alcohol]], toxin | ||
*Primarily unconjugated bili | *Primarily unconjugated bili | ||
'''Posthepatic (underexcretion):''' | '''Posthepatic (underexcretion):''' | ||
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*Primarily conjugated bili | *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== | ==Differential Diagnosis== | ||
[[File:Classification of Hyperbilirubinemia.jpeg|thumb]] | [[File:Classification of Hyperbilirubinemia.jpeg|thumb|Differential diagnosis of hyperbilirubinemia.]] | ||
===Indirect Hyperbilirubinemia=== | ===Indirect Hyperbilirubinemia=== | ||
*Hemolytic | *Hemolytic | ||
**G6PD | **[[G6PD]] | ||
**Drug related | **Drug related | ||
**Autoimmune | **[[Autoimmune hemolytic anemia]] | ||
*Hematoma resorption | *Hematoma resorption | ||
* | *Ineffective erythropoiesis | ||
*Gilbert's | *Gilbert's | ||
===Direct (Conjugated) Hyperbilirubinemia=== | ===Direct (Conjugated) Hyperbilirubinemia=== | ||
*[[Choledocholithiasis]] | *[[Choledocholithiasis]] | ||
*[[Cholecystitis]] | *[[Cholecystitis]] | ||
*[[ | *Ascending [[cholangitis]] | ||
*[[AIDS]] cholangiopathy | *[[AIDS]] cholangiopathy | ||
*Stricture | *Stricture | ||
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**Pancreatic head | **Pancreatic head | ||
**Gallbladder | **Gallbladder | ||
**Primary liver | **Primary liver (e.g. [[hepatocellular carcinoma]] | ||
**Metastatic | **Metastatic | ||
*Obstructing [[AAA]] | *Obstructing [[AAA]] | ||
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''Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase'' | ''Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase'' | ||
*[[Viral hepatitis]] | *[[Viral hepatitis]] | ||
*Fulminant hepatic failure | *[[Acute liver failure|Fulminant hepatic failure]] | ||
* | *[[alcoholic hepatitis]] | ||
* | *[[Ischemic hepatitis]] | ||
*Toxins | *Toxins | ||
** | **[[Isoniazid]] | ||
**[[Phenytoin]] | **[[Phenytoin]] | ||
**[[Acetaminophen (Tylenol) Toxicity|acetaminophen]] | **[[Acetaminophen (Tylenol) Toxicity|acetaminophen]] | ||
**Ritonavir | **Ritonavir | ||
**Halothane | **Halothane | ||
** | **Sulfonamide | ||
*[[Autoimmune hepatitis]] | *[[Autoimmune hepatitis]] | ||
**Primary biliary cirrhosis | **Primary biliary cirrhosis | ||
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*Congestive Hepatopathy | *Congestive Hepatopathy | ||
**[[CHF]] | **[[CHF]] | ||
**[[Sepsis]] (Shock Liver) | **[[Sepsis]] ([[ischemic hepatitis|Shock Liver]]) | ||
===Pregnancy Related=== | ===Pregnancy Related=== | ||
*[[HELLP Syndrome]] | *[[HELLP Syndrome]] | ||
*Acute fatty liver | *[[Acute fatty liver of pregnancy]] | ||
*[[Hyperemesis gravidarum]] | *[[Hyperemesis gravidarum]] | ||
*[[Cholestasis of pregnancy]] | *[[Cholestasis of pregnancy]] | ||
===Transplant Related=== | ===Transplant Related=== | ||
*Transplant rejection | *[[Transplant complications|Transplant rejection]] | ||
*Graft-vs-host | *[[Graft-vs-host disease]] | ||
===Pediatric Related=== | ===Pediatric Related=== | ||
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===Additional Differential Diagnosis=== | ===Additional Differential Diagnosis=== | ||
*Reye | *[[Reye syndrome]] | ||
*TPN | *TPN | ||
*[[Heatstroke]] | *[[Heatstroke]] | ||
*Budd-Chiari (with acute ascites) | *[[Budd-Chiari]] (with acute ascites) | ||
*Wilson's | *[[Wilson's disease]] | ||
*[[Sarcoidosis]] | *[[Sarcoidosis]] | ||
*[[Amyloidosis]] | *[[Amyloidosis]] | ||
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*Dinitrophenol, teryl (explosive chemicals) | *Dinitrophenol, teryl (explosive chemicals) | ||
== | ==Evaluation== | ||
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]] | |||
[[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]] | |||
*Urine pregnancy | *Urine pregnancy | ||
*CBC | *CBC | ||
*Chemistry | *Chemistry | ||
* | *[[LFTs]] | ||
**Hepatocyte injury: AST, ALT, alk phos | **Hepatocyte injury: AST, ALT, alk phos | ||
**Hepatocyte catabolic activity: Bilirubin | **Hepatocyte catabolic activity: Bilirubin | ||
*Coags | *[[liver disease induced coagulopathy|Coags]] | ||
**Hepatocyte synthetic function | **Hepatocyte synthetic function | ||
*Albumin | *Albumin | ||
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*Ammonia | *Ammonia | ||
**Hepatocyte catabolic activity | **Hepatocyte catabolic activity | ||
*Acute hepatitis panel | *[[viral hepatitis|Acute hepatitis panel]] | ||
*Lipase | *Lipase | ||
*[[Urinalysis]] | *[[Urinalysis]] | ||
*?US vs. CT | *?[[RUQ ultrasound|US]] vs. CT | ||
*?Retic count | *?Retic count | ||
*?Haptoglobin/LDH | *?Haptoglobin/LDH | ||
*?APAP/ASA/Utox/ETOH | *?APAP/ASA/Utox/ETOH | ||
== | ===[[Liver function tests]]=== | ||
[[ | |||
====Transaminases==== | ====Transaminases==== | ||
*Transaminases in hundreds associated with mild injury; thousands suggests extensive injury | *Transaminases in hundreds associated with mild injury; thousands suggests extensive injury | ||
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====Albumin==== | ====Albumin==== | ||
*Marker of synthetic function | *Marker of synthetic function | ||
**Half-life is | **Half-life is 3 weeks so less useful than PT in evaluating fulminant liver disease | ||
*Low levels also seen in malnutrition | *Low levels also seen in malnutrition | ||
==Management== | ==Management== | ||
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==See Also== | ==See Also== | ||
*[[Neonatal Jaundice]] | *[[Neonatal Jaundice]] | ||
*[[Acute | *[[Acute hepatitis]] | ||
*[[Viral | *[[Viral hepatitis]] | ||
*[[Acute hepatic failure]] | *[[Acute hepatic failure]] | ||
*[[Cirrhosis]] | |||
*[[Ascites]] | |||
==References== | ==References== | ||
<references/> | |||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:Symptoms]] | [[Category:Symptoms]] |
Revision as of 17:57, 4 June 2020
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
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
- ?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