Jaundice resident survival guide (pediatrics)

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Jaundice resident survival guide (pediatrics) Microchapters
Overview
Causes
FIRE
Diagnosis
Treatment
Do's
Don'ts

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.

• Biliary atresia
• Fulminant Liver failure

Common Causes

Causes of jaundice in children include:

• Unconjugated hyperbilirubinemia
  • Excessive hemolysis
  • Gilbert syndrome
  • Breast milk jaundice
  • Breast feeding failure jaundice
  • Crigler-Najjar syndrome
  • Hypothyroidism
  • Pyloric stenosis
  • Galactosemia

• Conjugated hyperbilirubinemia
  • Viral infections
    • Hepatitis A, Hepatitis B, Hepatitis C, Hepatitis D, and Hepatitis E
    • EBV
  • Sepsis
  • Urinary tract infection
  • Biliary atresia
  • Choledochal cyst
  • Breast milk jaundice
  • Metabolic disorders
  • Gallstone
  • Hepatotoxic drugs
    • Acetaminophen
    • Anticonvulsants
    • Anesthetics
    • Antituberculous drugs
    • Chemotherapeutic agents
    • Antibiotics
    • Oral contraceptives
  • Inspissated bile syndrome
  • Alagille syndrome
  • Wilson disease
  • Alpha-1-antitrypsin deficiency
  • Cystic fibrosis
  • Autoimmune hepatitis

Complete Diagnostic Approach

Shown below is an algorithm summarizing the diagnosis of jaundice in children.

Characterise jaundice ❑ Onset ❑ Duration (acute or chronic) ❑ Progression ❑ Location ❑ Precipitating events ❑ Dark urine ❑ Acholic stools

Ask about associated symptoms ❑ Abdominal pain ❑ Abdominal distension ❑ Nausea and Vomiting ❑ Dyspepsia ❑ Anorexia ❑ Weight gain or loss ❑ Fever and Chills ❑ Itching ❑ Steatorrhea ❑ Arthralgia ❑ Myalgia ❑ Urticaria ❑ Sore throat ❑ Rash ❑ Pale skin ❑ Fatigue ❑ Back pain ❑ Confusion ❑ Lethargy ❑ Poor feeding

Obtain a detailed history ❑ Age (causes of jaundice varies with age ❑ Race ❑ Past medical history ❑ Recurrent episodes of jaundice ❑ Hemolytic anemia ❑ Autoimmune disease ❑ Malignancy ❑ Past surgical history ❑ Family history ❑ Jaundice ❑ Liver disease ❑ Wilson disease ❑ Malignancy ❑ Anemia ❑ Autoimmune disease ❑ Travel history (poor sanitation) ❑ Medications or Herbal preparation ❑ Blood transfusion and Needle stick injury or unsterilized syringe use ❑ Sexual history ❑ Social history ❑ Smoking ❑ Alcohol ❑ Drug abuse ❑ Tattoo ❑ Occupational history ❑ Sewage worker (Leptospirosis) ❑ Health care worker (needle stick injury) ❑ Birth history (Neonatal jaundice) ❑ Maternal infection ❑ Maternal blood group ❑ Maternal Diabetes ❑ Medications during pregnancy ❑ Birth trauma ❑ Feeding history ❑ Breast milk ❑ Formula feeding ❑ Number of wet diapers per day

Examine the patient Check vitals ❑ Temperature ❑ Pulse ❑ Blood pressure ❑ Respiratory rate Perform a general physical exam ❑ HEENT examination ❑ Yellow sclera ❑ Cataract (TORCH infection) ❑ Hematoma (cephalhematoma) ❑ Lymphadenopathy ❑ Skin examination ❑ Yellow skin ❑ Pale skin ❑ Scratch mark (indicates pruritus) ❑ Bruise ❑ Spider nevi and palmar erythema (seen in liver disease) ❑ Abdominal examination ❑ Signs of previous surgery ❑ Right upper quadrant tenderness ❑ Murphy sign ❑ Courvoisier law ❑ Abdominal distension (hepatomegaly, enlarged gall bladder, splenomegaly, ascites, malignancy) ❑ CNS examination (Kernicterus) ❑ Altered mental status ❑ Hyoptonia ❑ Asterixis ❑ Lymph nodes (infection, malignancy) ❑ Extremities examination ❑ Lower limb edema (cirrhosis, malignancy) ❑ Dysmorphic features (Alagille syndrome)

Order serum bilirubin

Increased Indirect bilirubin

Increased Direct bilirubin

Unconjugated hyperbilirubinemia

Conjugated hyperbilirubinemia

Liver function test

Pathological jaundice

Physiological jaundice

Increased ALT and AST

Increased ALP and GGT

Features of hemolysis

Hepatic etiology Viral hepatitis ❑ Recent travel history ❑ Blood transfusion and needle stick injury ❑ Injection drug use ❑ Promiscuous sexual behavior ❑ Healthcare worker ❑ Family history of hepatitis Sepsis ❑ Fever ❑ Hypotension ❑ Shock Hepatotoxic drugs ❑ Acetaminophen ❑ Oral contraceptives Wilson disease ❑ Neuropsychiatric symptoms ❑ Kayser-Fleischer ring Metabolic disorders ❑ Failure to thrive ❑ Growth retardation ❑ Congenital malformations ❑ Hepatomeagly Autoimmune hepatitis ❑ Fatigue ❑ Myalgia ❑ Arthralgia ❑ Anorexia ❑ Weight loss Alpha-1-antitrypsin deficiency ❑ Dyspnea with wheeze and rhonchi ❑ Recurrent respiratory infections Emphysema

Post-hepatic etiology Biliary atresia ❑ Jaundice develops within 1-8 weeks ❑ Fat-soluble vitamin deficiencies ❑ Growth retardation Choledochal cyst ❑ Abdominal pain ❑ Palpable abdominal mass ❑ Pancreatitis Inspissated bile syndrome Gallstone ❑ History of hemolytic anemia ❑ Right upper quadrant pain ❑ Nausea and Vomiting

Present

Absent

Diagnostic work up Viral Hepatitis ❑ CBC with differentials ❑ Hepatitis serology ❑ Monospot test and Heterophile antibody test ❑ CMV serology Sepsis and other infections ❑ Blood culture and sensitivity ❑ Urinanalysis ❑ Urine culture and sensitivity Wilson's disease ❑ Low serum ceruloplasmin ❑ High serum calcium ❑ 24-hour urinary copper excretion more than 100 μg/24h ❑ Coombs negative hemolytic anemia ❑ Liver bopsy Metabolic syndrome ❑ Newborn screening tests Alpha-1-antitrypsin deficiency ❑ Serum alpha-1 AT ❑ LFT ❑ PFT ❑ ABG Autoimmune hepatitis ❑ ANA ❑ ASMA ❑ ANCA ❑ ALKM-1 antibodies

Diagnostic work up Biliary atresia ❑ LFT ❑ Serum bile acid ❑ Abdominal ultrasonography ❑ ERCP ❑ Hepatobiliary scintigraphy ❑ Intraoperative cholangiography ❑ Liver biopsy Choledochal cyst ❑ LFT ❑ Abdominal ultrasonography ❑ ERCP Gallstone ❑ LFT ❑ Serum amylase and lipase ❑ CBC with differentials ❑ Transabdominal ultrasonography ❑ Urine analysis

Hemolytic anemia ❑ Pallor ❑ Fatigue ❑ Fever ❑ Chills ❑ Dark urine ❑ Splenomegaly ❑ Gallstone

Breast milk jaundice ❑ Breastfeeding history Breast feeding jaundice ❑ Inadequate breastfeeding Gilbert syndrome ❑ Mild jaundice seen in neonates ❑ Positive family history ❑ History of exertion, stress, illness, fasting, infection ❑ No hemolysis Crigler-Najjar syndrome ❑ Neonatal jaundice ❑ Positive family history ❑ No hemolysis

Diagnostic work up ❑ Complete blood count with platelets ❑ Increased reticulocyte count ❑ Osmotic fragility test ❑ Direct and indirect Coombs test ❑ Serum haptoglobin ❑ Hemoglobin electrophoresis ❑ Increased serum lactate dehydrogenase ❑ Urine hemosiderin ❑ Urine hemoglobin ❑ Peripheral smear ❑ Schistocytes ❑ Spherocytes ❑ Target cell ❑ Bite cell ❑ Sickle shaped RBC

Diagnostic work up ❑ Normal blood profile ❑ Normal LFT ❑ Normal liver histology

Treatment

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Do's

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Don'ts

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References

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