Jaundice resident survival guide

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Jaundice
Resident Survival Guide
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Roghayeh Marandi, M.D.[2]

Synonyms and Keywords: Approach to jaundice, Jaundice workup, Jaundice management

Overview

The classic definition of jaundice is a serum bilirubin level higher than 2.5 to 3 mg per dL (42.8 to 51.3 μper L) in conjunction with clinical evidence of yellow skin and sclera. The causes of jaundice can be classified by measuring total bilirubin. The conjugated and unconjugated levels determine whether there is dysfunction of bilirubin metabolism.

Causes

Life Threatening Causes

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

Common Causes

Common causes of acute Jaundice[1]

Common causes of chronic progressive jaundice

Diagnosis

Shown below is an algorithm summarizing the diagnosis of jaundice.[2][3][4][5]
Abbreviations: ALT:Alanine transaminase, AST:Aspartate transaminase, ALP: Alkaline phosphatase, INR:International normalized ratio, ERCP:Endoscopic retrograde cholangiopancreatography, HAV: Hepatitis A virus, HBV: Hepatitis B virus, HCV: Hepatitis C virus, TIBC:Total iron binding capacity,Hb: Hemoglobin, LDH: lactate dehydrogenase, HbA1C:Hemoglobin A1c, CBC:Complete blood count, LFT: Liver function tests, MRCP: Magnetic resonance cholangiopancreatography, G6PD:Glucose-6-phosphate dehydrogenase deficiency

 
 
 
 
 
 
 
 
 
 
Characterize the jaundice duration and frequency
❑Duration: short vs long
❑Frequency: episodic vesus constant
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about associated symptoms

Abdominal pain (episodic or constant)
Abdominal distension
Fever
❑ Clay colored stool
❑ Dark urine
Weight gain or loss
Anorexia
Dyspepsia
Arthralgia
Myalgia
Back pain
Rash
Confusion
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Inquire about

❑ Past medical history
Blood disorder
Liver diseases
Biliary diseases
Pancreatic disease
Cardiac disease
Infectious disease
HIV
Malaria
❑ Etc

❑ Family history of

Hemolytic anemias
Congenital hyperbilirubinemia
Wilson disease

Medication history
Parentral exposure

Blood transfusion
IV drug abuse

❑ Recent travel history
❑ Social history

❑ Excess alcohol intake
❑ Sexual history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient

General Appearance
❑ Check for:
Pale skin (hemolysis/cancer/cirrhosis)
❑ Gross weight loss (cancer/severe malabsorption)
❑ Fetor hepaticus
❑ Flapping tremor (impending hepatic coma)

Skin exam
❑ Check for:

❑ Scratch marks
Melanin pigmentation
Xanthoma of eyelids (chronic cholestasis)
Signs of liver disease: spider nevi, palmar erythema
❑ Bruising, purpuric spots, clotting defects due to thrombocytopenia of cirrhosis

Cardiac exam
❑ Check JVP (right sided heart failure)
Full abdominal exam
❑ Size and consistency of liver and spleen

❑ A grossly enlarged nodular liver or an obvious abdominal mass suggests malignancy
❑ Small liver can be seen in (severe hepatitis/cirrhosis)
❑ An enlarged tender liver could be due to:
Viral hepatitis
Alcoholic hepatitis
❑ An infiltrative process such as amyloidosis
❑ Acutely congested liver secondary to right-sided heart failure)

❑ Check gallbladder area if it is tender

❑ Positive murphy sign due to choledocholithiasis
Palpable, visibly enlarged gallbladder can be due to pancreatic cancer

Splenomegaly can be seen in hemolytic states, Hodgkin’s lymphoma, portal hypertension
Ascites due to cirrhosis/abdominal malignancy
caput medosa
Extremity examination
❑ Ankle edema due to:

Cirrhosis
IVC obstruction due to hepatic or pancreatic malignancy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order

❑ Blood tests
CBC
❑ Total Bilirubin
❑ Conjugated or unconjugated bilirubin
❑ Metabolic panel
LFT
❑ Albumin
γ-glutamyltransferase
INR
prothrombin time

Urine

Bilirubin
Urobilinogen
❑Urine positive for bilirubin in conjugated hyperbilirubinemia
❑Urine Negative for bilirubin in unconjugated hyperbilirubinemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Isolated unconjugated hyperbilirubinemia]
 
 
 
 
Isolated conjugated hyperbilirubinemia
 
 
 
Unconjugated & conjugated hyperbilirubinemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Inquire about
any recent trauma
hematoma
blood transfusion
 
 
 
 
Dubin-Johnson syndrome
Rotor syndrome
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If none of them
 
 
 
 
 
 
 
With Liver enzyme changes
 
 
 
with ↑ INR,↓ Albumin,↓ Platelet
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Check Hb,LDH,Haptoglobin,Recticulocyte count
 
 
 
 
 
If ⇈AST/ALT out of proportion to ALP
 
If ⇈AlP out of proportion to AST/ALT
 
Suggestive of cCirrhosis
Additional tests to find the cause of cirrhosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Abnormal
 
Normal
 
Hepatocellular pattern
 
Cholestatic pattern
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Start workup of hemolytic anemia with blood smear & coombs test
 
Gilbert syndrome
Crigler-Najjar type I,II
 
Additional work-up for specific diseases
Viral hepatitis serology(e.g. HAV,HBV,HCV)
Toxicology screen
Acetaminophen level
Cereuloplasmin if patient<40 years of age
Autoantibodies (ANA,Anti-sm,LKM,...)
Ferritin & TIBC
HbA1c
Pregnancy test
a1-antitrypsin
❑Consider work-up for rare cases
Liver biopsy if results negative
 
Ultrasound
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider following based on the results:
 
 
 
 
 
Consider following based on the results:
Viral hepatitis
❑ NAFLD (Non-alcoholic liver disease)
❑ ppAlcoholic liver disease]]
Metabolic/genetic diseases
Hereditary hemochromatosis
Wilson's disease
Alpha-1 antitrypsin deficiency
❑ Drug-induced and supplemental-induced injury
Acetaminophen, kavakava, Vinyl cholride
Pregnancy
AFLP,HELLP syndrome
Autoimmune hepatitis
Ischemic hepatitis
 
Bile ducts dilatedBile ducts not dilated
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ERCP/CT
 
Additional work-up for intrahepatic cholestasis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Common bile duct stones
Biliray stricture
❑ Worms/flukes
Extrahepatic sources:
Cholangiocarcinoma
Pancreatic cancer
 
Consider following based on the results:

Treatment

[3][6][7][8][9]

Type of hyperbilirubinemia Diagnostic Indicators Management Recommendations
Managment of isolated unconjugated jaundice, hemolytic
Managment of isolated unconjugated jaundice, Non-hemolytic
Managment of isolated conjugated jaundice
  • Suspect for Dubin-Johnson syndrome before considering surgery if the healthy patient with long-standing conjugated hyperbilirubinemia, other normal liver function tests, and a non visualized gallbladder.
  • Hepatic architecture is normal but there is an accumulation of hepatic pigment compatible with melanin in patients with Dubin-Johnson syndrome
  • In Rotor's syndrome the gallbladder opacifies normally with cholecystographic dye and no pigmentation be seen in the liver.
Managment of conjugated & unconjugated hyperbilirubinemia jaundice with ⇈AST/ALT out of proportion to ALP'
Managment of conjugated & unconjugated hyperbilirubinemia jaundice with ⇈ AlP out of proportion to AST/ALT
  • History of intermittent right upper quadrant pain radiating to the back or right shoulder favors gallstones, fever and chills suggest cholangitis.
  • History of biliary tract surgery within 2 years should alert the physician to possible biliary stricture.
  • History recent weight loss, constant epigastric or right upper quadrant pain radiating to the back suggests malignancy
  • Icteric patient with extrahepatic obstruction due to gallstones or postsurgical biliary stricture has usually had acute symptoms for less than 2 weeks
  • Those with carcinoma, chronic pancreatitis, or primary sclerosing cholangitis have had symptoms of longer duration
  • A middle-aged woman with a history of itching and autoimmune disease raises the suspicion of primary biliary cirrhosis
    More than half the people with primary biliary cirrhosis do not have any symptoms when diagnosed. Symptoms develop over the next five to 20 years. Those who do have symptoms at diagnosis typically have poorer outcomes.
  • Commonly used drugs such as antihypertensives (e.g., angiotensin-converting enzyme inhibitors) or hormones (e.g., estrogen) may cause cholestasis
  • Abnormal ALP levels may be a sign of metastatic cancer of the liver, lymphoma or infiltrative diseases such as sarcoidosis.
  • History of inflammatory bowel disease (most commonly ulcerative colitis) suggests the presence of primary sclerosing cholangitis since about 70% of these cases are associated with inflammatory bowel disease
  • TPN is associated with ↑ AlP and GGT level.|
  • Obstruction removal by ERCP, PTC, Surgery (e.g.Cholecystectomy or Palliative Bypass procedures such as hepaticojejunostomy if stenting has failed in patients with tumors)
  • Primary biliary cholangitis management: no cure for primary biliary cholangitis, but medications are available for slow the progression and prevent complications of the disease: Ursodeoxycholic acid (UDCA), Obeticholic acid (Ocaliva), Fibrates, Liver transplantation may help prolongs life.
  • Treatments for primary sclerosing cholangitis focus on managing complications and monitoring liver damage. None of the medications have been found to slow or reverse the liver damage associated with this disease.
Managment of conjugated & unconjugated hyperbilirubinemia jaundice with ↑ INR,↓ Alb,↓ PLT |

Do's

Don'ts

References

  1. Warner, Ben; Wilkinson, Mark (2017). "Acute jaundice": 150–154. doi:10.1002/9781119389613.ch23.
  2. Giannini EG, Testa R, Savarino V (February 2005). "Liver enzyme alteration: a guide for clinicians". CMAJ. 172 (3): 367–79. doi:10.1503/cmaj.1040752. PMC 545762. PMID 15684121.
  3. 3.0 3.1 Walker HK, Hall WD, Hurst JW, Stillman AE. PMID 21250253. Missing or empty |title= (help)
  4. Gondal B, Aronsohn A (December 2016). "A Systematic Approach to Patients with Jaundice". Semin Intervent Radiol. 33 (4): 253–258. doi:10.1055/s-0036-1592331. PMC 5088098. PMID 27904243.
  5. Syhavong B, Rasachack B, Smythe L, Rolain JM, Roque-Afonso AM, Jenjaroen K, Soukkhaserm V, Phongmany S, Phetsouvanh R, Soukkhaserm S, Thammavong T, Mayxay M, Blacksell SD, Barnes E, Parola P, Dussaix E, Raoult D, Humphreys I, Klenerman P, White NJ, Newton PN (July 2010). "The infective causes of hepatitis and jaundice amongst hospitalised patients in Vientiane, Laos". Trans. R. Soc. Trop. Med. Hyg. 104 (7): 475–83. doi:10.1016/j.trstmh.2010.03.002. PMC 2896487. PMID 20378138.
  6. Shroff H, Maddur H (April 2020). "Isolated Elevated Bilirubin". Clin Liver Dis (Hoboken). 15 (4): 153–156. doi:10.1002/cld.944. PMC 7206321 Check |pmc= value (help). PMID 32395242 Check |pmid= value (help).
  7. Garcia-Tsao G (February 2001). "Current management of the complications of cirrhosis and portal hypertension: variceal hemorrhage, ascites, and spontaneous bacterial peritonitis". Gastroenterology. 120 (3): 726–48. doi:10.1053/gast.2001.22580. PMID 11179247.
  8. McCullough AJ, O'Connor JF (November 1998). "Alcoholic liver disease: proposed recommendations for the American College of Gastroenterology". Am. J. Gastroenterol. 93 (11): 2022–36. doi:10.1111/j.1572-0241.1998.00587.x. PMID 9820369.
  9. Baldwin C, Olarewaju O. PMID 32644330 Check |pmid= value (help). Missing or empty |title= (help)