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<translate>
''For neonatal jaundice please see the [[Special:MyLanguage/Neonatal jaundice|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
*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
**Transported from albumin into hepatocytes; combine with glucuronic acid into conj bili
*Conjugated bilirubin is then excreted into biliary tract
***Excreted into biliary tract in conjugated form
*Only conjugated bilirubin is water-soluble (present in urine)
*Only conjugated bilirubin is water-soluble (present in urine)
*Types:
*Normal bilirubin level is <1.1 (70% unconjugated)
**Prehepatic (overproduction)
 
***Hemolysis
 
***Primarily unconj bili
===Jaundice Types===
**Hepatic (inadequate processing)
 
***Viral, alcohol, toxin
'''Prehepatic (overproduction):'''
***Primarily unconj bili
*[[Special:MyLanguage/hemolytic anemia|Hemolysis]]
**Posthepatic (underexcretion)
*Primarily unconjugated bili
***Pancreatic tumor, choledocholithiasis
'''Hepatic (inadequate processing):'''
*[[Special:MyLanguage/viral hepatitis|Viral]], [[Special:MyLanguage/alcoholic hepatitis|alcohol]], toxin
*Primarily unconjugated bili
'''Posthepatic (underexcretion):'''
*Pancreatic tumor, [[Special:MyLanguage/choledocholithiasis|choledocholithiasis]]
*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==


==Workup==
</translate>
#Urine pregnancy
{{Jaundice DDX}}
#CBC
<translate>
#Chemistry
#LFT
##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
#UA
#?US vs. CT
#?Retic count
#?Haptoglobin/LDH
#?APAP/ASA/Utox/ETOH


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


NB: Only bilirubin stains the sclera
==Evaluation==


==DDX==
[[File:Evaluation of Hyperbilirubinemia.png|thumb|Evaluation algorithm]]
#Indirect >> direct (Hematologic) [near nl AST/ALT/Alk P/PT/PTT]
[[File:Ddx for jaundice by labs.gif|right|550px|Lab test for jaundice]]
##Hemolytic
*Urine pregnancy
###G6PD
*CBC
###Drug related
*Chemistry
###Autoimmune
*[[Special:MyLanguage/LFTs|LFTs]]
##Hematoma resorption
**Hepatocyte injury: AST, ALT, alk phos
##Infective erythropoiesis
**Hepatocyte catabolic activity: Bilirubin
##Gilbert's
*[[Special:MyLanguage/liver disease induced coagulopathy|Coags]]
#Direct >> indirect
**Hepatocyte synthetic function
##Increased Alk P (Obstructive)  [nl to mild inc AST/ALT]
*Albumin
##Choledocholithiasis
**Hepatocyte synthetic function
##Cholecystitis
*Ammonia
##Cholangitis (Ascending)
**Hepatocyte catabolic activity
##AIDS cholangiopathy
*[[Special:MyLanguage/viral hepatitis|Acute hepatitis panel]]
##Stricture
*Lipase
##Neoplasm
*[[Special:MyLanguage/Urinalysis|Urinalysis]]
###Panc head
*?[[Special:MyLanguage/RUQ ultrasound|US]] vs. CT vs MRCP
###Gallbladder
*?Retic count
###Primary liver
*?Haptoglobin/LDH
###Metastatic
*?APAP/ASA/Utox/ETOH
##Obstructing AAA
#Nl Alk P (Hepatocellular/cholestatic) [greatly elevated AST/ALT]
##Viral hepatitis
##Fulminant hepatic failure
##ETOH hepatitis
##Ischemia
##Toxins
###isoniazide
###phenytoin
###acetaminophen
###ritonavir
###halothane
###sulronamide
##Autoimmune hepatitis
###1 biliary cirhosis
##HELLP syndrome
##Congestive
###CHF
###Sepsis


===Pregnancy Related===
#HELP
#Acute fatty liver
#Hyperemesis gravidarum
#Cholestasis of pregnancy


===Transplant Related===
===[[Special:MyLanguage/Liver function tests|Liver function tests]]===
#Transplant regection
#Graft-vs-host


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


===Additional DDX===
====Transaminases====
#Reye's syndrome
 
#TPN
*Transaminases  in hundreds associated with mild injury; thousands suggests extensive injury
#Heatstroke
*Elevations <5x normal typical of alcoholic liver disease
#Budd-Chiari (with acute ascites)
*AST:ALT ratio > 2 common in [[Special:MyLanguage/acute alcoholic hepatitis|acute alcoholic hepatitis]] (alcohol stimulates AST production)
#Wilson's
*May be normal in end-stage liver failure
#Sarcoidosis
*ALT more specific marker of hepatocyte injury than AST
#Amyloidosis
 
====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
 
====[[Special:MyLanguage/hyperammonemia|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==
==Disposition==
New Onset Jaundice Admission Criteria
 
#Transaminase >1000IU/L
 
#Tbil >10mg/dL
===New Onset Jaundice Admission Criteria===
#Evidence coagulopathy
 
*Transaminase >1,000 IU/L
*Tbil >10mg/dL
*Evidence coagulopathy
 


==See Also==
==See Also==
*[[Neonatal Jaundice]]
*[[Hepatitis]]


==Source ==
*[[Special:MyLanguage/Neonatal Jaundice|Neonatal Jaundice]]
3/14/06 DONALDSON (adapted from Rosen), H-N
*[[Special:MyLanguage/Acute hepatitis|Acute hepatitis]]
*[[Special:MyLanguage/Viral hepatitis|Viral hepatitis]]
*[[Special:MyLanguage/Acute hepatic failure|Acute hepatic failure]]
*[[Special:MyLanguage/Cirrhosis|Cirrhosis]]
*[[Special:MyLanguage/Ascites|Ascites]]
 
 
==References==
 
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:Symptoms]]
</translate>

Revisión actual - 23:15 4 ene 2026

For neonatal jaundice please see the Neonatal jaundice page

Background

Cycle of heme breakdown and excretion.
  • 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):

Hepatic (inadequate processing):

Posthepatic (underexcretion):


Clinical Features

Jaundice of the skin
Pediatric jaundice with icterus of sclera.
  • Yellow skin, sclera
  • +/- dark urine


Differential Diagnosis

Jaundice

Differential diagnosis of hyperbilirubinemia.

Indirect Hyperbilirubinemia

Direct (Conjugated) Hyperbilirubinemia

Hepatocellular damage

Patient will have severely elevated AST/ALT with often normal Alkaline Phosphatase

Pregnancy Related

Transplant Related

Pediatric Related

Additional Differential Diagnosis

Masqueraders

Only bilirubin stains the sclera

  • Carotenemia
  • Quinacrine ingestion
  • Dinitrophenol, teryl (explosive chemicals)


Evaluation

Evaluation algorithm
Lab test for jaundice
  • 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 vs MRCP
  • ?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


See Also


References

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