Jaundice - Dr. Jessica Nelson

So, What is Jaundice

Anyway?

So, What is Jaundice

Anyway?

Causes of Jaundice

Liver Function Testing

Patterns elevation

Diagnosis

Disposition

Bilirubin

Aspartate Aminotransferase

Alanine Transaminase

International Normalized Ratio

Gamma-glutamyl Transpeptidase

Alkaline Phosphatase

Ammonia

Albumin

LFT Panel

AST

ALT

ALP

Total Bilirubin

Albumin

Specific Orders

GGT

INR

Direct Bilirubin

Ammonia

Product of heme catabolism

Metabolized in the liver

Conjugated vs. Unconjugated

Patterns of elevation

What are they?

Where are they?

How high can they go?

Slight to moderate

Moderate to high

Very high

How high can they go?

Slight to moderate

Moderate to high

Very high

Hemolysis

Fatty liver

Metastatic disease

Pancreatitis

Medications

How high can they go?

Slight to moderate

Moderate to high

Very high

Chronic hepatitis

Skeletal muscle

MI

Mononucleosis

Alcoholic cirrhosis

How high can they go?

Slight to moderate

Moderate to high

Very high

Muscle trauma

Acute viral hepatitis

Toxic hepatitis

Ischemic hepatitis

How can ratios help?

AST/ALT = 1

AST/ALT <1

AST/ALT >2

How can ratios help?

AST/ALT = 1

AST/ALT <1

AST/ALT >2

Ischemia

How can ratios help?

AST/ALT = 1

AST/ALT <1

AST/ALT >2

Hepatocellular damage

Viral hepatitis

Ischemia

Toxic hepatitis

How can ratios help?

AST/ALT = 1

AST/ALT <1

AST/ALT >2

Alcoholic hepatitis

Hepatocellular injury

Active cirrhosis

Tylenol overdose

Medication

Marker of synthetic function

Liver produces:

Factors 1, 2, 5, 7, 8, 9, 10, and 11

Protein C and Protein S

Antithrombin

Correlation with clinical outcome

ALP

Composite assay

Non-specific

Suggests:

Obstruction

Infiltration

GGT

Amino acid transfer

Sensitive

Alcohol ingestion

Suggests:

Obstruction

Nitrogen waste from protein breakdown

Liver converts to urea

How do we interpret elevations?

Protein synthesized by the liver

Marker of malnutrition

Do we care about it?

Albumin

Protein synthesized by the liver

Marker of malnutrition

Do we care about it?

Sort of….but not today

A 23 year old male with a history of G6PD

presents with diffuse abdominal pain and

vomiting for two days.

He comes in now because of dark urine,

yellow eyes and breathlessness for the past

few hours.

Guess what he took home after his

abscess I&D a week ago…

Guess what he took home after his

abscess I&D a week ago…Bactrim

HR 124 Bp 110/30 RR 28 O2 88% T 100.4°F

Pale male in mild distress, eyes are icteric

RRR, lungs clear, abdomen soft, extremity rash

Labs

HgB 6 /μL

WBC 5 μL

Platelets 15 μL

LDH 400 U/L

Haptoglobin 20 mg/dL

Reticulocyte count 4%

Bilirubin total: 5 mg/dL

Labs

HgB 6 /μL

WBC 5 μL

Platelets 15 μL

LDH 400 U/L

Haptoglobin 20 mg/dL

Reticulocyte count 4%

Bilirubin total: 5 mg/dL

○ Direct bilirubin?

Imaging?

Disposition?

Admit Discharge

16 year old female presents with vomiting,

abdominal pain, and skin discoloration.

Mom leaves to park the car.

When interviewed alone, the patient starts

to cry and tells you she doesn’t want to live

anymore.

With further questioning, she talks about a

fight with her boyfriend and admits to taking

some pills later that night…

With further questioning, she talks about a

fight with her boyfriend and admit to taking

some pills later that night…2 days ago.

Bp 110/70 HR 120 RR 18 T 37.2 O2 98%

Alert, quiet with poor eye contact, tearful.

Faint jaundice, RRR, CTAB, mild RUQ tenderness.

AST 1500 U/L

ALT 2000 U/L

INR 3 IU

Bili 8 mg/dL

Alk Phos 250 UL

Acetaminophen <1mg/mL

CBC, BMP, UA, U preg

RUQ US?

AST 1500 U/L

ALT 2000 U/L

INR 3 IU Bili 8 mg/dL

Alk Phos 250 UL

Acetaminophen <1mg/mL

CBC, BMP, UA, U preg

RUQ US?

Imaging?

Disposition?

Admit or Discharge

44 year old male with a history of DM2 and

HTN presents with a 1-month history of

fatigue, nausea, and progressive jaundice.

He denies alcohol, drug abuse, blood

transfusion, or recent international travel.

Bp 140/85 HR100 RR14 T 37.5 O2 99%

Alert, no distress, overall thin

Scleral icterus and jaundiced skin

RRR, CTAB, abd distended but soft with no tenderness

T Bili 9.0

AST 70

ALT 150

INR 1.1

ALP 200

GGT 100

HgB 13

WBC 10.4

Platelets 268

T Bili 9.0

AST 70

ALT 150

INR 1.1

ALP 250

GGT 100

HgB 13

WBC 10.4

Platelets 268

Imaging?

Treatment?

Disposition?

Neonatal Jaundice

Jaundice in Pregnancy

References

Hasler WL, Owyang C. Chapter 290. Approach to the Patient with Gastrointestinal Disease. Harrison's Principles of Internal Medicine, 18e. New York, NY: McGraw-Hill; 2012.

O'Mara SR, Gebreyes K. Chapter 83. Hepatic Disorders, Jaundice, and Hepatic Failure. Tintinalli'sEmergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.

http://lifeinthefastlane.com/investigations/liver-function-tests/

http://jaundicepictures.com/Jaundiced.php

http://emedicine.medscape.com